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10,023,404
| 28,217,007
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old woman with IgG deficiency and
recently diagnosed PE on apixaban who presents as a transfer
from
___ out of concern for RCVS.
The patient states that she was in her usual state of health
prior to this past ___. At that time, she developed acute
onset shortness of breath as well as excruciating pain under her
right breast in the lateral aspect of her right shoulder. She
presented to the emergency room at ___ where a
D-dimer was positive. CTA revealed PE. She was started on
Lovenox
as a bridge to apixaban. She has been on apixaban 10 mg BID
since
___.
The patient was discharged from ___ on ___.
She states that she has had mild pain in the right chest since
that time but no recurrent episodes of dyspnea. She has been
taking her apixaban without any missed doses.
Yesterday evening, the patient was watching a movie on the
couch,
when she developed a sudden onset left-sided frontal headache.
She states that this was located just above her left eye. She
states that the pain was excruciating to the point that she
could
not get off the couch. She describes the pain as sharp,
throbbing pain. She notes that when she put her hand on her
head
she could "feel the throbbing." The pain seemed to worsen over
the course of approximately 30 minutes. She notes that it was a
first limited to the area above her left eye but subsequently
spread to involve the entire forehead.
She states that she was sensitive to light during this time and
had trouble opening her eyes. However, she denies any vision
loss, scintillating lights, fortifications, or diplopia.
Given her recently diagnosed PE, the patient was brought to ___ via EMS. There she received morphine which
helped with her pain. She also underwent CT and CTA of the head
and neck. This revealed "mild narrowing of the proximal and mid
and severe narrowing of the distal bilateral posterior cerebral
arteries, left greater than right, no aneurysm." Given these
findings, the patient's case was discussed with the vascular
fellow at ___ who recommended
transfer for further evaluation.
On neurological ROS, the patient denies any significant headache
history. She notes that she may be had one migraine
approximately 4 months ago but does not routinely get headaches.
She denies dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, endorses shortness of breath as noted above. Denies
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:
IgG deficiency, diagnosed approximately 1 month ago. She
received a single treatment of IVIG at this time. She has
received no treatment since.
- Suspected POTS in the setting of recurrent episodes of syncope
(for ___ years, worse over the past ___ year) - followed by
cardiologist, Dr. ___, on ___. In ___, had SBP > 180 for
a week straight, admitted to ___ and concerned for POTS.
Subsequently referred to the autonomic neurology division here
at
___ for further work-up and
evaluation. She is scheduled for autonomic testing on ___.
Social History:
___
Family History:
Parents both alive and healthy. Mother has mild asthma. Older
brother is healthy. Grandfather had MI in his ___. No family or
personal history of miscarriage.
Physical Exam:
Day of admission
PHYSICAL EXAMINATION:
=====================
Vitals: T 97.8, HR 71, BP 137/87, RR 19, Sa 100% RA
General: Sleepy, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx. There is mild tenderness to palpation of the
frontalis muscle bilaterally.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: Soft, non-distended
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic Exam:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Fundoscopic
exam revealed no papilledema, exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ 5 ___ 5 5 5
R 5 ___ 5 ___ 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
No astereognosis in either hand.
-DTRs: ___ adductors bilaterally
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait/Station: Deferred
Day of discharge
Vitals: T 97.9, HR 85, BP 128/87, RR 19, Sa 100% RA
General: Sleepy, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx. No tenderness to palpation of the
frontalis muscle bilaterally.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: Soft, non-distended
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic Exam:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Fundoscopic
exam revealed no papilledema, exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ 5 ___ 5 5 5
R 5 ___ 5 ___ 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
No astereognosis in either hand.
-DTRs: ___ adductors bilaterally
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait/Station: Deferred
Pertinent Results:
___ 05:21AM BLOOD WBC-10.7* RBC-4.06 Hgb-12.2 Hct-37.0
MCV-91 MCH-30.0 MCHC-33.0 RDW-12.2 RDWSD-40.9 Plt ___
___ 05:21AM BLOOD Neuts-58.4 ___ Monos-5.1 Eos-4.9
Baso-0.5 Im ___ AbsNeut-6.24* AbsLymp-3.28 AbsMono-0.54
AbsEos-0.52 AbsBaso-0.05
___ 05:21AM BLOOD ___ PTT-37.0* ___
___ 05:21AM BLOOD Glucose-97 UreaN-12 Creat-0.7 Na-140
K-4.2 Cl-104 HCO3-20* AnGap-16
___ 05:21AM BLOOD cTropnT-<0.01
Brief Hospital Course:
___ is a ___ year old with history of IgG deficiency
on IVIG, PE on apixaban (likely provoked given on OCP and PE)
who presented with initial dull headache that rapidly progressed
to severe unilateral headache with photophobia, phonophobia and
nausea. On evaluation at an outside hospital she had imaging
which showed normal CTH and possible vasoconstriction of her
PCAs and was thus transferred to ___. At ___ her neurologic
exam was normal. She was treated with Toradol, Compazine and
fluids and began to improve. Initially her apixaban was held.
She had MRI brain with venous and arterial imaging which showed
no evidence of RCVS, venous thrombus, SAH or any other
abnormality. She responded well to analgesics and hydration.
Based on her presentation, we initially considered RCVS as
potential diagnosis (although not true thunderclap headache) and
ultimately migraine was likely diagnosis. We started verapamil
to help with prophylaxis against migraines. We initially
entertained stopping Celexa given can be associated with RCVS,
but ultimately did not given lower suspicion for RCVS.
Psychiatry consult was done as well, and their team recommended
to continue with Celexa and ask PCP for outpatient psychiatry
referral. Abixaban, celexa were restarted and patient was
discharged on Verapamil 120 mg ER daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 40 mg PO DAILY
2. Apixaban 10 mg PO BID
Discharge Medications:
1. DiphenhydrAMINE 25 mg PO Q6H:PRN migraine
take with Compazine, do not drive after taking
2. Naproxen 500 mg PO Q12H:PRN Pain - Moderate Duration: 5 Days
500 mg BID PRN for headache. Maximum 5 days
RX *naproxen [EC-Naprosyn] 500 mg 1 tablet(s) by mouth Q12 PRN
Disp #*10 Tablet Refills:*2
3. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - First
Line Duration: 5 Days
10 mg Q8 PRN for nausea. Maximum duration 5 days
RX *prochlorperazine maleate [Compazine] 10 mg 1 tablet(s) by
mouth Q8 PRN Disp #*15 Tablet Refills:*2
4. Verapamil SR 120 mg PO Q24H
RX *verapamil [Calan SR] 120 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*2
5. Apixaban 10 mg PO BID
6. Citalopram 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Migraine with visual aura
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of headache resulting from
migraine with aura attack. To decrease risk of future migraines,
please continue to drink 2L of water daily, get 8 hours of sleep
at night and do not skip meals.
We are changing your medications as follows:
For migraine prevention: start verapamil 120 mg daily
At the onset of headache, you can take a combination of
naproxen, Compazine and diphenhydramine (doses below). This can
be repeated after 6 hours as needed.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
[
"G43109",
"D803",
"I2699",
"F419",
"F329",
"Z7902"
] |
Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Chief Complaint: Headache Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a [MASKED] year old woman with IgG deficiency and recently diagnosed PE on apixaban who presents as a transfer from [MASKED] out of concern for RCVS. The patient states that she was in her usual state of health prior to this past [MASKED]. At that time, she developed acute onset shortness of breath as well as excruciating pain under her right breast in the lateral aspect of her right shoulder. She presented to the emergency room at [MASKED] where a D-dimer was positive. CTA revealed PE. She was started on Lovenox as a bridge to apixaban. She has been on apixaban 10 mg BID since [MASKED]. The patient was discharged from [MASKED] on [MASKED]. She states that she has had mild pain in the right chest since that time but no recurrent episodes of dyspnea. She has been taking her apixaban without any missed doses. Yesterday evening, the patient was watching a movie on the couch, when she developed a sudden onset left-sided frontal headache. She states that this was located just above her left eye. She states that the pain was excruciating to the point that she could not get off the couch. She describes the pain as sharp, throbbing pain. She notes that when she put her hand on her head she could "feel the throbbing." The pain seemed to worsen over the course of approximately 30 minutes. She notes that it was a first limited to the area above her left eye but subsequently spread to involve the entire forehead. She states that she was sensitive to light during this time and had trouble opening her eyes. However, she denies any vision loss, scintillating lights, fortifications, or diplopia. Given her recently diagnosed PE, the patient was brought to [MASKED] via EMS. There she received morphine which helped with her pain. She also underwent CT and CTA of the head and neck. This revealed "mild narrowing of the proximal and mid and severe narrowing of the distal bilateral posterior cerebral arteries, left greater than right, no aneurysm." Given these findings, the patient's case was discussed with the vascular fellow at [MASKED] who recommended transfer for further evaluation. On neurological ROS, the patient denies any significant headache history. She notes that she may be had one migraine approximately 4 months ago but does not routinely get headaches. She denies dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the patient denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, endorses shortness of breath as noted above. Denies 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: IgG deficiency, diagnosed approximately 1 month ago. She received a single treatment of IVIG at this time. She has received no treatment since. - Suspected POTS in the setting of recurrent episodes of syncope (for [MASKED] years, worse over the past [MASKED] year) - followed by cardiologist, Dr. [MASKED], on [MASKED]. In [MASKED], had SBP > 180 for a week straight, admitted to [MASKED] and concerned for POTS. Subsequently referred to the autonomic neurology division here at [MASKED] for further work-up and evaluation. She is scheduled for autonomic testing on [MASKED]. Social History: [MASKED] Family History: Parents both alive and healthy. Mother has mild asthma. Older brother is healthy. Grandfather had MI in his [MASKED]. No family or personal history of miscarriage. Physical Exam: Day of admission PHYSICAL EXAMINATION: ===================== Vitals: T 97.8, HR 71, BP 137/87, RR 19, Sa 100% RA General: Sleepy, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. There is mild tenderness to palpation of the frontalis muscle bilaterally. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Normal work of breathing Cardiac: RRR, warm, well-perfused Abdomen: Soft, non-distended Extremities: No [MASKED] edema. Skin: No rashes or lesions noted. Neurologic Exam: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA [MASKED] [MASKED] L 5 [MASKED] 5 [MASKED] 5 5 5 R 5 [MASKED] 5 [MASKED] 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. No astereognosis in either hand. -DTRs: [MASKED] adductors bilaterally Bi Tri [MASKED] Pat Ach L 2 2 2 3 2 R 2 2 2 3 2 Plantar response was flexor bilaterally. -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. -Gait/Station: Deferred Day of discharge Vitals: T 97.9, HR 85, BP 128/87, RR 19, Sa 100% RA General: Sleepy, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. No tenderness to palpation of the frontalis muscle bilaterally. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Normal work of breathing Cardiac: RRR, warm, well-perfused Abdomen: Soft, non-distended Extremities: No [MASKED] edema. Skin: No rashes or lesions noted. Neurologic Exam: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA [MASKED] [MASKED] L 5 [MASKED] 5 [MASKED] 5 5 5 R 5 [MASKED] 5 [MASKED] 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. No astereognosis in either hand. -DTRs: [MASKED] adductors bilaterally Bi Tri [MASKED] Pat Ach L 2 2 2 3 2 R 2 2 2 3 2 Plantar response was flexor bilaterally. -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. -Gait/Station: Deferred Pertinent Results: [MASKED] 05:21AM BLOOD WBC-10.7* RBC-4.06 Hgb-12.2 Hct-37.0 MCV-91 MCH-30.0 MCHC-33.0 RDW-12.2 RDWSD-40.9 Plt [MASKED] [MASKED] 05:21AM BLOOD Neuts-58.4 [MASKED] Monos-5.1 Eos-4.9 Baso-0.5 Im [MASKED] AbsNeut-6.24* AbsLymp-3.28 AbsMono-0.54 AbsEos-0.52 AbsBaso-0.05 [MASKED] 05:21AM BLOOD [MASKED] PTT-37.0* [MASKED] [MASKED] 05:21AM BLOOD Glucose-97 UreaN-12 Creat-0.7 Na-140 K-4.2 Cl-104 HCO3-20* AnGap-16 [MASKED] 05:21AM BLOOD cTropnT-<0.01 Brief Hospital Course: [MASKED] is a [MASKED] year old with history of IgG deficiency on IVIG, PE on apixaban (likely provoked given on OCP and PE) who presented with initial dull headache that rapidly progressed to severe unilateral headache with photophobia, phonophobia and nausea. On evaluation at an outside hospital she had imaging which showed normal CTH and possible vasoconstriction of her PCAs and was thus transferred to [MASKED]. At [MASKED] her neurologic exam was normal. She was treated with Toradol, Compazine and fluids and began to improve. Initially her apixaban was held. She had MRI brain with venous and arterial imaging which showed no evidence of RCVS, venous thrombus, SAH or any other abnormality. She responded well to analgesics and hydration. Based on her presentation, we initially considered RCVS as potential diagnosis (although not true thunderclap headache) and ultimately migraine was likely diagnosis. We started verapamil to help with prophylaxis against migraines. We initially entertained stopping Celexa given can be associated with RCVS, but ultimately did not given lower suspicion for RCVS. Psychiatry consult was done as well, and their team recommended to continue with Celexa and ask PCP for outpatient psychiatry referral. Abixaban, celexa were restarted and patient was discharged on Verapamil 120 mg ER daily. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 40 mg PO DAILY 2. Apixaban 10 mg PO BID Discharge Medications: 1. DiphenhydrAMINE 25 mg PO Q6H:PRN migraine take with Compazine, do not drive after taking 2. Naproxen 500 mg PO Q12H:PRN Pain - Moderate Duration: 5 Days 500 mg BID PRN for headache. Maximum 5 days RX *naproxen [EC-Naprosyn] 500 mg 1 tablet(s) by mouth Q12 PRN Disp #*10 Tablet Refills:*2 3. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - First Line Duration: 5 Days 10 mg Q8 PRN for nausea. Maximum duration 5 days RX *prochlorperazine maleate [Compazine] 10 mg 1 tablet(s) by mouth Q8 PRN Disp #*15 Tablet Refills:*2 4. Verapamil SR 120 mg PO Q24H RX *verapamil [Calan SR] 120 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 5. Apixaban 10 mg PO BID 6. Citalopram 40 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Migraine with visual aura Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were hospitalized due to symptoms of headache resulting from migraine with aura attack. To decrease risk of future migraines, please continue to drink 2L of water daily, get 8 hours of sleep at night and do not skip meals. We are changing your medications as follows: For migraine prevention: start verapamil 120 mg daily At the onset of headache, you can take a combination of naproxen, Compazine and diphenhydramine (doses below). This can be repeated after 6 hours as needed. Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your [MASKED] Neurology Team Followup Instructions: [MASKED]
|
[] |
[
"F419",
"F329",
"Z7902"
] |
[
"G43109: Migraine with aura, not intractable, without status migrainosus",
"D803: Selective deficiency of immunoglobulin G [IgG] subclasses",
"I2699: Other pulmonary embolism without acute cor pulmonale",
"F419: Anxiety disorder, unspecified",
"F329: Major depressive disorder, single episode, unspecified",
"Z7902: Long term (current) use of antithrombotics/antiplatelets"
] |
10,023,486
| 20,530,186
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Lamictal / Cipro
Attending: ___.
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt.is a ___ year old male with history of HTN, HLD,
myelofibrosis,G6PD deficiency who had previously been admitted
following a ground level fall causing a left renal
retroperitoneal hematoma s/p two attempts at ___ embolization and
finally an exploratory laparotomy with left nephrectomy and
hematoma evacuation. Of note, ___ hospital course was
complicated by new consent a-fib(now on Coumadin) and potential
withdrawal from ruxolitinib-pt.'s myleofibrosis medication.
Pt.'s
was later discharged with scheduled appointment ___ with
notable improvement however with mild drainage from his lower
midline wound. Pt. was scheduled for follow up abdominal CT this
upcoming ___.
Today, patient presented to ___ ED after recently being
discharged from rehab yesterday. His wife stated he became
increasingly altered with associated weakness this morning and
became concerned. Upon arrival to the ED pt. was noted to be
febrile to 104, lethargic, but oriented. He complains of very
mild abdominal tenderness. He denies n/v, SOB, chest pain.
Past Medical History:
Past Medical History:
-Myleofibrosis, HTN, HLD, AF
Past Surgical History:
___: Left mid kidney selective arterial embolization.
___: Repeat left mid kidney selective arterial coil embolization
Social History:
___
Family History:
NC
Physical Exam:
Admission Physical Exam:
Physical Exam:
Vitals:T:100 and 104 on recheck(rectal), BP:115/59/RR:18. 99% on
RA
GEN: A&Ox3,malaise, warm to touch, sick in appearance
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, normal S1 an S2
PULM: Clear to auscultation b/l, no increased work of breathing
ABD: Soft, nondistended, mild tenderness around JP site,
purulent
drainage from midline wound(grey/yellow in appearance, no
purulent drainage expressed from JP drain site-serous output,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 97.6, 116/77, 67, 18, 97 Ra
Gen: A&O x3, sitting up in chair
CV: HR irregular, rate controlled
Pulm: LS diminished at bases
Abd: soft, Mildly TTP around midline incision. Incision with
opening at inferior section, scant drainage, no erythema. JP has
been removed.
Ext: thick lower extremities. no pitting edema.
Pertinent Results:
___ 06:50AM BLOOD WBC-5.1 RBC-3.33* Hgb-9.4* Hct-31.4*
MCV-94 MCH-28.2 MCHC-29.9* RDW-20.8* RDWSD-72.0* Plt ___
___ 06:54AM BLOOD WBC-5.7 RBC-3.14* Hgb-8.7* Hct-29.3*
MCV-93 MCH-27.7 MCHC-29.7* RDW-20.9* RDWSD-71.5* Plt ___
___ 06:34AM BLOOD WBC-5.9 RBC-3.19* Hgb-8.8* Hct-29.3*
MCV-92 MCH-27.6 MCHC-30.0* RDW-20.6* RDWSD-69.8* Plt ___
___ 11:56PM BLOOD Hct-30.3*
___ 03:30PM BLOOD WBC-7.3 RBC-3.72* Hgb-10.5* Hct-34.0*
MCV-91 MCH-28.2 MCHC-30.9* RDW-20.9* RDWSD-69.0* Plt ___
___ 06:50AM BLOOD Glucose-89 UreaN-22* Creat-1.7* Na-147
K-4.1 Cl-103 HCO3-33* AnGap-11
___ 06:54AM BLOOD Glucose-95 UreaN-23* Creat-1.8* Na-146
K-4.2 Cl-104 HCO3-32 AnGap-10
___ 06:34AM BLOOD Glucose-117* UreaN-25* Creat-1.6* Na-144
K-3.7 Cl-102 HCO3-32 AnGap-10
___ 03:30PM BLOOD Glucose-124* UreaN-27* Creat-1.4* Na-141
K-4.6 Cl-98 HCO3-31 AnGap-12
___ 06:50AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0
___ 06:54AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.4
___ 06:34AM BLOOD Calcium-8.1* Phos-3.9 Mg-1.7
___ ___ M ___ ___ Microbiology Lab
Results
___ 4:00 pm URINE
URINE CULTURE (Preliminary):
PROTEUS MIRABILIS. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Imaging:
CT Abdomen/Pelvis
1. No fluid collection is noted along the course of the left
anterior approach
drain terminating adjacent to the spleen in the left mid
abdomen.
The tip of the drain does not terminate in a fluid collection.
No substantial
subcutaneous changes are noted along its course.
2. Hematoma in the left nephrectomy bed contains area of
increased density measuring up to 53 in ___ suggestive of areas
of
more acute hemorrhage, but difficult to compare as there are no
postoperative images.
3. Air and soft tissue edema is noted along the tract of the
surgical scar along the mid abdomen, consistent with recent
intervention
Brief Hospital Course:
___ year old male with history of HTN, HLD, myelofibrosis,G6PD
deficiency who had previously been admitted following a ground
level fall causing a left renal
retroperitoneal hematoma s/p two attempts at ___ embolization and
finally an exploratory laparotomy with left nephrectomy and
hematoma evacuation, admitted to the Acute Care Surgery service
with fevers to 104 and lethargy. CT abdomen pelvis notable for
hematoma in the left nephrectomy bed but no other fluid
collections. The JP drain was removed. The surgical wound had
recently been opened up in clinic and drained, was currently
packed lightly with wet to dry gauze. Interventional radiology
was consulted for the hematoma but they felt it was too
loculated and dense to drain. The patient was started on IV
antibiotics. Fever work-up also revealed a positive urinalysis
with culture growing proteus mirabilis, sensitive to
ciprofloxacin. Wound swab with moderate staph aureas coag+.
Creatinine was noted to be rising, FeUrea 41% consistent with
intrinsic process. Lasix was held.
The patient was hemodynamically stable and was afebrile during
the hospital stay. Antibiotics were narrowed based on culture
sensitivities. Coumadin was restarted. Physical therapy worked
with the patient and he was cleared for discharge home with ___
for INR monitoring and wound care.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with a walker, voiding without assistance,
moving his bowels, and pain was well controlled. The patient
was discharged home with ___ services. The patient and his wife
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
He was sent with a prescription to complete a course of
ciprofloxacin. He was instructed to closely monitor INR while
taking cipro. He would follow-up in ___ clinic and with his PCP.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. OXcarbazepine 150 mg PO BID
6. Pregabalin 150 mg PO TID
7. Tizanidine 4 mg PO Q8H:PRN muscle spasms
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Jakafi (ruxolitinib) 5 mg oral BID
10. Docusate Sodium 100 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Senna 8.6 mg PO BID:PRN Constipation - First Line
13. Warfarin 7.5 mg PO DAILY16
14. Lactulose 15 mL PO BID
Discharge Medications:
1. Baclofen 10 mg PO TID:PRN Muscle Spasms
RX *baclofen 10 mg 1 tablet(s) by mouth three times a day Disp
#*20 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*11 Tablet Refills:*0
3. Herb-Lax 1 TAB PO QID:PRN
4. Morphine SR (MS ___ 15 mg PO Q12H
5. Warfarin 5 mg PO DAILY16
6. Allopurinol ___ mg PO DAILY
7. Atenolol 50 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. Furosemide 40 mg PO DAILY
11. Jakafi (ruxolitinib) 5 mg oral BID
12. Lactulose 15 mL PO BID
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. Multivitamins 1 TAB PO DAILY
15. OXcarbazepine 150 mg PO BID
16. Pregabalin 150 mg PO TID
17. Senna 8.6 mg PO BID:PRN Constipation - First Line
18. Tizanidine 4 mg PO Q8H:PRN muscle spasms
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Urinary tract infection
Hematoma in the left nephrectomy bed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with fevers. A CT scan was done which
showed a hematoma around the left nephrectomy site.
Interventional Radiology evaluated this but felt it was too
coagulated to drain. Your urine came back positive for an
infection, so you have begun a course of antibiotics to treat
this. This antibiotic can elevate your INR so you will need
close monitoring of your INR and adjustments to the dose of
coumadin as needed. You are now doing better and have been
cleared by Physical Therapy for discharge home.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry
Followup Instructions:
___
|
[
"N390",
"D7581",
"I10",
"E785",
"D6959",
"I4891",
"Z7901",
"B964",
"D649",
"G629"
] |
Allergies: Lamictal / Cipro Chief Complaint: fevers Major Surgical or Invasive Procedure: None History of Present Illness: Pt.is a [MASKED] year old male with history of HTN, HLD, myelofibrosis,G6PD deficiency who had previously been admitted following a ground level fall causing a left renal retroperitoneal hematoma s/p two attempts at [MASKED] embolization and finally an exploratory laparotomy with left nephrectomy and hematoma evacuation. Of note, [MASKED] hospital course was complicated by new consent a-fib(now on Coumadin) and potential withdrawal from ruxolitinib-pt.'s myleofibrosis medication. Pt.'s was later discharged with scheduled appointment [MASKED] with notable improvement however with mild drainage from his lower midline wound. Pt. was scheduled for follow up abdominal CT this upcoming [MASKED]. Today, patient presented to [MASKED] ED after recently being discharged from rehab yesterday. His wife stated he became increasingly altered with associated weakness this morning and became concerned. Upon arrival to the ED pt. was noted to be febrile to 104, lethargic, but oriented. He complains of very mild abdominal tenderness. He denies n/v, SOB, chest pain. Past Medical History: Past Medical History: -Myleofibrosis, HTN, HLD, AF Past Surgical History: [MASKED]: Left mid kidney selective arterial embolization. [MASKED]: Repeat left mid kidney selective arterial coil embolization Social History: [MASKED] Family History: NC Physical Exam: Admission Physical Exam: Physical Exam: Vitals:T:100 and 104 on recheck(rectal), BP:115/59/RR:18. 99% on RA GEN: A&Ox3,malaise, warm to touch, sick in appearance HEENT: No scleral icterus, mucus membranes moist CV: RRR, normal S1 an S2 PULM: Clear to auscultation b/l, no increased work of breathing ABD: Soft, nondistended, mild tenderness around JP site, purulent drainage from midline wound(grey/yellow in appearance, no purulent drainage expressed from JP drain site-serous output, normoactive bowel sounds, no palpable masses Ext: No [MASKED] edema, [MASKED] warm and well perfused Discharge Physical Exam: VS: 97.6, 116/77, 67, 18, 97 Ra Gen: A&O x3, sitting up in chair CV: HR irregular, rate controlled Pulm: LS diminished at bases Abd: soft, Mildly TTP around midline incision. Incision with opening at inferior section, scant drainage, no erythema. JP has been removed. Ext: thick lower extremities. no pitting edema. Pertinent Results: [MASKED] 06:50AM BLOOD WBC-5.1 RBC-3.33* Hgb-9.4* Hct-31.4* MCV-94 MCH-28.2 MCHC-29.9* RDW-20.8* RDWSD-72.0* Plt [MASKED] [MASKED] 06:54AM BLOOD WBC-5.7 RBC-3.14* Hgb-8.7* Hct-29.3* MCV-93 MCH-27.7 MCHC-29.7* RDW-20.9* RDWSD-71.5* Plt [MASKED] [MASKED] 06:34AM BLOOD WBC-5.9 RBC-3.19* Hgb-8.8* Hct-29.3* MCV-92 MCH-27.6 MCHC-30.0* RDW-20.6* RDWSD-69.8* Plt [MASKED] [MASKED] 11:56PM BLOOD Hct-30.3* [MASKED] 03:30PM BLOOD WBC-7.3 RBC-3.72* Hgb-10.5* Hct-34.0* MCV-91 MCH-28.2 MCHC-30.9* RDW-20.9* RDWSD-69.0* Plt [MASKED] [MASKED] 06:50AM BLOOD Glucose-89 UreaN-22* Creat-1.7* Na-147 K-4.1 Cl-103 HCO3-33* AnGap-11 [MASKED] 06:54AM BLOOD Glucose-95 UreaN-23* Creat-1.8* Na-146 K-4.2 Cl-104 HCO3-32 AnGap-10 [MASKED] 06:34AM BLOOD Glucose-117* UreaN-25* Creat-1.6* Na-144 K-3.7 Cl-102 HCO3-32 AnGap-10 [MASKED] 03:30PM BLOOD Glucose-124* UreaN-27* Creat-1.4* Na-141 K-4.6 Cl-98 HCO3-31 AnGap-12 [MASKED] 06:50AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0 [MASKED] 06:54AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.4 [MASKED] 06:34AM BLOOD Calcium-8.1* Phos-3.9 Mg-1.7 [MASKED] [MASKED] M [MASKED] [MASKED] Microbiology Lab Results [MASKED] 4:00 pm URINE URINE CULTURE (Preliminary): PROTEUS MIRABILIS. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] PROTEUS MIRABILIS | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Imaging: CT Abdomen/Pelvis 1. No fluid collection is noted along the course of the left anterior approach drain terminating adjacent to the spleen in the left mid abdomen. The tip of the drain does not terminate in a fluid collection. No substantial subcutaneous changes are noted along its course. 2. Hematoma in the left nephrectomy bed contains area of increased density measuring up to 53 in [MASKED] suggestive of areas of more acute hemorrhage, but difficult to compare as there are no postoperative images. 3. Air and soft tissue edema is noted along the tract of the surgical scar along the mid abdomen, consistent with recent intervention Brief Hospital Course: [MASKED] year old male with history of HTN, HLD, myelofibrosis,G6PD deficiency who had previously been admitted following a ground level fall causing a left renal retroperitoneal hematoma s/p two attempts at [MASKED] embolization and finally an exploratory laparotomy with left nephrectomy and hematoma evacuation, admitted to the Acute Care Surgery service with fevers to 104 and lethargy. CT abdomen pelvis notable for hematoma in the left nephrectomy bed but no other fluid collections. The JP drain was removed. The surgical wound had recently been opened up in clinic and drained, was currently packed lightly with wet to dry gauze. Interventional radiology was consulted for the hematoma but they felt it was too loculated and dense to drain. The patient was started on IV antibiotics. Fever work-up also revealed a positive urinalysis with culture growing proteus mirabilis, sensitive to ciprofloxacin. Wound swab with moderate staph aureas coag+. Creatinine was noted to be rising, FeUrea 41% consistent with intrinsic process. Lasix was held. The patient was hemodynamically stable and was afebrile during the hospital stay. Antibiotics were narrowed based on culture sensitivities. Coumadin was restarted. Physical therapy worked with the patient and he was cleared for discharge home with [MASKED] for INR monitoring and wound care. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with a walker, voiding without assistance, moving his bowels, and pain was well controlled. The patient was discharged home with [MASKED] services. The patient and his wife received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. He was sent with a prescription to complete a course of ciprofloxacin. He was instructed to closely monitor INR while taking cipro. He would follow-up in [MASKED] clinic and with his PCP. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Allopurinol [MASKED] mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Furosemide 40 mg PO DAILY 4. Lidocaine 5% Patch 1 PTCH TD QAM 5. OXcarbazepine 150 mg PO BID 6. Pregabalin 150 mg PO TID 7. Tizanidine 4 mg PO Q8H:PRN muscle spasms 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY 9. Jakafi (ruxolitinib) 5 mg oral BID 10. Docusate Sodium 100 mg PO BID 11. Multivitamins 1 TAB PO DAILY 12. Senna 8.6 mg PO BID:PRN Constipation - First Line 13. Warfarin 7.5 mg PO DAILY16 14. Lactulose 15 mL PO BID Discharge Medications: 1. Baclofen 10 mg PO TID:PRN Muscle Spasms RX *baclofen 10 mg 1 tablet(s) by mouth three times a day Disp #*20 Tablet Refills:*0 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*11 Tablet Refills:*0 3. Herb-Lax 1 TAB PO QID:PRN 4. Morphine SR (MS [MASKED] 15 mg PO Q12H 5. Warfarin 5 mg PO DAILY16 6. Allopurinol [MASKED] mg PO DAILY 7. Atenolol 50 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Fluticasone Propionate NASAL 2 SPRY NU DAILY 10. Furosemide 40 mg PO DAILY 11. Jakafi (ruxolitinib) 5 mg oral BID 12. Lactulose 15 mL PO BID 13. Lidocaine 5% Patch 1 PTCH TD QAM 14. Multivitamins 1 TAB PO DAILY 15. OXcarbazepine 150 mg PO BID 16. Pregabalin 150 mg PO TID 17. Senna 8.6 mg PO BID:PRN Constipation - First Line 18. Tizanidine 4 mg PO Q8H:PRN muscle spasms Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Urinary tract infection Hematoma in the left nephrectomy bed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [MASKED] with fevers. A CT scan was done which showed a hematoma around the left nephrectomy site. Interventional Radiology evaluated this but felt it was too coagulated to drain. Your urine came back positive for an infection, so you have begun a course of antibiotics to treat this. This antibiotic can elevate your INR so you will need close monitoring of your INR and adjustments to the dose of coumadin as needed. You are now doing better and have been cleared by Physical Therapy for discharge home. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within [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",
"I10",
"E785",
"I4891",
"Z7901",
"D649"
] |
[
"N390: Urinary tract infection, site not specified",
"D7581: Myelofibrosis",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"D6959: Other secondary thrombocytopenia",
"I4891: Unspecified atrial fibrillation",
"Z7901: Long term (current) use of anticoagulants",
"B964: Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere",
"D649: Anemia, unspecified",
"G629: Polyneuropathy, unspecified"
] |
10,023,486
| 25,262,533
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Lamictal
Attending: ___
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
___ ___ Left mid kidney selective arterial embolization
___ ___ no active extrav, coil x2 to PsA
___ Exploratory laparotomy, left nephrectomy
History of Present Illness:
Mr. ___ is a ___ year old man with a past medical history
of HTN, HLD, myelofibrosis, G6PD deficiency who was admitted
with left renal rupture and retroperitoneal hematoma requiring
embolization by ___. Nephrology has been consulted for ___.
Patient apparently had a fall 5 days before admission, after
being hit in the head by the trunk of his car. He did not have
LOC, but had mild abdominal pain. On the day of admission, his
abdominal pain worsened and he went to OSH, where he was found
to be hypotensive (BP 60/40). CTA performed showed showed
retroperitoneal hematoma secondary to left renal rupture. He was
given 3 units of pRBC and transferred to ___. In the ED, pt
received additional unit of blood (4 total) and 2 units of FFP.
Pt went to ___ procedure with coiling of a psueoaneurysm and has
remained intubated since.
In TSICU, he was noted to have a falling H/H and had repeat
embolization on ___. Today, he was noted to have poor urine
output and a rising Cr. He has also been hypotensive and on
pressors. On ___ he was started on antobiotics for fever to
102. On ___ he was extubated and being weaned off the
pressors. On ___ he was transferred in stable condition to
the floor for further recovery. Because of newly dg. AFib the
patient was started on lovenox and bridged to warfarin. On the
floor he was triggered for HR 130s, which resumed after iv
metoprolol. His H/H was followed on daily basis. After return of
his bowel function and tolerating diet, with good pain control
and stable H/H he was cleared to go to Rehab facility for
further care.
Past Medical History:
HTN, HLD, Myelofibrosis
Social History:
___
Family History:
NC
Physical Exam:
O: P/E:
VS: BP 113 / 75, HR 81, RR 16, ___ 92 on RA, temp 98.1
GEN: AOx3 WN, WD in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR
PULM: unlabored breathing with symmetric chest rise, no
respiratory distress
ABD: soft, NT, ND, no mass, no hernia
EXT: WWP, no CCE, no tenderness, 2+ B/L ___
[ ] foley ___________
[X] surgical drain JP drain, serosanguinous output, 410cc
during last day
Pertinent Results:
IMAGING:
___
___ EMBO ARTERIAL
IMPRESSION:
Uncomplicated coil embolization of the left mid kidney
pseudoaneurysm.
TRAUMA #3 (PORT CHEST ONLY)
IMPRESSION:
Low lung volumes without evidence of focal consolidation or
pleural effusion.
___:
PORTABLE ABDOMEN
IMPRESSION:
No abnormal bowel dilation to suggest ileus or obstruction
Labs at discharge:
___ 05:45AM BLOOD WBC-22.4* RBC-3.73* Hgb-10.1* Hct-34.2*
MCV-92 MCH-27.1 MCHC-29.5* RDW-21.6* RDWSD-71.5* Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD ___ PTT-31.6 ___
___ 05:45AM BLOOD Glucose-110* UreaN-30* Creat-1.5* Na-145
K-4.2 Cl-103 HCO3-33* AnGap-9*
___ 05:45AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.1
Brief Hospital Course:
ICU course per Dr. ___: ___ s/p fall p/w L renal laceration.
He is s/p ___ where they coiled L renal PsA. Despite coiling, the
patient was still febrile and had a dropping HCT. ___ did a
takeback on ___ and saw no active extrav. They placed 2
coils. However, this still did not control the bleeding so Mr.
___ underwent a ___, left nephrectomy on ___.
Following these procedures, his main issue became tachycardia
and Afib w/ RVR. He was diagnosed with ruxolitinib withdrawal.
Heme was consulted and they restarted this home med and
steroids. He responded well and was transitoned to PO dilt. Mr.
___ was transferred out of the unit on ___ with a JP
drain from the nephrectomy. The DHT was *** prior to transfer
and he was tolerating PO feeds.
Following transfer to the surgical ward, the ___ hospital
course is as follows:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with oxycodone and the
patient's home regimen consisting of a lidocaine patch,
tizanidine and lyrica. Additionally, he was given ramelteon for
sleep with good effect while hospitalized.
CV/Pulm: On POD6, the patient triggered for a fib with rapid
ventricular response (P 130s) with associated tachypnea and
diaphoresis. A chest ___ was consistent with volume overload
for which IV furosemide was administered; po furosemide was
continued daily for the remainder of the hospitalization. Rate
control was initially achieved with IV push metoprolol and po
diltiazem, which were continued with adequate rate control
remainder of the hospitalization and upon discharge. Pt was
started on lovenox with bridge to warfarin.
GI/GU/FEN: The patient was initially kept NPO with a dobhoff for
tube feedings. However, following transfer to the floor, the
dobhoff was removed and the patient tolerating a regular diet
without difficulty. Patient's intake and output were closely
monitored. Bowel regimen consisted of Miralax, Colace, senna
and an herbal remedy brought from home; last BM POD 10. Of note,
he developed ATN post-operatively in the PACU, which resolved
....
HEME: The patient was followed by Heme/Onc given his history of
myelofibrosis and ruxolitinib withdrawal in the ICU.
Recommendations for ongoing management included continuation of
the current 5 mg bid dose with daily monitoring of his blood
counts; WBC 27.7 on day of discharge.
Prophylaxis: The patient received prophylactic SC enoxaparin
given ongoing atrial fibrillation; there were no s/s of bleeding
while receiving this medication. Patient was then started on
lovenox and bridged to warfarin.
Rehab: The patient was evaluated by physical therapy who felt
the patient was functioning below baseline and would benefit
from acute rehab following his hospitalization; please see ___
evaluation for full recommendations.
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:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. OXcarbazepine 150 mg PO BID
3. Pregabalin 150 mg PO TID
4. ___ (morphine) 30 mg oral BID
5. HYDROmorphone (Dilaudid) 4 mg PO TID:PRN BREAKTHROUGH PAIN
6. Furosemide 40 mg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Atenolol 50 mg PO DAILY
10. Lisinopril 5 mg PO DAILY
11. Jakafi (ruxolitinib) 5 mg oral BID
12. Tizanidine 4 mg PO Q8H:PRN muscle spasms
13. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Lactulose 15 mL PO BID
Use when constipated
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
4. Warfarin 7.5 mg PO DAILY16
adjust dose per INR monitoring
RX *warfarin [Coumadin] 7.5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Allopurinol ___ mg PO DAILY
6. Atenolol 50 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Furosemide 40 mg PO DAILY
9. Jakafi (ruxolitinib) 5 mg oral BID
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Multivitamins 1 TAB PO DAILY
12. OXcarbazepine 150 mg PO BID
13. Pregabalin 150 mg PO TID
RX *pregabalin [Lyrica] 150 mg 1 capsule(s) by mouth three times
a day Disp #*30 Capsule Refills:*0
14. Tizanidine 4 mg PO Q8H:PRN muscle spasms
RX *tizanidine 4 mg 1 tablet(s) by mouth Q8 hr Disp #*20 Tablet
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Grade IV left renal laceration
Refractory hemorrhage with retroperitoneal hematoma
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 have undergone removal of your left kidney after sustaining
a laceration following a fall. You have recovered in the
hospital and are now preparing for discharge to a rehabilitation
facility with the following 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. Because of newly dg. AFib you
are now taking warfarin 7.5 mg daily. The dose will be adjusted
to target INR ___.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
[
"S37062A",
"N170",
"T794XXA",
"D7581",
"N179",
"E870",
"D62",
"Z6841",
"E872",
"W1809XA",
"I10",
"E669",
"I878",
"Z781",
"G629",
"K760",
"I722",
"M1990",
"E785",
"E875",
"N141",
"T508X5A",
"Y92239",
"E8770",
"I9589",
"I4891",
"R5081",
"D550"
] |
Allergies: Lamictal Chief Complaint: s/p fall Major Surgical or Invasive Procedure: [MASKED] [MASKED] Left mid kidney selective arterial embolization [MASKED] [MASKED] no active extrav, coil x2 to PsA [MASKED] Exploratory laparotomy, left nephrectomy History of Present Illness: Mr. [MASKED] is a [MASKED] year old man with a past medical history of HTN, HLD, myelofibrosis, G6PD deficiency who was admitted with left renal rupture and retroperitoneal hematoma requiring embolization by [MASKED]. Nephrology has been consulted for [MASKED]. Patient apparently had a fall 5 days before admission, after being hit in the head by the trunk of his car. He did not have LOC, but had mild abdominal pain. On the day of admission, his abdominal pain worsened and he went to OSH, where he was found to be hypotensive (BP 60/40). CTA performed showed showed retroperitoneal hematoma secondary to left renal rupture. He was given 3 units of pRBC and transferred to [MASKED]. In the ED, pt received additional unit of blood (4 total) and 2 units of FFP. Pt went to [MASKED] procedure with coiling of a psueoaneurysm and has remained intubated since. In TSICU, he was noted to have a falling H/H and had repeat embolization on [MASKED]. Today, he was noted to have poor urine output and a rising Cr. He has also been hypotensive and on pressors. On [MASKED] he was started on antobiotics for fever to 102. On [MASKED] he was extubated and being weaned off the pressors. On [MASKED] he was transferred in stable condition to the floor for further recovery. Because of newly dg. AFib the patient was started on lovenox and bridged to warfarin. On the floor he was triggered for HR 130s, which resumed after iv metoprolol. His H/H was followed on daily basis. After return of his bowel function and tolerating diet, with good pain control and stable H/H he was cleared to go to Rehab facility for further care. Past Medical History: HTN, HLD, Myelofibrosis Social History: [MASKED] Family History: NC Physical Exam: O: P/E: VS: BP 113 / 75, HR 81, RR 16, [MASKED] 92 on RA, temp 98.1 GEN: AOx3 WN, WD in NAD HEENT: NCAT, EOMI, anicteric CV: RRR PULM: unlabored breathing with symmetric chest rise, no respiratory distress ABD: soft, NT, ND, no mass, no hernia EXT: WWP, no CCE, no tenderness, 2+ B/L [MASKED] [ ] foley [MASKED] [X] surgical drain JP drain, serosanguinous output, 410cc during last day Pertinent Results: IMAGING: [MASKED] [MASKED] EMBO ARTERIAL IMPRESSION: Uncomplicated coil embolization of the left mid kidney pseudoaneurysm. TRAUMA #3 (PORT CHEST ONLY) IMPRESSION: Low lung volumes without evidence of focal consolidation or pleural effusion. [MASKED]: PORTABLE ABDOMEN IMPRESSION: No abnormal bowel dilation to suggest ileus or obstruction Labs at discharge: [MASKED] 05:45AM BLOOD WBC-22.4* RBC-3.73* Hgb-10.1* Hct-34.2* MCV-92 MCH-27.1 MCHC-29.5* RDW-21.6* RDWSD-71.5* Plt [MASKED] [MASKED] 05:45AM BLOOD Plt [MASKED] [MASKED] 05:45AM BLOOD [MASKED] PTT-31.6 [MASKED] [MASKED] 05:45AM BLOOD Glucose-110* UreaN-30* Creat-1.5* Na-145 K-4.2 Cl-103 HCO3-33* AnGap-9* [MASKED] 05:45AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.1 Brief Hospital Course: ICU course per Dr. [MASKED]: [MASKED] s/p fall p/w L renal laceration. He is s/p [MASKED] where they coiled L renal PsA. Despite coiling, the patient was still febrile and had a dropping HCT. [MASKED] did a takeback on [MASKED] and saw no active extrav. They placed 2 coils. However, this still did not control the bleeding so Mr. [MASKED] underwent a [MASKED], left nephrectomy on [MASKED]. Following these procedures, his main issue became tachycardia and Afib w/ RVR. He was diagnosed with ruxolitinib withdrawal. Heme was consulted and they restarted this home med and steroids. He responded well and was transitoned to PO dilt. Mr. [MASKED] was transferred out of the unit on [MASKED] with a JP drain from the nephrectomy. The DHT was *** prior to transfer and he was tolerating PO feeds. Following transfer to the surgical ward, the [MASKED] hospital course is as follows: Neuro: The patient was alert and oriented throughout hospitalization; pain was managed with oxycodone and the patient's home regimen consisting of a lidocaine patch, tizanidine and lyrica. Additionally, he was given ramelteon for sleep with good effect while hospitalized. CV/Pulm: On POD6, the patient triggered for a fib with rapid ventricular response (P 130s) with associated tachypnea and diaphoresis. A chest [MASKED] was consistent with volume overload for which IV furosemide was administered; po furosemide was continued daily for the remainder of the hospitalization. Rate control was initially achieved with IV push metoprolol and po diltiazem, which were continued with adequate rate control remainder of the hospitalization and upon discharge. Pt was started on lovenox with bridge to warfarin. GI/GU/FEN: The patient was initially kept NPO with a dobhoff for tube feedings. However, following transfer to the floor, the dobhoff was removed and the patient tolerating a regular diet without difficulty. Patient's intake and output were closely monitored. Bowel regimen consisted of Miralax, Colace, senna and an herbal remedy brought from home; last BM POD 10. Of note, he developed ATN post-operatively in the PACU, which resolved .... HEME: The patient was followed by Heme/Onc given his history of myelofibrosis and ruxolitinib withdrawal in the ICU. Recommendations for ongoing management included continuation of the current 5 mg bid dose with daily monitoring of his blood counts; WBC 27.7 on day of discharge. Prophylaxis: The patient received prophylactic SC enoxaparin given ongoing atrial fibrillation; there were no s/s of bleeding while receiving this medication. Patient was then started on lovenox and bridged to warfarin. Rehab: The patient was evaluated by physical therapy who felt the patient was functioning below baseline and would benefit from acute rehab following his hospitalization; please see [MASKED] evaluation for full recommendations. 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: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Allopurinol [MASKED] mg PO DAILY 2. OXcarbazepine 150 mg PO BID 3. Pregabalin 150 mg PO TID 4. [MASKED] (morphine) 30 mg oral BID 5. HYDROmorphone (Dilaudid) 4 mg PO TID:PRN BREAKTHROUGH PAIN 6. Furosemide 40 mg PO DAILY 7. Lidocaine 5% Patch 1 PTCH TD QAM 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY 9. Atenolol 50 mg PO DAILY 10. Lisinopril 5 mg PO DAILY 11. Jakafi (ruxolitinib) 5 mg oral BID 12. Tizanidine 4 mg PO Q8H:PRN muscle spasms 13. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Lactulose 15 mL PO BID Use when constipated 3. Senna 8.6 mg PO BID:PRN Constipation - First Line 4. Warfarin 7.5 mg PO DAILY16 adjust dose per INR monitoring RX *warfarin [Coumadin] 7.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Allopurinol [MASKED] mg PO DAILY 6. Atenolol 50 mg PO DAILY 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY 8. Furosemide 40 mg PO DAILY 9. Jakafi (ruxolitinib) 5 mg oral BID 10. Lidocaine 5% Patch 1 PTCH TD QAM 11. Multivitamins 1 TAB PO DAILY 12. OXcarbazepine 150 mg PO BID 13. Pregabalin 150 mg PO TID RX *pregabalin [Lyrica] 150 mg 1 capsule(s) by mouth three times a day Disp #*30 Capsule Refills:*0 14. Tizanidine 4 mg PO Q8H:PRN muscle spasms RX *tizanidine 4 mg 1 tablet(s) by mouth Q8 hr Disp #*20 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Grade IV left renal laceration Refractory hemorrhage with retroperitoneal hematoma 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 have undergone removal of your left kidney after sustaining a laceration following a fall. You have recovered in the hospital and are now preparing for discharge to a rehabilitation facility with the following 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. Because of newly dg. AFib you are now taking warfarin 7.5 mg daily. The dose will be adjusted to target INR [MASKED]. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips [MASKED] days after surgery. Followup Instructions: [MASKED]
|
[] |
[
"N179",
"D62",
"E872",
"I10",
"E669",
"E785",
"I4891"
] |
[
"S37062A: Major laceration of left kidney, initial encounter",
"N170: Acute kidney failure with tubular necrosis",
"T794XXA: Traumatic shock, initial encounter",
"D7581: Myelofibrosis",
"N179: Acute kidney failure, unspecified",
"E870: Hyperosmolality and hypernatremia",
"D62: Acute posthemorrhagic anemia",
"Z6841: Body mass index [BMI]40.0-44.9, adult",
"E872: Acidosis",
"W1809XA: Striking against other object with subsequent fall, initial encounter",
"I10: Essential (primary) hypertension",
"E669: Obesity, unspecified",
"I878: Other specified disorders of veins",
"Z781: Physical restraint status",
"G629: Polyneuropathy, unspecified",
"K760: Fatty (change of) liver, not elsewhere classified",
"I722: Aneurysm of renal artery",
"M1990: Unspecified osteoarthritis, unspecified site",
"E785: Hyperlipidemia, unspecified",
"E875: Hyperkalemia",
"N141: Nephropathy induced by other drugs, medicaments and biological substances",
"T508X5A: Adverse effect of diagnostic agents, initial encounter",
"Y92239: Unspecified place in hospital as the place of occurrence of the external cause",
"E8770: Fluid overload, unspecified",
"I9589: Other hypotension",
"I4891: Unspecified atrial fibrillation",
"R5081: Fever presenting with conditions classified elsewhere",
"D550: Anemia due to glucose-6-phosphate dehydrogenase [G6PD] deficiency"
] |
10,023,708
| 21,451,830
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Darvon / aspirin / Advil
Attending: ___
Chief Complaint:
word finding difficulties
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ year-old F w/ hx of HTN, HLD, ___, ovarian CA
s/p
chemo and multiple surgical procedures who presents with
language
difficulties. Hx obtained from pt at bedside and daughter over
phone. Of note, pt is inconsistent historian.
Pt was in USOH until on ___ while working in ___ she
noticed difficulty finding her words in conversation. She
further
elaborated as maintaining a conversation with others but
stopping
occasionally due to difficulty finding the right words to say.
Upon going home later that evening she was called by her
co-workers who said she didn't seem like herself. The next day,
pt went to see her sister who has ___, with her language
subjectively intact. The following day, she was playing bridge
with some friends at the beauty shop when she began to have
similar language difficulties, although again reports she was
still able participate in conversation. She states she is not
sure if sx persisted into next day as she was alone and did not
interact with anyone. On morning of presentation, she again
noticed these sx. Feeling that they were slightly worse, she
called her PCP's office who recommended she come to ED for
evaluation.
Collateral from daughter indicates that she spoke to pt over
phone multiple times on ___ evening, multiple times during
the day on ___, and this morning. She feels that pt had word
finding issues as noted above but were more severe, with pt
stopping after every few words and unable to complete sentences.
She noticed that pt was frustrated with her language output. She
also was concerned that on a few occasions pt's speech was
slurred.
No associated facial weakness, visual changes, or other focal
deficits. Of note, around the time of onset she also began to
have gait difficulties. Pt denies recent chest pain, dyspnea,
cough, abdominal pain, n/v, diarrhea, dysuria, or polyuria. No
clear triggers or atypical events last week prior to onset of
her
sx. No recent difficulties with sleep or acute stressors. At
baseline she lives and ambulates independently. However, she did
have fall 6 weeks resulting in L distal radius fx. No recent
neck/back pain, parasthesias in extremities, or bowel/bladder
dysfunction. No similar sx in past.
Neuro and General ROS negative except as noted above
Past Medical History:
PMH: HTN, ___ diagnosed ___, anxiety/depression (recent).
Denies h/o thromboembolic disorder.
PSH: D&C ___ secondary to irregular bleeding,
cholecystectomy via laparotomy ___, right ankle ORIF ___.
OB: G2P2, NVD x2
GYN: Menarche age ___, menopause mid-______. H/O fibroids.
Denies h/o previous ovarian cysts, STI or abnormal pap.
Social History:
___
Family History:
Paternal cousin died of breast cancer age ___. Maternal cousin
ALS. Multiple family members have HTN, ___ and CAD. Denies
family history of ovarian cancer, endometrial cancer and colon
cancer.
Physical Exam:
Admission:
Physical Exam:
Vitals: T: 98.2 P: 77 BP: 215/70 RR: 17 O2sat: 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. L wrist splint in place.
Skin: no rashes or lesions noted.
-Mental Status: Alert, oriented x 3. Inconsistent historian.
Attentive, able to name ___ backward without difficulty.
Language
is fluent with intact repetition and comprehension. Normal
prosody. There were no paraphasic errors. Pt was able to name
both high and low frequency objects. Speech was not dysarthric.
Able to follow both midline and appendicular commands. Pt was
able to register 3 objects and recall ___ at 5 minutes. There
was
no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 2 to 1mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: Subtle decreased Marionette line on L.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No orbiting.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 5 5 * ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
*limited due to splint
-Sensory: No deficits to light touch, pinprick or cold
sensation.
Inconsistent responses to vibratory sense and proprioception at
level of great toe. Intact at medial malleoli b/l. No extinction
to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was WD bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or TTF bilaterally.
-Gait: Significantly slowed initiation requiring 1 person
assistance to stand up from bed. Wide base w/ small stride.
Unable to complete Romberg due to significant sway with feet
together.
=======================
Discharge:
Vitals: T 98.4 BP ___ HR 62 RR 16 O2 95%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple. No nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: WWP
Abdomen: soft, NT/ND
Extremities: WWP, no obvious deformities
Skin: no rashes or lesions noted.
-Mental Status: Alert, oriented x 3. Language
is fluent with intact repetition and comprehension. Normal
prosody. Pt was able to name both high
and low frequency objects. following commands
-Cranial Nerves:
II, III, IV, VI: PERRL 2->1 and brisk. EOMI without
nystagmus.
V: Facial sensation intact to light touch.
VII: facial droop improved, unable to detect on today's exam
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No orbiting.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 4 ___ ___ 4 5 5 5 5 5 5
-Sensory: No deficits to light touch.
-DTRs: deferred
-___: finger to nose without dysmetria
-Gait: deferred
Pertinent Results:
___ 02:31PM BLOOD WBC-8.8 RBC-5.42* Hgb-14.6 Hct-45.5*
MCV-84 MCH-26.9 MCHC-32.1 RDW-13.2 RDWSD-40.1 Plt ___
___ 06:00AM BLOOD WBC-11.4* RBC-5.25* Hgb-14.9 Hct-44.5
MCV-85 MCH-28.4 MCHC-33.5 RDW-13.4 RDWSD-41.1 Plt ___
___ 05:49AM BLOOD WBC-10.2* RBC-5.10 Hgb-14.3 Hct-43.6
MCV-86 MCH-28.0 MCHC-32.8 RDW-13.0 RDWSD-39.8 Plt ___
___:05AM BLOOD WBC-10.5* RBC-5.01 Hgb-13.6 Hct-42.7
MCV-85 MCH-27.1 MCHC-31.9* RDW-12.9 RDWSD-39.8 Plt ___
___ 02:31PM BLOOD ___ PTT-28.4 ___
___ 06:30AM BLOOD ___ PTT-26.2 ___
___ 05:05AM BLOOD ___ PTT-29.0 ___
___ 02:31PM BLOOD Glucose-144* UreaN-12 Creat-0.8 Na-140
K-4.3 Cl-101 HCO3-25 AnGap-14
___ 09:30AM BLOOD Glucose-191* UreaN-14 Creat-0.9 Na-140
K-4.0 Cl-100 HCO3-23 AnGap-17
___ 07:14AM BLOOD Glucose-140* UreaN-18 Creat-0.9 Na-140
K-4.5 Cl-101 HCO3-26 AnGap-13
___ 05:05AM BLOOD Glucose-142* UreaN-15 Creat-0.8 Na-142
K-4.4 Cl-102 HCO3-29 AnGap-11
___ 02:31PM BLOOD ALT-11 AST-22 CK(CPK)-53 AlkPhos-120*
TotBili-0.6
___ 09:30AM BLOOD ALT-9 AST-14 LD(LDH)-190 AlkPhos-116*
TotBili-0.7
___ 04:38AM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:30AM BLOOD CK-MB-2 cTropnT-<0.01
___ 02:31PM BLOOD Albumin-4.1 Calcium-10.1 Phos-3.5 Mg-1.7
___ 09:30AM BLOOD Albumin-3.8 Calcium-9.9 Phos-3.4 Mg-1.7
___ 05:49AM BLOOD Calcium-9.4 Phos-3.4 Mg-1.8
___ 05:05AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.9
___ 04:38AM BLOOD VitB12-___
___ 04:38AM BLOOD %HbA1c-7.7* eAG-174*
___ 04:38AM BLOOD Triglyc-142 HDL-48 CHOL/HD-4.1
LDLcalc-123
___ 04:38AM BLOOD TSH-0.40
___ 02:31PM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
___ 09:30AM BLOOD Lactate-1.6
___ 09:30AM BLOOD freeCa-1.16
Imaging:
CTA ___
CT HEAD WITHOUT CONTRAST:
There is no evidence of infarction,hemorrhage,edema,ormass. The
ventricles
and sulci are prominent, consistent global cerebral volume loss.
Patchy
periventricular hypodensities are most consistent with chronic
microvascular
ischemic disease.
There is complete opacification of the right sphenoid sinus with
aerosolized
secretions seen superiorly. There is severe narrowing of the
right sphenoid
ethmoidal recess. There is mild mucosal thickening of the left
sphenoid and
the bilateral ethmoid sinuses. The mastoid air cells are clear.
The patient
is status post bilateral cataract surgery.
CTA HEAD:
Atherosclerotic changes of the intracranial internal carotid
arteries are
seen without significant narrowing. There is narrowing and
irregularity,
likely atherosclerotic, along the basilar artery. Otherwise, the
vessels of the circle of ___ and their principal intracranial
branches appear normal without stenosis, occlusion, or aneurysm
formation. There is fetal origin of the right posterior
cerebral artery and fetal type origin of the left posterior
cerebral artery. A dominant right vertebral artery is seen.
The dural venous sinuses are patent.
CTA NECK:
A 2 vessel arch is seen. Atherosclerotic changes of the carotid
bifurcations are seen without narrowing of the internal carotid
arteries, by NASCET criteria. The vertebral arteries and their
major branches appear normal with no evidence of stenosis or
occlusion.
OTHER:
The visualized portion of the lungs are clear. A multinodular
goiter is seen. There is no lymphadenopathy by CT size criteria.
Mild cervical spondylosis is seen.
IMPRESSION:
1. Severe right sphenoid sinus disease.
2. Otherwise, no acute intracranial abnormality.
3. Intracranial atherosclerotic disease, most prominent
involving the basilar
artery.
4. No other significant narrowing of the circle of ___
arteries.
5. No internal carotid artery stenosis, by NASCET criteria.
6. Multinodular goiter.
CTA ___
IMPRESSION:
1. No acute intracranial hemorrhage or new large territory
infarct.
2. Noncalcified atherosclerosis irregularity of the basilar
artery and
atherosclerotic disease of cavernous segments of the bilateral
ICA, unchanged
from prior.
3. No other significant narrowing of the circle ___ arteries.
4. Multinodular goiter.
MRI ___
IMPRESSION:
1. Examination is mildly degraded by motion.
2. Evolving left this pallidus subacute infarct without definite
evidence of
hemorrhagic transformation, as described.
3. No evidence of new acute infarction.
4. Moderate cerebral atrophy and chronic small vessel ischemic
disease.
5. Paranasal sinus disease as described above.
TTE ___:
CONCLUSION: The left atrium is normal in size. There is no
evidence for an atrial septal defect by 2D/color Doppler. The
estimated right atrial pressure is ___ mmHg. There is normal
left ventricular wall thickness with a normal cavity size. There
is suboptimal image quality to assess regional left ventricular
function. The visually estimated left ventricular ejection
fraction is 70%. Left ventricular cardiac index is normal (>2.5
L/min/m2). There is no resting left ventricular outflow tract
gradient. No ventricular septal defect is seen. Tissue Doppler
suggests an increased left ventricular filling pressure (PCWP
greater than 18mmHg). 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. There is
no evidence for an aortic arch coarctation. The aortic valve
leaflets (?#) are mildly thickened. There is no aortic valve
stenosis. There is trace aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral valve prolapse. The
transmitral E-wave deceleration time is prolonged (>250ms).
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 a trivial pericardial effusion.
IMPRESSION: Suboptimal image quality. No intracardiac source of
thromboembolism identified. Preserved global biventricular
systolic function. Mild mitral regurgitation. Normal pulmonary
pressure.
Brief Hospital Course:
Patient is a ___ year old female with a history of hypertension,
hyperlipidemia, Type 2 Diabetes Mellitus, ovarian cancer s/p
chemo and surgical interventions, who presents with word finding
difficulties and recent falls.
#Subacute left globus pallidus infarct: Initial Non-contrast
headache CT was negative for acute hemorrhage, and alteplase was
not administered due to extended duration of symptoms and
thrombectomy was not done d/t no large vessel occlusion. MRI
head w/ contrast revealed a possible subacute infarct in left
basal ganglia. Exam was notable for very subtle apraxia,
neglect, and migrographia which the patient said was new. She
had mild hesitancy in her speech but no aphasia. Clinically, the
patient appeared to be improving, however had two episodes on
___, in which the patient experienced nausea and bradycardia
(heart rate in ___, and was briefly unresponsive for a few
seconds. The first of these episodes began while the patient was
walking with ___, with bradycardia and unresponsiveness occurring
after the patient lay down. She regained conscious within a few
seconds. The second episode occurred while the patient was
sitting in bed and included a 5.5 second pause on telemetry with
loss of consciousness, left eye deviation, left head turning and
bilateral upper extremity shaking. She regained consciousness in
~30 seconds and was noted to have new right facial droop, right
upper extremity weakness, and fluent aphasia with word salad.
NIHSS at this time was 10. Imaging at that time, including
non-contrast head CT and CTA were unremarkable, and following
CT, NIHSS improved to 5. Alteplase was not administered due
fluctuating exam and rapid improvement. Exam continued to
improve with only mild aphasia. EEG was done that showed mild
left sided slowing but no discharges or electrographic seizures.
Likely episode of eye deviation, head deviation, and upper
extremity shaking iso bradycarida and sinus pause was convulsive
syncope. MRI head without contrast later revealed stable
subacute infarct in the left globus pallidus without any new
areas of infarct or hemorrhage. Stroke risk factors include TSH
0.4, fasting lipid panel LDL 123, and HBA1c 7.7. She was started
on aspirin 81mg and her simvastatin was changed to atorvastatin
40mg. Likely etiology of stokes is small vessel/lacunar.
#Cognitive Decline: Felt that likely some of her symptoms were
due to overlying dementia that may have been worsening as
patient lives alone and per family recently stopped taking her
medications. B12 and RPR were checked and were normal. Unclear
how well she has been functioning at home prior to this as she
lives alone. She also has had repeated falls at home which she
is unable to describe or explain.
#HTN: Her hypertensive medications were held other than HCTZ to
allow blood pressure to auto-regulate. She was noted to be
intermittently hypertensive and her home medications were
re-started. There were held again after syncope described above.
Prior to discharge she was restarted on amlodipine but losartan
and HCTZ were held.
#Syncope: During hospitalization, as described above, she had
had a series of episodes of bradycardia. During the first
episode, she became unresponsive and was noted to be bradycardic
to as low as the ___ on telemetry with a 3 second pause,
followed by subsequent hypertension and tachycardia up to the
110 bpm range. About 10 minutes later, she had a similar
episode. Finally, after she had been stabilized in bed, a third
episode of bradycardia occurred with a documented 5.5 second
pause and associated period of unresponsiveness. After she
recovered, she had worsened aphasia, as well as weakness and
facial droop, as described above. Telemetry was considered to be
consistent with vagal etiology, without nodal block. She has no
prior history of arrhythmias or conduction disease.
Transthoracic echocardiogram was obtained, which revealed normal
Biventricular systolic function, no cardiac source of embolus.
EP Cardiology was consulted and felt that these episodes were
consistent with vasovagal and did not warrant any further
investigation or intervention. We discussed worry that this
episode may have caused some increased hypoperfusion and
re-infarction iso new facial droop, weakness, and aphasia after
syncope. EP felt that since likely vasovagual there was no
indication for pacemaker as this would not prevent the
vasodilation associated with vasovagual and would not prevent
hypoperfusion. They felt that if highly symptomatic episodes
continue even with vagal triggers minimized. In the future all
nodal blockade should be avoided. She has been scheduled for
cardiology follow up. She was discharged with ___ of hearts
monitor.
#Diabetes: Glucose was monitored throughout stay and insulin
administered on sliding scale. HbgA1C 7.7. Per daughter she has
not been taking her medications for at least a the past week or
so. She was restarted on home metformin at discharge. She has an
endocrinology appointment scheduled for this month.
====================
Transitional Issues
[] Patient has neurology appointment scheduled in ___ with
Dr. ___. She can be referred to cognitive neurology at that
time if she has decline in cognition
[] Patient should have Holter monitor to assess for continued
vagal syncope. Has cardiology outpatient follow up
[] Please avoid all nodal blockade in the future
[] Holding losartan and HCTZ due to lightheadedness on standing,
PCP to check BP in outpatient setting and manage medications
==========================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack 1. Dysphagia screening before any PO intake? (x) Yes,
confirmed done - () Not confirmed () No. If no, reason why: 2.
DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.) 3. Antithrombotic therapy
administered by end of hospital day 2? (x) Yes - () No. If not,
why not? (I.e. bleeding risk, hemorrhage, etc.) 4. LDL
documented? (x) Yes (LDL =123 ) - () No 5. Intensive statin
therapy administered? (simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL > 70) () Yes - () No [if LDL >70, reason
not given: [ ] Statin medication allergy [ ] Other reasons
documented by physician/advanced practice nurse/physician
___ (physician/APN/PA) or pharmacist [ ] LDL-c less than
70 mg/dL 6. Smoking cessation counseling given? () Yes - (x) No
[reason (x) non-smoker - () unable to participate] 7. Stroke
education (personal modifiable risk factors, how to activate EMS
for stroke, stroke warning signs and symptoms, prescribed
medications, need for followup) given (verbally or written)? (x)
Yes - () No 8. Assessment for rehabilitation or rehab services
considered? (x) Yes - () No. If no, why not? (I.e. patient at
baseline functional status) 9. Discharged on statin therapy? (x)
Yes - () No [if LDL >70, reason not given: [ ] Statin medication
allergy [ ] Other reasons documented by physician/advanced
practice nurse/physician ___ (physician/APN/PA) or
pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on
antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - ()
Anticoagulation] - () No 11. Discharged on oral anticoagulation
for patients with atrial fibrillation/flutter? () Yes - () No -
If no, why not (I.e. bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 10 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Losartan Potassium 50 mg PO DAILY
4. Hydrocortisone Cream 1% 1 Appl TP BID
5. MetFORMIN (Glucophage) 500 mg PO DAILY
6. MetFORMIN (Glucophage) 250 mg PO QPM
7. Simvastatin 20 mg PO QPM
8. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. amLODIPine 10 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. MetFORMIN (Glucophage) 250 mg PO QPM
6. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
==================
Ischemic Stroke
Vasovagal syncope
Secondary Diagnosis
=================
Hypertension
Hyperlipidemia
Type 2 Diabetes Mellitus
Osteoporosis
Stage IIB Grade 3 ovarian CA s/p ex-lap, TAH/BSO, pelvic tumor
resection, omentectomy, and chemo in ___
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of language difficulties.
We think this is due to an ischemic stroke. While you were
admitted in the hospital, you had an episode of impaired
consciousness and were found to have low heart rate, which led
to new symptoms of difficulty talking. These episodes are
consistent with ISCHEMIC STROKE, a condition where the brain
does not receive enough oxygen and nutrients. The brain is the
part of your body that controls and directs all the other parts
of your body, so damage to the brain from being deprived of its
blood supply can result in a variety of symptoms.
In addition, there was concern that these episodes of low heart
rate/fainting were related to an abnormality in your heart, so
the cardiology and electrophysiology teams were consulted. They
felt these episodes were more likely due to an episode of
increased vagal tone, and we felt dehydration contributed so we
gave you fluids after which your symptoms improved.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Hypertension
- Hyperlipidemia
- Diabetes
We are changing your medications as follows:
- Please stop taking losartan and HCTZ, you can continue taking
amlodipine until you see your primary care doctor
- We started Aspirin 81 mg daily
- We started Atorvastatin 40 mg daily
Please take your other medications as prescribed.
Please follow up with Neurology, Cardiology and your primary
care physician as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
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Allergies: Codeine / Darvon / aspirin / Advil Chief Complaint: word finding difficulties Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a [MASKED] year-old F w/ hx of HTN, HLD, [MASKED], ovarian CA s/p chemo and multiple surgical procedures who presents with language difficulties. Hx obtained from pt at bedside and daughter over phone. Of note, pt is inconsistent historian. Pt was in USOH until on [MASKED] while working in [MASKED] she noticed difficulty finding her words in conversation. She further elaborated as maintaining a conversation with others but stopping occasionally due to difficulty finding the right words to say. Upon going home later that evening she was called by her co-workers who said she didn't seem like herself. The next day, pt went to see her sister who has [MASKED], with her language subjectively intact. The following day, she was playing bridge with some friends at the beauty shop when she began to have similar language difficulties, although again reports she was still able participate in conversation. She states she is not sure if sx persisted into next day as she was alone and did not interact with anyone. On morning of presentation, she again noticed these sx. Feeling that they were slightly worse, she called her PCP's office who recommended she come to ED for evaluation. Collateral from daughter indicates that she spoke to pt over phone multiple times on [MASKED] evening, multiple times during the day on [MASKED], and this morning. She feels that pt had word finding issues as noted above but were more severe, with pt stopping after every few words and unable to complete sentences. She noticed that pt was frustrated with her language output. She also was concerned that on a few occasions pt's speech was slurred. No associated facial weakness, visual changes, or other focal deficits. Of note, around the time of onset she also began to have gait difficulties. Pt denies recent chest pain, dyspnea, cough, abdominal pain, n/v, diarrhea, dysuria, or polyuria. No clear triggers or atypical events last week prior to onset of her sx. No recent difficulties with sleep or acute stressors. At baseline she lives and ambulates independently. However, she did have fall 6 weeks resulting in L distal radius fx. No recent neck/back pain, parasthesias in extremities, or bowel/bladder dysfunction. No similar sx in past. Neuro and General ROS negative except as noted above Past Medical History: PMH: HTN, [MASKED] diagnosed [MASKED], anxiety/depression (recent). Denies h/o thromboembolic disorder. PSH: D&C [MASKED] secondary to irregular bleeding, cholecystectomy via laparotomy [MASKED], right ankle ORIF [MASKED]. OB: G2P2, NVD x2 GYN: Menarche age [MASKED], menopause mid-[MASKED]. H/O fibroids. Denies h/o previous ovarian cysts, STI or abnormal pap. Social History: [MASKED] Family History: Paternal cousin died of breast cancer age [MASKED]. Maternal cousin ALS. Multiple family members have HTN, [MASKED] and CAD. Denies family history of ovarian cancer, endometrial cancer and colon cancer. Physical Exam: Admission: Physical Exam: Vitals: T: 98.2 P: 77 BP: 215/70 RR: 17 O2sat: 98% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. L wrist splint in place. Skin: no rashes or lesions noted. -Mental Status: Alert, oriented x 3. Inconsistent historian. Attentive, able to name [MASKED] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall [MASKED] at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 2 to 1mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: Subtle decreased Marionette line on L. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No orbiting. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [MASKED] L 5 5 5 * [MASKED] 5 5 5 5 5 5 5 R 5 [MASKED] [MASKED] 5 5 5 5 5 5 5 *limited due to splint -Sensory: No deficits to light touch, pinprick or cold sensation. Inconsistent responses to vibratory sense and proprioception at level of great toe. Intact at medial malleoli b/l. No extinction to DSS. -DTRs: Bi Tri [MASKED] Pat Ach L 2 2 2 1 0 R 2 2 2 1 0 Plantar response was WD bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or TTF bilaterally. -Gait: Significantly slowed initiation requiring 1 person assistance to stand up from bed. Wide base w/ small stride. Unable to complete Romberg due to significant sway with feet together. ======================= Discharge: Vitals: T 98.4 BP [MASKED] HR 62 RR 16 O2 95%RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple. No nuchal rigidity Pulmonary: breathing comfortably on room air Cardiac: WWP Abdomen: soft, NT/ND Extremities: WWP, no obvious deformities Skin: no rashes or lesions noted. -Mental Status: Alert, oriented x 3. Language is fluent with intact repetition and comprehension. Normal prosody. Pt was able to name both high and low frequency objects. following commands -Cranial Nerves: II, III, IV, VI: PERRL 2->1 and brisk. EOMI without nystagmus. V: Facial sensation intact to light touch. VII: facial droop improved, unable to detect on today's exam VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No orbiting. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [MASKED] L 5 [MASKED] [MASKED] 5 5 5 5 5 5 5 R 4 [MASKED] [MASKED] 4 5 5 5 5 5 5 -Sensory: No deficits to light touch. -DTRs: deferred -[MASKED]: finger to nose without dysmetria -Gait: deferred Pertinent Results: [MASKED] 02:31PM BLOOD WBC-8.8 RBC-5.42* Hgb-14.6 Hct-45.5* MCV-84 MCH-26.9 MCHC-32.1 RDW-13.2 RDWSD-40.1 Plt [MASKED] [MASKED] 06:00AM BLOOD WBC-11.4* RBC-5.25* Hgb-14.9 Hct-44.5 MCV-85 MCH-28.4 MCHC-33.5 RDW-13.4 RDWSD-41.1 Plt [MASKED] [MASKED] 05:49AM BLOOD WBC-10.2* RBC-5.10 Hgb-14.3 Hct-43.6 MCV-86 MCH-28.0 MCHC-32.8 RDW-13.0 RDWSD-39.8 Plt [MASKED] [MASKED]:05AM BLOOD WBC-10.5* RBC-5.01 Hgb-13.6 Hct-42.7 MCV-85 MCH-27.1 MCHC-31.9* RDW-12.9 RDWSD-39.8 Plt [MASKED] [MASKED] 02:31PM BLOOD [MASKED] PTT-28.4 [MASKED] [MASKED] 06:30AM BLOOD [MASKED] PTT-26.2 [MASKED] [MASKED] 05:05AM BLOOD [MASKED] PTT-29.0 [MASKED] [MASKED] 02:31PM BLOOD Glucose-144* UreaN-12 Creat-0.8 Na-140 K-4.3 Cl-101 HCO3-25 AnGap-14 [MASKED] 09:30AM BLOOD Glucose-191* UreaN-14 Creat-0.9 Na-140 K-4.0 Cl-100 HCO3-23 AnGap-17 [MASKED] 07:14AM BLOOD Glucose-140* UreaN-18 Creat-0.9 Na-140 K-4.5 Cl-101 HCO3-26 AnGap-13 [MASKED] 05:05AM BLOOD Glucose-142* UreaN-15 Creat-0.8 Na-142 K-4.4 Cl-102 HCO3-29 AnGap-11 [MASKED] 02:31PM BLOOD ALT-11 AST-22 CK(CPK)-53 AlkPhos-120* TotBili-0.6 [MASKED] 09:30AM BLOOD ALT-9 AST-14 LD(LDH)-190 AlkPhos-116* TotBili-0.7 [MASKED] 04:38AM BLOOD CK-MB-2 cTropnT-<0.01 [MASKED] 09:30AM BLOOD CK-MB-2 cTropnT-<0.01 [MASKED] 02:31PM BLOOD Albumin-4.1 Calcium-10.1 Phos-3.5 Mg-1.7 [MASKED] 09:30AM BLOOD Albumin-3.8 Calcium-9.9 Phos-3.4 Mg-1.7 [MASKED] 05:49AM BLOOD Calcium-9.4 Phos-3.4 Mg-1.8 [MASKED] 05:05AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.9 [MASKED] 04:38AM BLOOD VitB12-[MASKED] [MASKED] 04:38AM BLOOD %HbA1c-7.7* eAG-174* [MASKED] 04:38AM BLOOD Triglyc-142 HDL-48 CHOL/HD-4.1 LDLcalc-123 [MASKED] 04:38AM BLOOD TSH-0.40 [MASKED] 02:31PM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 09:30AM BLOOD Lactate-1.6 [MASKED] 09:30AM BLOOD freeCa-1.16 Imaging: CTA [MASKED] CT HEAD WITHOUT CONTRAST: There is no evidence of infarction,hemorrhage,edema,ormass. The ventricles and sulci are prominent, consistent global cerebral volume loss. Patchy periventricular hypodensities are most consistent with chronic microvascular ischemic disease. There is complete opacification of the right sphenoid sinus with aerosolized secretions seen superiorly. There is severe narrowing of the right sphenoid ethmoidal recess. There is mild mucosal thickening of the left sphenoid and the bilateral ethmoid sinuses. The mastoid air cells are clear. The patient is status post bilateral cataract surgery. CTA HEAD: Atherosclerotic changes of the intracranial internal carotid arteries are seen without significant narrowing. There is narrowing and irregularity, likely atherosclerotic, along the basilar artery. Otherwise, the vessels of the circle of [MASKED] and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. There is fetal origin of the right posterior cerebral artery and fetal type origin of the left posterior cerebral artery. A dominant right vertebral artery is seen. The dural venous sinuses are patent. CTA NECK: A 2 vessel arch is seen. Atherosclerotic changes of the carotid bifurcations are seen without narrowing of the internal carotid arteries, by NASCET criteria. The vertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion. OTHER: The visualized portion of the lungs are clear. A multinodular goiter is seen. There is no lymphadenopathy by CT size criteria. Mild cervical spondylosis is seen. IMPRESSION: 1. Severe right sphenoid sinus disease. 2. Otherwise, no acute intracranial abnormality. 3. Intracranial atherosclerotic disease, most prominent involving the basilar artery. 4. No other significant narrowing of the circle of [MASKED] arteries. 5. No internal carotid artery stenosis, by NASCET criteria. 6. Multinodular goiter. CTA [MASKED] IMPRESSION: 1. No acute intracranial hemorrhage or new large territory infarct. 2. Noncalcified atherosclerosis irregularity of the basilar artery and atherosclerotic disease of cavernous segments of the bilateral ICA, unchanged from prior. 3. No other significant narrowing of the circle [MASKED] arteries. 4. Multinodular goiter. MRI [MASKED] IMPRESSION: 1. Examination is mildly degraded by motion. 2. Evolving left this pallidus subacute infarct without definite evidence of hemorrhagic transformation, as described. 3. No evidence of new acute infarction. 4. Moderate cerebral atrophy and chronic small vessel ischemic disease. 5. Paranasal sinus disease as described above. TTE [MASKED]: CONCLUSION: The left atrium is normal in size. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is [MASKED] mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is suboptimal image quality to assess regional left ventricular function. The visually estimated left ventricular ejection fraction is 70%. Left ventricular cardiac index is normal (>2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). 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. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (?#) are mildly thickened. There is no aortic valve stenosis. There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. The transmitral E-wave deceleration time is prolonged (>250ms). 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 a trivial pericardial effusion. IMPRESSION: Suboptimal image quality. No intracardiac source of thromboembolism identified. Preserved global biventricular systolic function. Mild mitral regurgitation. Normal pulmonary pressure. Brief Hospital Course: Patient is a [MASKED] year old female with a history of hypertension, hyperlipidemia, Type 2 Diabetes Mellitus, ovarian cancer s/p chemo and surgical interventions, who presents with word finding difficulties and recent falls. #Subacute left globus pallidus infarct: Initial Non-contrast headache CT was negative for acute hemorrhage, and alteplase was not administered due to extended duration of symptoms and thrombectomy was not done d/t no large vessel occlusion. MRI head w/ contrast revealed a possible subacute infarct in left basal ganglia. Exam was notable for very subtle apraxia, neglect, and migrographia which the patient said was new. She had mild hesitancy in her speech but no aphasia. Clinically, the patient appeared to be improving, however had two episodes on [MASKED], in which the patient experienced nausea and bradycardia (heart rate in [MASKED], and was briefly unresponsive for a few seconds. The first of these episodes began while the patient was walking with [MASKED], with bradycardia and unresponsiveness occurring after the patient lay down. She regained conscious within a few seconds. The second episode occurred while the patient was sitting in bed and included a 5.5 second pause on telemetry with loss of consciousness, left eye deviation, left head turning and bilateral upper extremity shaking. She regained consciousness in ~30 seconds and was noted to have new right facial droop, right upper extremity weakness, and fluent aphasia with word salad. NIHSS at this time was 10. Imaging at that time, including non-contrast head CT and CTA were unremarkable, and following CT, NIHSS improved to 5. Alteplase was not administered due fluctuating exam and rapid improvement. Exam continued to improve with only mild aphasia. EEG was done that showed mild left sided slowing but no discharges or electrographic seizures. Likely episode of eye deviation, head deviation, and upper extremity shaking iso bradycarida and sinus pause was convulsive syncope. MRI head without contrast later revealed stable subacute infarct in the left globus pallidus without any new areas of infarct or hemorrhage. Stroke risk factors include TSH 0.4, fasting lipid panel LDL 123, and HBA1c 7.7. She was started on aspirin 81mg and her simvastatin was changed to atorvastatin 40mg. Likely etiology of stokes is small vessel/lacunar. #Cognitive Decline: Felt that likely some of her symptoms were due to overlying dementia that may have been worsening as patient lives alone and per family recently stopped taking her medications. B12 and RPR were checked and were normal. Unclear how well she has been functioning at home prior to this as she lives alone. She also has had repeated falls at home which she is unable to describe or explain. #HTN: Her hypertensive medications were held other than HCTZ to allow blood pressure to auto-regulate. She was noted to be intermittently hypertensive and her home medications were re-started. There were held again after syncope described above. Prior to discharge she was restarted on amlodipine but losartan and HCTZ were held. #Syncope: During hospitalization, as described above, she had had a series of episodes of bradycardia. During the first episode, she became unresponsive and was noted to be bradycardic to as low as the [MASKED] on telemetry with a 3 second pause, followed by subsequent hypertension and tachycardia up to the 110 bpm range. About 10 minutes later, she had a similar episode. Finally, after she had been stabilized in bed, a third episode of bradycardia occurred with a documented 5.5 second pause and associated period of unresponsiveness. After she recovered, she had worsened aphasia, as well as weakness and facial droop, as described above. Telemetry was considered to be consistent with vagal etiology, without nodal block. She has no prior history of arrhythmias or conduction disease. Transthoracic echocardiogram was obtained, which revealed normal Biventricular systolic function, no cardiac source of embolus. EP Cardiology was consulted and felt that these episodes were consistent with vasovagal and did not warrant any further investigation or intervention. We discussed worry that this episode may have caused some increased hypoperfusion and re-infarction iso new facial droop, weakness, and aphasia after syncope. EP felt that since likely vasovagual there was no indication for pacemaker as this would not prevent the vasodilation associated with vasovagual and would not prevent hypoperfusion. They felt that if highly symptomatic episodes continue even with vagal triggers minimized. In the future all nodal blockade should be avoided. She has been scheduled for cardiology follow up. She was discharged with [MASKED] of hearts monitor. #Diabetes: Glucose was monitored throughout stay and insulin administered on sliding scale. HbgA1C 7.7. Per daughter she has not been taking her medications for at least a the past week or so. She was restarted on home metformin at discharge. She has an endocrinology appointment scheduled for this month. ==================== Transitional Issues [] Patient has neurology appointment scheduled in [MASKED] with Dr. [MASKED]. She can be referred to cognitive neurology at that time if she has decline in cognition [] Patient should have Holter monitor to assess for continued vagal syncope. Has cardiology outpatient follow up [] Please avoid all nodal blockade in the future [] Holding losartan and HCTZ due to lightheadedness on standing, PCP to check BP in outpatient setting and manage medications ========================== AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No. If no, reason why: 2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not (I.e. bleeding risk, hemorrhage, etc.) 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No. If not, why not? (I.e. bleeding risk, hemorrhage, etc.) 4. LDL documented? (x) Yes (LDL =123 ) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician [MASKED] (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician [MASKED] (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - If no, why not (I.e. bleeding risk, etc.) (x) N/A Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. amLODIPine 10 mg PO DAILY 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. Losartan Potassium 50 mg PO DAILY 4. Hydrocortisone Cream 1% 1 Appl TP BID 5. MetFORMIN (Glucophage) 500 mg PO DAILY 6. MetFORMIN (Glucophage) 250 mg PO QPM 7. Simvastatin 20 mg PO QPM 8. Vitamin D [MASKED] UNIT PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. amLODIPine 10 mg PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO DAILY 5. MetFORMIN (Glucophage) 250 mg PO QPM 6. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis ================== Ischemic Stroke Vasovagal syncope Secondary Diagnosis ================= Hypertension Hyperlipidemia Type 2 Diabetes Mellitus Osteoporosis Stage IIB Grade 3 ovarian CA s/p ex-lap, TAH/BSO, pelvic tumor resection, omentectomy, and chemo in [MASKED] Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You were hospitalized due to symptoms of language difficulties. We think this is due to an ischemic stroke. While you were admitted in the hospital, you had an episode of impaired consciousness and were found to have low heart rate, which led to new symptoms of difficulty talking. These episodes are consistent with ISCHEMIC STROKE, a condition where the brain does not receive enough oxygen and nutrients. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. In addition, there was concern that these episodes of low heart rate/fainting were related to an abnormality in your heart, so the cardiology and electrophysiology teams were consulted. They felt these episodes were more likely due to an episode of increased vagal tone, and we felt dehydration contributed so we gave you fluids after which your symptoms improved. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: - Hypertension - Hyperlipidemia - Diabetes We are changing your medications as follows: - Please stop taking losartan and HCTZ, you can continue taking amlodipine until you see your primary care doctor - We started Aspirin 81 mg daily - We started Atorvastatin 40 mg daily Please take your other medications as prescribed. Please follow up with Neurology, Cardiology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your [MASKED] Neurology Team Followup Instructions: [MASKED]
|
[] |
[
"I10",
"E119",
"E785"
] |
[
"I638: Other cerebral infarction",
"I10: Essential (primary) hypertension",
"E119: Type 2 diabetes mellitus without complications",
"E785: Hyperlipidemia, unspecified",
"M810: Age-related osteoporosis without current pathological fracture",
"R55: Syncope and collapse",
"Z8543: Personal history of malignant neoplasm of ovary",
"R001: Bradycardia, unspecified",
"R29710: NIHSS score 10"
] |
10,023,948
| 24,863,234
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___
Chief Complaint:
right hip dislocation s/p failed closed reduction on ___
Major Surgical or Invasive Procedure:
right THR explant, antibiotic spacer placement ___, ___
History of Present Illness:
___ year old female with right THA (___) s/p multiple
dislocations +revisions, s/p failed closed reduction on ___, now
s/p right THA explant, abx spacer on ___.
Past Medical History:
HTN, depression, bilateral total hip arthroplasty, status post
multiple revisions since ___ on right hip
Social History:
___
Family History:
Non-contributory
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Aquacel dressing with mild old drainage distal aspect
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 05:25AM BLOOD WBC-6.6 RBC-3.41* Hgb-10.1* Hct-30.2*
MCV-89 MCH-29.6 MCHC-33.4 RDW-14.5 RDWSD-46.9* Plt ___
___ 05:32AM BLOOD WBC-6.5 RBC-3.32* Hgb-9.8* Hct-29.1*
MCV-88 MCH-29.5 MCHC-33.7 RDW-14.9 RDWSD-48.3* Plt ___
___ 06:44AM BLOOD WBC-6.1 RBC-3.37* Hgb-10.2* Hct-30.4*
MCV-90 MCH-30.3 MCHC-33.6 RDW-15.4 RDWSD-51.4* Plt ___
___ 07:20PM BLOOD Hgb-9.7* Hct-28.7*
___ 07:15AM BLOOD Hgb-8.3* Hct-24.6*
___ 06:10AM BLOOD WBC-6.1 RBC-2.91* Hgb-9.0* Hct-26.9*
MCV-92 MCH-30.9 MCHC-33.5 RDW-14.8 RDWSD-50.0* Plt ___
___ 08:25PM BLOOD WBC-13.8* RBC-3.71* Hgb-11.4 Hct-33.7*
MCV-91 MCH-30.7 MCHC-33.8 RDW-14.6 RDWSD-48.5* Plt ___
___ 06:10PM BLOOD WBC-9.6 RBC-4.03 Hgb-12.5 Hct-36.5 MCV-91
MCH-31.0 MCHC-34.2 RDW-14.9 RDWSD-49.5* Plt ___
___ 08:25PM BLOOD Neuts-88.2* Lymphs-6.8* Monos-3.7*
Eos-0.2* Baso-0.4 Im ___ AbsNeut-12.16* AbsLymp-0.94*
AbsMono-0.51 AbsEos-0.03* AbsBaso-0.06
___ 06:10PM BLOOD Neuts-73.4* Lymphs-17.0* Monos-7.9
Eos-0.7* Baso-0.5 Im ___ AbsNeut-7.01* AbsLymp-1.63
AbsMono-0.76 AbsEos-0.07 AbsBaso-0.05
___ 08:25PM BLOOD ___ PTT-28.6 ___
___ 06:10PM BLOOD ___ PTT-30.5 ___
___ 05:32AM BLOOD Creat-0.4
___ 06:44AM BLOOD Creat-0.5
___ 06:10AM BLOOD Glucose-92 UreaN-9 Creat-0.4 Na-137 K-4.2
Cl-101 HCO3-24 AnGap-12
___ 06:10PM BLOOD Glucose-91 UreaN-15 Creat-0.5 Na-134*
K-4.3 Cl-98 HCO3-19* AnGap-17
___ 05:32AM BLOOD Mg-2.1
___ 06:44AM BLOOD Mg-1.9
___ 07:15AM BLOOD Mg-1.7
___ 06:10AM BLOOD Calcium-7.8* Phos-3.7 Mg-1.5*
___ 09:07AM BLOOD CRP-87.5*
___ 05:32AM BLOOD Vanco-10.6
___ 05:45PM BLOOD ___ pO2-78* pCO2-45 pH-7.30*
calTCO2-23 Base XS--3
___ 05:45PM BLOOD Glucose-74 Lactate-1.1 Na-136 K-3.4*
Cl-107
___ 05:45PM BLOOD Hgb-10.3* calcHCT-31 O2 Sat-91
___ 06:25PM URINE Color-Straw Appear-Clear Sp ___
___ 06:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 11:00AM JOINT FLUID TNC-827* ___ Polys-57*
___ Macro-11
___ 11:00AM JOINT FLUID TNC-9056* HCT,Fl-20.0* Polys-99*
___ ___ 11:00AM JOINT FLUID Crystal-NONE
Brief Hospital Course:
The patient was admitted to the orthopedic surgery service after
being admitted through the ED. A closed reduction was attempted
in the OR the following day and was unsuccessful. She was
eventually taken to the operating room for above described
procedure. Please see separately dictated operative report for
details. The surgery was uncomplicated and the patient tolerated
the procedure well. Patient received perioperative IV
antibiotics.
Postoperative course was remarkable for the following:
POD #0, the patient lost one-liter and received 3.3 liters of
fluid and 2 units of blood intra-operatively.
POD #1, Infectious Disease was consulted for antibiotic
management. OR cultures showed no growth to date. ID recommended
continuing Ancef and obtaining a right knee x-ray due to a past
knee replacement. Patient was started on daily Vitamin D
supplement to prevent vitamin D defieciency. Magnesium of 1.5
was repleted. Foley was discontinued and the patient was able
to void independently. Patient was orthostatic with physical
therapy and was given 500ml fluid bolus.
POD #2, hematocrit was 24.6 and patient was transfused 2 units
pRBCS. Post-transfusion hct was 28.7. Right knee x-ray results
unable to rule out hardware loosening. Due to ongoing knee
swelling and warmth, a right knee aspiration under ___ was
obtained. OR cultures showed coag negative staph. ID recommended
continuing IV Ancef and starting IV Vanco 1g every 12 hours.
POD #3, hct was 30.4. Joint aspiration results showed WBC 827,
RBC > 152k, polys 57, no crystals. ID recommended
discontinuation of IV Ancef and continuing Vancomycin.
Tizanidine was added for c/o muscle spasms. Urinalysis was
obtained for c/o urinary urgency/frequency, which results were
negative. Urine cultures showed ** PICC line was placed.
POD #4, vancomycin trough was low at 10.6 and dose was increased
to 1250mg every 12 hours. Joint aspiration cultures showed NGTD.
Final OPAT recommended to continue Vancomycin 1250mg every 12
hours.
POD #5, knee aspiration cultures continued to show no growth to
date. Final urine cultures were negative.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient received Lovenox daily for DVT
prophylaxis . The surgical dressing will remain on until POD#7
after surgery. The patient was seen daily by physical therapy.
Labs were checked throughout the hospital course and repleted
accordingly. At the time of discharge the patient was tolerating
a regular diet and feeling well. The patient was afebrile with
stable vital signs. The patient's hematocrit was acceptable and
pain was adequately controlled on an oral regimen. The operative
extremity was neurovascularly intact and the dressing was
intact.
The patient's weight-bearing status is TOUCH DOWN weight bearing
on the operative extremity. No hip precautions. Walker or two
crutches at all times.
Ms. ___ is discharged to rehab in stable condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. etodolac 400 mg oral BID
2. FLUoxetine 20 mg PO DAILY
3. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate
4. lisinopril-hydrochlorothiazide ___ mg oral DAILY
5. Gabapentin 600 mg PO TID
6. Gabapentin 300 mg PO QHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QPM
4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
5. Senna 17.2 mg PO BID
6. Vancomycin 1250 mg IV Q 12H
Start Date: ___
Projected End Date: ___
7. Vitamin D 1000 UNIT PO DAILY
8. FLUoxetine 20 mg PO DAILY
9. Gabapentin 600 mg PO TID
10. Gabapentin 300 mg PO QHS
11. lisinopril-hydrochlorothiazide ___ mg oral DAILY
12. HELD- etodolac 400 mg oral BID This medication was held. Do
not restart etodolac until you've been cleared by your surgeon
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right hip dislocation s/p failed closed reduction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow an
extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
8. ANTICOAGULATION: Please continue your Lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots). If you
were taking Aspirin prior to your surgery, you should hold this
medication while on the one-month course of anticoagulation
medication.
9. WOUND CARE: Please remove Aquacel dressing on POD#7 after
surgery. It is okay to shower after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
after aqaucel is removed each day if there is drainage,
otherwise leave it open to air. Check wound regularly for signs
of infection such as redness or thick yellow drainage.
10. ___ (once at home): Home ___, dressing changes as
instructed, and wound checks.
11. ACTIVITY: TOUCH DOWN weight bearing with walker or 2
crutches. No hip precautions. Wean assistive device as able.
No strenuous exercise or heavy lifting until follow up
appointment. Mobilize frequently.
12. ___ CARE: Per protocol
13. WEEKLY LABS: draw on ___ and send result to ___
clinic at ___:
- CBC/DIFF
- CHEM 7
- LFTS
- ESR/CRP
- Vancomycin trough
**All questions regarding outpatient parenteral antibiotics
should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.**
Physical Therapy:
TDWB RLE
No hip precautions
Assistive device at all times
Mobilize frequently
Treatments Frequency:
remove aquacel POD#7 after surgery
apply dry sterile dressing daily if needed after aquacel
dressing is removed
wound checks daily after aquacel removed
Followup Instructions:
___
|
[
"T84020A",
"D62",
"T8451XA",
"Y792",
"E8342",
"Z96642",
"Z96651",
"M25561"
] |
Allergies: Penicillins Chief Complaint: right hip dislocation s/p failed closed reduction on [MASKED] Major Surgical or Invasive Procedure: right THR explant, antibiotic spacer placement [MASKED], [MASKED] History of Present Illness: [MASKED] year old female with right THA ([MASKED]) s/p multiple dislocations +revisions, s/p failed closed reduction on [MASKED], now s/p right THA explant, abx spacer on [MASKED]. Past Medical History: HTN, depression, bilateral total hip arthroplasty, status post multiple revisions since [MASKED] on right hip 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 mild old drainage distal aspect * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: [MASKED] 05:25AM BLOOD WBC-6.6 RBC-3.41* Hgb-10.1* Hct-30.2* MCV-89 MCH-29.6 MCHC-33.4 RDW-14.5 RDWSD-46.9* Plt [MASKED] [MASKED] 05:32AM BLOOD WBC-6.5 RBC-3.32* Hgb-9.8* Hct-29.1* MCV-88 MCH-29.5 MCHC-33.7 RDW-14.9 RDWSD-48.3* Plt [MASKED] [MASKED] 06:44AM BLOOD WBC-6.1 RBC-3.37* Hgb-10.2* Hct-30.4* MCV-90 MCH-30.3 MCHC-33.6 RDW-15.4 RDWSD-51.4* Plt [MASKED] [MASKED] 07:20PM BLOOD Hgb-9.7* Hct-28.7* [MASKED] 07:15AM BLOOD Hgb-8.3* Hct-24.6* [MASKED] 06:10AM BLOOD WBC-6.1 RBC-2.91* Hgb-9.0* Hct-26.9* MCV-92 MCH-30.9 MCHC-33.5 RDW-14.8 RDWSD-50.0* Plt [MASKED] [MASKED] 08:25PM BLOOD WBC-13.8* RBC-3.71* Hgb-11.4 Hct-33.7* MCV-91 MCH-30.7 MCHC-33.8 RDW-14.6 RDWSD-48.5* Plt [MASKED] [MASKED] 06:10PM BLOOD WBC-9.6 RBC-4.03 Hgb-12.5 Hct-36.5 MCV-91 MCH-31.0 MCHC-34.2 RDW-14.9 RDWSD-49.5* Plt [MASKED] [MASKED] 08:25PM BLOOD Neuts-88.2* Lymphs-6.8* Monos-3.7* Eos-0.2* Baso-0.4 Im [MASKED] AbsNeut-12.16* AbsLymp-0.94* AbsMono-0.51 AbsEos-0.03* AbsBaso-0.06 [MASKED] 06:10PM BLOOD Neuts-73.4* Lymphs-17.0* Monos-7.9 Eos-0.7* Baso-0.5 Im [MASKED] AbsNeut-7.01* AbsLymp-1.63 AbsMono-0.76 AbsEos-0.07 AbsBaso-0.05 [MASKED] 08:25PM BLOOD [MASKED] PTT-28.6 [MASKED] [MASKED] 06:10PM BLOOD [MASKED] PTT-30.5 [MASKED] [MASKED] 05:32AM BLOOD Creat-0.4 [MASKED] 06:44AM BLOOD Creat-0.5 [MASKED] 06:10AM BLOOD Glucose-92 UreaN-9 Creat-0.4 Na-137 K-4.2 Cl-101 HCO3-24 AnGap-12 [MASKED] 06:10PM BLOOD Glucose-91 UreaN-15 Creat-0.5 Na-134* K-4.3 Cl-98 HCO3-19* AnGap-17 [MASKED] 05:32AM BLOOD Mg-2.1 [MASKED] 06:44AM BLOOD Mg-1.9 [MASKED] 07:15AM BLOOD Mg-1.7 [MASKED] 06:10AM BLOOD Calcium-7.8* Phos-3.7 Mg-1.5* [MASKED] 09:07AM BLOOD CRP-87.5* [MASKED] 05:32AM BLOOD Vanco-10.6 [MASKED] 05:45PM BLOOD [MASKED] pO2-78* pCO2-45 pH-7.30* calTCO2-23 Base XS--3 [MASKED] 05:45PM BLOOD Glucose-74 Lactate-1.1 Na-136 K-3.4* Cl-107 [MASKED] 05:45PM BLOOD Hgb-10.3* calcHCT-31 O2 Sat-91 [MASKED] 06:25PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 06:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [MASKED] 11:00AM JOINT FLUID TNC-827* [MASKED] Polys-57* [MASKED] Macro-11 [MASKED] 11:00AM JOINT FLUID TNC-9056* HCT,Fl-20.0* Polys-99* [MASKED] [MASKED] 11:00AM JOINT FLUID Crystal-NONE Brief Hospital Course: The patient was admitted to the orthopedic surgery service after being admitted through the ED. A closed reduction was attempted in the OR the following day and was unsuccessful. She was eventually taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: POD #0, the patient lost one-liter and received 3.3 liters of fluid and 2 units of blood intra-operatively. POD #1, Infectious Disease was consulted for antibiotic management. OR cultures showed no growth to date. ID recommended continuing Ancef and obtaining a right knee x-ray due to a past knee replacement. Patient was started on daily Vitamin D supplement to prevent vitamin D defieciency. Magnesium of 1.5 was repleted. Foley was discontinued and the patient was able to void independently. Patient was orthostatic with physical therapy and was given 500ml fluid bolus. POD #2, hematocrit was 24.6 and patient was transfused 2 units pRBCS. Post-transfusion hct was 28.7. Right knee x-ray results unable to rule out hardware loosening. Due to ongoing knee swelling and warmth, a right knee aspiration under [MASKED] was obtained. OR cultures showed coag negative staph. ID recommended continuing IV Ancef and starting IV Vanco 1g every 12 hours. POD #3, hct was 30.4. Joint aspiration results showed WBC 827, RBC > 152k, polys 57, no crystals. ID recommended discontinuation of IV Ancef and continuing Vancomycin. Tizanidine was added for c/o muscle spasms. Urinalysis was obtained for c/o urinary urgency/frequency, which results were negative. Urine cultures showed ** PICC line was placed. POD #4, vancomycin trough was low at 10.6 and dose was increased to 1250mg every 12 hours. Joint aspiration cultures showed NGTD. Final OPAT recommended to continue Vancomycin 1250mg every 12 hours. POD #5, knee aspiration cultures continued to show no growth to date. Final urine cultures were negative. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Lovenox daily for DVT prophylaxis . The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is TOUCH DOWN weight bearing on the operative extremity. No hip precautions. Walker or two crutches at all times. Ms. [MASKED] is discharged to rehab in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. etodolac 400 mg oral BID 2. FLUoxetine 20 mg PO DAILY 3. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 4. lisinopril-hydrochlorothiazide [MASKED] mg oral DAILY 5. Gabapentin 600 mg PO TID 6. Gabapentin 300 mg PO QHS Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC QPM 4. HYDROmorphone (Dilaudid) [MASKED] mg PO Q3H:PRN Pain - Moderate 5. Senna 17.2 mg PO BID 6. Vancomycin 1250 mg IV Q 12H Start Date: [MASKED] Projected End Date: [MASKED] 7. Vitamin D 1000 UNIT PO DAILY 8. FLUoxetine 20 mg PO DAILY 9. Gabapentin 600 mg PO TID 10. Gabapentin 300 mg PO QHS 11. lisinopril-hydrochlorothiazide [MASKED] mg oral DAILY 12. HELD- etodolac 400 mg oral BID This medication was held. Do not restart etodolac until you've been cleared by your surgeon Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: right hip dislocation s/p failed closed reduction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking Aspirin prior to your surgery, you should hold this medication while on the one-month course of anticoagulation medication. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, and wound checks. 11. ACTIVITY: TOUCH DOWN weight bearing with walker or 2 crutches. No hip precautions. Wean assistive device as able. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. 12. [MASKED] CARE: Per protocol 13. WEEKLY LABS: draw on [MASKED] and send result to [MASKED] clinic at [MASKED]: - CBC/DIFF - CHEM 7 - LFTS - ESR/CRP - Vancomycin trough **All questions regarding outpatient parenteral antibiotics should be directed to the [MASKED] R.N.s at [MASKED] or to the on-call ID fellow when the clinic is closed.** Physical Therapy: TDWB RLE No hip precautions Assistive device at all times Mobilize frequently Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed Followup Instructions: [MASKED]
|
[] |
[
"D62"
] |
[
"T84020A: Dislocation of internal right hip prosthesis, initial encounter",
"D62: Acute posthemorrhagic anemia",
"T8451XA: Infection and inflammatory reaction due to internal right hip prosthesis, initial encounter",
"Y792: Prosthetic and other implants, materials and accessory orthopedic devices associated with adverse incidents",
"E8342: Hypomagnesemia",
"Z96642: Presence of left artificial hip joint",
"Z96651: Presence of right artificial knee joint",
"M25561: Pain in right knee"
] |
10,023,994
| 21,824,032
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Aneurysm
Major Surgical or Invasive Procedure:
Pipeline embolization of Left ICA aneurysm
History of Present Illness:
She is a ___ nurse that works in the ___ in the dialysis
unit. She started noticing some tingling sensation on the right
side of the face that did not disappear, and work up obtained an
MRI/MRA; the report came back positive for aneurysm. +FH for
aneurysm. She presents today for Pipeline embolization of Left
ICA aneurysm.
Past Medical History:
Anxiety
depression
Social History:
___
Family History:
her father is diagnosed with a 3 to 4 mm aneurysm that he has
actually been followed by Dr. ___ here at ___, she had also
two second-degree relatives with brain aneurysms.
Physical Exam:
on discharge:
___ x 3. NAD. PERRLA, 3-2mm.
CN II-XII intact.
LS clear
RRR
abdomen soft, NTND.
___ BUE and BLE. No drift.
Groin site, clean, dry, intact without hematoma.
Pertinent Results:
Please see OMR for relevant imaging reports
Brief Hospital Course:
Pipeline embolization of her Left ICA aneurysm
On ___ she was admitted to the neurosurgical service and
under general anesthesia had a successful Pipeline embolization
of her Left ICA aneurysm. Her operative
course was uncomplicated. For further procedure details, please
see separately dictated operative report by Dr. ___. She was
extubated, groin angiosealed and transferred to be recovered in
the PACU and then transferred to the ___ when stable. On POD
#1 she remained stable. She ambulated well independently and
was discharged home.
Medications on Admission:
NuvaRing
lorazepam 0.5 ___ daily as needed
sertraline 25 mg daily
brilinta 90 bid
aspirin 81
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
no greater than 4 grams of Tylenol in 24 hours
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 (One) tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*1
3. Docusate Sodium 100 mg PO BID
hold for loose stool. Stop once done taking oxycodone
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain
decrease use as pain improves. ___ request less than
prescribed.
RX *oxycodone 5 mg 1 (One) tablet(s) by mouth every six (6)
hours Disp #*20 Tablet Refills:*0
5. Senna 17.2 mg PO QHS
hold for loose stools. Stop once done taking oxycodone
6. TiCAGRELOR 90 mg PO BID
RX *ticagrelor [Brilinta] 90 mg 1 (One) tablet(s) by mouth twice
a day Disp #*60 Tablet Refills:*1
7. Sertraline 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Activity
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 may be instructed by your doctor to take one ___ a day
and/or Plavix. If so, 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",
"F329",
"F419",
"Z8489"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Aneurysm Major Surgical or Invasive Procedure: Pipeline embolization of Left ICA aneurysm History of Present Illness: She is a [MASKED] nurse that works in the [MASKED] in the dialysis unit. She started noticing some tingling sensation on the right side of the face that did not disappear, and work up obtained an MRI/MRA; the report came back positive for aneurysm. +FH for aneurysm. She presents today for Pipeline embolization of Left ICA aneurysm. Past Medical History: Anxiety depression Social History: [MASKED] Family History: her father is diagnosed with a 3 to 4 mm aneurysm that he has actually been followed by Dr. [MASKED] here at [MASKED], she had also two second-degree relatives with brain aneurysms. Physical Exam: on discharge: [MASKED] x 3. NAD. PERRLA, 3-2mm. CN II-XII intact. LS clear RRR abdomen soft, NTND. [MASKED] BUE and BLE. No drift. Groin site, clean, dry, intact without hematoma. Pertinent Results: Please see OMR for relevant imaging reports Brief Hospital Course: Pipeline embolization of her Left ICA aneurysm On [MASKED] she was admitted to the neurosurgical service and under general anesthesia had a successful Pipeline embolization of her Left ICA aneurysm. Her operative course was uncomplicated. For further procedure details, please see separately dictated operative report by Dr. [MASKED]. She was extubated, groin angiosealed and transferred to be recovered in the PACU and then transferred to the [MASKED] when stable. On POD #1 she remained stable. She ambulated well independently and was discharged home. Medications on Admission: NuvaRing lorazepam 0.5 [MASKED] daily as needed sertraline 25 mg daily brilinta 90 bid aspirin 81 Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain no greater than 4 grams of Tylenol in 24 hours 2. Aspirin 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 (One) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 3. Docusate Sodium 100 mg PO BID hold for loose stool. Stop once done taking oxycodone 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain decrease use as pain improves. [MASKED] request less than prescribed. RX *oxycodone 5 mg 1 (One) tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills:*0 5. Senna 17.2 mg PO QHS hold for loose stools. Stop once done taking oxycodone 6. TiCAGRELOR 90 mg PO BID RX *ticagrelor [Brilinta] 90 mg 1 (One) tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 7. Sertraline 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Activity 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 may be instructed by your doctor to take one [MASKED] a day and/or Plavix. If so, 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]
|
[] |
[
"F329",
"F419"
] |
[
"I671: Cerebral aneurysm, nonruptured",
"F329: Major depressive disorder, single episode, unspecified",
"F419: Anxiety disorder, unspecified",
"Z8489: Family history of other specified conditions"
] |
10,024,012
| 23,111,013
|
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / ACE Inhibitors
Attending: ___.
Chief Complaint:
This is a ___ year old woman with atrial fibrillation on coumadin
and metoprolol, AS s/p AVR with bioprosthetic valve on
___, ascending aortic aneurysm, HTN, HLD, who presents as
transfer for R femur neck fracture.
She was with her husband at the ___ when she fell. She reports
she was accompanying him to an appointment when she tripped over
some carpeting. She did not hit her head, ___ LOC. She had NCHCT
which revealed on bleed and plain films which revealed R femur
neck fracture.
She was seen by orthopedics in the ED who will surgically repair
in AM. She is admitted to medicine for new O2 requirement.
In the ED, initial vitals: T 97.4 HR65 BP174/84 RR18 92% RA
- Exam notable for: ___ systolic murmur heard best at ULSB, ___
equal lengths, ___ strength in feet and ankles, able to
internall
and externally rotate at hip bilaterally"
- Labs notable for:
INR: 1.7
WBC 12.4
- Imaging notable for:
CTA chest:
1. ___ evidence of pulmonary embolism or aortic abnormality.
2. Mild interstitial edema.
3. Multiple subpleural rule opacities throughout the lungs with
the largest measures 1.3 x 1.0 cm in the right upper lobe, which
may be
infectious/inflammatory. Follow-up chest CT in 3 months is
recommended to assess resolution.
4. T8 deformity of indeterminate chronicity, although ___
definite
surrounding hematoma or fracture line identified.
CXR:
IMPRESSION:
1. Large retrocardiac opacity likely represents known large
hiatal hernia.
2. ___ gross signs for pneumonia or edema.
R hip plain films
IMPRESSION:
Right femoral neck fracture better assessed on outside hospital
radiographs performed on same date. ___ additional fracture is
seen.
- Pt given:
___ 18:56 IV Ondansetron 4 mg
___ 21:13 IVF LR 250 mL/hr
- Vitals prior to transfer:
T 74 BP 170/86 RR 18 94% 3L NC
On the floor, she feels quite well. She is tired. She has ___
pain. She is not dyspneic despite her O2 requirement. She has ___
chest pain or heart palpitations. ROS is otherwise negative.
Major Surgical or Invasive Procedure:
___: Percutaneous pinning of right femoral neck fracture
History of Present Illness:
This is a ___ year old woman with atrial fibrillation on coumadin
and metoprolol, AS s/p AVR with bioprosthetic valve on
___, ascending aortic aneurysm, HTN, HLD, who presents as
transfer for R femur neck fracture.
She was with her husband at the ___ when she fell. She reports
she was accompanying him to an appointment when she tripped over
some carpeting. She did not hit her head, ___ LOC. She had NCHCT
which revealed on bleed and plain films which revealed R femur
neck fracture.
She was seen by orthopedics in the ED who will surgically repair
in AM. She is admitted to medicine for new O2 requirement.
In the ED, initial vitals: T 97.4 HR65 BP174/84 RR18 92% RA
- Exam notable for: ___ systolic murmur heard best at ULSB, ___
equal lengths, ___ strength in feet and ankles, able to
internall
and externally rotate at hip bilaterally"
- Labs notable for:
INR: 1.7
WBC 12.4
- Imaging notable for:
CTA chest:
1. ___ evidence of pulmonary embolism or aortic abnormality.
2. Mild interstitial edema.
3. Multiple subpleural rule opacities throughout the lungs with
the largest measures 1.3 x 1.0 cm in the right upper lobe, which
may be
infectious/inflammatory. Follow-up chest CT in 3 months is
recommended to assess resolution.
4. T8 deformity of indeterminate chronicity, although ___
definite
surrounding hematoma or fracture line identified.
CXR:
IMPRESSION:
1. Large retrocardiac opacity likely represents known large
hiatal hernia.
2. ___ gross signs for pneumonia or edema.
R hip plain films
IMPRESSION:
Right femoral neck fracture better assessed on outside hospital
radiographs performed on same date. ___ additional fracture is
seen.
- Pt given:
___ 18:56 IV Ondansetron 4 mg
___ 21:13 IVF LR 250 mL/hr
- Vitals prior to transfer:
T 74 BP 170/86 RR 18 94% 3L NC
On the floor, she feels quite well. She is tired. She has ___
pain. She is not dyspneic despite her O2 requirement. She has ___
chest pain or heart palpitations. ROS is otherwise negative.
Past Medical History:
1. Aortic stenosis, status post AVR with a bioprosthetic valve
___
2. Ascending aortic aneurysm
3. Hypertension
4. Hypercholesterolemia
5. Iron deficiency anemia: thought to be from blood loss from a
hiatal hernia.
6. s/p bilateral cataracts
7. Hearing loss
8. Osteoporosis
Social History:
___
Family History:
Mother - CHF, HTN, hearing loss
Father - CHF
MGM - colon cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
VITALS: ___ 0128 Temp: 98.2 PO BP: 144/86 L Lying HR: 95
RR: 17 O2 sat: 95% O2 delivery: 2L
General: Pleasant, alert, oriented, ___ acute distress, very hard
of hearing
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, ___ LAD
CV: Irregular, normal S1 + S2, low pitched systolic murmur
across
precordium
Lungs: diminished ___ bases with crackles in mid lung fields
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
___ organomegaly, ___ rebound or guarding
GU: ___ foley
Ext: Warm, well perfused, 2+ pulses, ___ clubbing, cyanosis or
edema. There is ___ bruising or TTP over R hip or knee. Legs are
equal in length. ___ internal or external rotation.
Skin: Warm, dry, ___ rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
DISCHARGE PHYSICAL EXAM:
============================
VS: ___ 0126 Temp: 98.4 Axillary BP: 132/69 L Lying HR: 82
RR: 20 O2 sat: 91% O2 delivery: RA
PHYSICAL EXAM:
General: Pleasant, alert, ___ acute distress, very hard of
hearing, JVP not elevated, ___ LAD
CV: Irregular, normal S1 + S2, low pitched systolic murmur
across
precordium
Lungs: CTAB
Abdomen: Soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, ___ clubbing, cyanosis or edema.
Dressing on R hip looks c/d/I. Mild TTP over R hip. Legs are
equal
in length. ___ internal or external rotation.
Skin: Warm, dry, ___ rashes or notable lesions.
Neuro: AOx1 (to name only).
___ Results:
ADMISSION LABS
=========================
___ 07:45PM ___ PO2-19* PCO2-51* PH-7.35 TOTAL
CO2-29 BASE XS-0
___ 07:45PM LACTATE-2.0
___ 07:45PM O2 SAT-22
___ 07:38PM GLUCOSE-149* UREA N-20 CREAT-0.7 SODIUM-143
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15
___ 07:38PM cTropnT-<0.01
___ 07:38PM WBC-12.4* RBC-4.26 HGB-12.5 HCT-39.9 MCV-94
MCH-29.3 MCHC-31.3* RDW-15.6* RDWSD-53.1*
___:38PM NEUTS-81.0* LYMPHS-10.7* MONOS-7.2 EOS-0.3*
BASOS-0.2 IM ___ AbsNeut-10.01* AbsLymp-1.32 AbsMono-0.89*
AbsEos-0.04 AbsBaso-0.02
___ 07:38PM PLT COUNT-234
___ 05:50PM GLUCOSE-105* UREA N-21* CREAT-0.8 SODIUM-143
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16
___ 05:50PM estGFR-Using this
___ 05:50PM WBC-10.8* RBC-4.23 HGB-12.4 HCT-39.5 MCV-93
MCH-29.3 MCHC-31.4* RDW-15.5 RDWSD-52.8*
___ 05:50PM NEUTS-81.6* LYMPHS-11.4* MONOS-5.5 EOS-0.7*
BASOS-0.1 IM ___ AbsNeut-8.78* AbsLymp-1.23 AbsMono-0.59
AbsEos-0.08 AbsBaso-0.01
___ 05:50PM PLT COUNT-234
___ 05:50PM ___ PTT-30.2 ___
DISCHARGE LABS
===============================
___ 07:10AM BLOOD WBC-7.0 RBC-3.14* Hgb-9.3* Hct-28.9*
MCV-92 MCH-29.6 MCHC-32.2 RDW-15.3 RDWSD-51.8* Plt ___
___ 07:10AM BLOOD Plt ___
___ 07:10AM BLOOD Glucose-119* UreaN-19 Creat-0.8 Na-141
K-4.3 Cl-102 HCO3-26 AnGap-13
___ 07:10AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.8
Brief Hospital Course:
PATIENT SUMMARY:
===========================
Ms. ___ is a ___ year old woman with atrial fibrillation on
Coumadin and metoprolol, aortic stenosis s/p AVR with
bioprosthetic valve on ___, ascending aortic aneurysm,
HTN, HLD, who presents as transfer for R femur neck fracture now
s/p closed reduction and percutaneous pinning course complicated
by hypoactive delirium.
ACTIVE ISSUES:
===========================
#R impacted femur neck fracture - Initially presented status
post fall, found to have right femoral neck fracture on XR. Was
evaluated by orthopedic surgery underwent right hip closed
reduction and percutaneous pinning on ___. She had minimal
pain post-op and received tyelnol for pain control. She was
started on Vit D supplementation at 1000u daily. Please consider
initiating bisphosphonate in ___ weeks as an outpatient. While
she remained sub-therpaeutic on warfarin for atrial
fibrillation, was also started on lovenox 40 SC QD for DVT
prophylxais. At rehab once therapeutic on warfarin can
discontinue lovenox. Dressing to remain intact until follow-up
in 2 weeks with orthopedics unless saturated.
#Hypoxemic respiratory failure
Initially with 2L O2 requirement thought to be secondary to IV
fluids received during early admission. Patient was afebrile, ___
leukocytosis and CXR with ___ signs of pneumonia. Patient was
diuresed with intermittent IV lasix. We were able to wean her
off oxygen prior to discharge. At this point hypoxemia thought
to be primarily related to atelectasis post-op. Was encouraged
to use incentive spirometry.
#Atrial fibrillation
CHADSVASC = 4 (age, sex and HTN)- Maintained on metoprolol
succinate 50 mg daily at home for rate control and warfarin and
warfarin 2mg daily. Was initiallyon heparin prior to surgery,
was re-started on warfarin 2mg daily. INR on discharge was 1.4
so 5mg administered on day of discharge given remains
subtherapeutic. Please discontinue lovenox once warfarin is
therapeutic (goal INR ___.
#Hypoactive delirium
Patient had waxing and weaning mentation. She was also alert and
oriented x1 (to name only). She is also very hard of hearing.
Infectious work-up was sent. CXR with ___ consolidation, UA was
bland and ___ other localizing symptoms. This was felt to be
hospital/post-op hypoactive delirium. Delirium precautions were
put in place.
#Recurrent falls
Pt with listed history of gait disorder listed in chart, has
recurrent falls (including one in ___ which resulted in head
lac requiring staples). She remains on AC for atrial
fibrillation. She reports using a walker. She denies pre-syncope
or LOC during these events. ___ to continue working with patient
and discharge to rehab.
#Urinary retention - Issues with intermittent urinary retention
requiring straight cath x1. Continue to monitor at rehab.
CHRONIC/STABLE ISSUES
=============================
#HTN - Patient was continued on home metoprolol 50XL daily,
however home valsartan was initially held ___ was
not continued on discharge given she remained normotensive off
of this.
#HLD: continued home statin
#AS s/p AVR
#TR, MR
___ specific therapy. Mild to moderate MR and moderate TR.
#TRANSITIONAL ISSUES:
==============================
[ ] NEW/CHANGED MEDICATIONS
- Started vitamin D 1000 U QD
- Started lovenox 40mg SC QD while sub-therapeutic post
operatively
- Held valsartan 320mg PO QD given normotensive off of this
[ ] Received warfarin 2mg QD ___ and 5mg on ___.
Discharge INR 1.4. Continue with daily dosing until INR
therapeutic ___
[ ] Continue lovenox 40mg SC QD until INR therapeutic
[ ] Multiple subpleural rule opacities throughout the lungs with
the largest measures 1.3 x 1.0 cm in the right upper lobe, which
may be infectious/inflammatory. Follow-up chest CT in 3 months
is recommended to assess resolution.
#CONTACT:
Name of health care proxy: Dr ___
Relationship: Son
Phone number: ___
#Code Status: Full, presumed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 40 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Valsartan 320 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Enoxaparin Sodium 40 mg SC DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. ___ MD to order daily dose PO DAILY16
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis
-R hip fracture
Secondary diagnosis
-Hypoxemic respiratory failure
-A fib
-Hypoactive delirium
-Hypertension
-Hyperlipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___.
Why did you come to the hospital?
-You came to the hospital because you fell and broke your right
hip.
What did you receive in the hospital?
-While you were in the hospital, you went to the operating room
to fix the hip fracture with the orthopedic surgeous.
-You also had some trouble breathing requiring oxygen by nasal
cannula. We think this is due to the fact that you are taking
shallow breaths. Please continue using the incentive spirometry
to open up your lungs. We also want you to continue working with
physical therapy while at rehab
What should you do once you leave the hospital?
- Continue to take all of your medications as prescribed
- Follow-up with your scheduled appointments as listed below
We wish you all the best!
Your ___ Care Team
Followup Instructions:
___
|
[
"M80851A",
"J9691",
"J810",
"F05",
"I4891",
"Z7901",
"Z952",
"I714",
"I10",
"E785",
"D509",
"H9190",
"Z9181",
"R339",
"I081",
"Z66"
] |
Allergies: Codeine / ACE Inhibitors Chief Complaint: This is a [MASKED] year old woman with atrial fibrillation on coumadin and metoprolol, AS s/p AVR with bioprosthetic valve on [MASKED], ascending aortic aneurysm, HTN, HLD, who presents as transfer for R femur neck fracture. She was with her husband at the [MASKED] when she fell. She reports she was accompanying him to an appointment when she tripped over some carpeting. She did not hit her head, [MASKED] LOC. She had NCHCT which revealed on bleed and plain films which revealed R femur neck fracture. She was seen by orthopedics in the ED who will surgically repair in AM. She is admitted to medicine for new O2 requirement. In the ED, initial vitals: T 97.4 HR65 BP174/84 RR18 92% RA - Exam notable for: [MASKED] systolic murmur heard best at ULSB, [MASKED] equal lengths, [MASKED] strength in feet and ankles, able to internall and externally rotate at hip bilaterally" - Labs notable for: INR: 1.7 WBC 12.4 - Imaging notable for: CTA chest: 1. [MASKED] evidence of pulmonary embolism or aortic abnormality. 2. Mild interstitial edema. 3. Multiple subpleural rule opacities throughout the lungs with the largest measures 1.3 x 1.0 cm in the right upper lobe, which may be infectious/inflammatory. Follow-up chest CT in 3 months is recommended to assess resolution. 4. T8 deformity of indeterminate chronicity, although [MASKED] definite surrounding hematoma or fracture line identified. CXR: IMPRESSION: 1. Large retrocardiac opacity likely represents known large hiatal hernia. 2. [MASKED] gross signs for pneumonia or edema. R hip plain films IMPRESSION: Right femoral neck fracture better assessed on outside hospital radiographs performed on same date. [MASKED] additional fracture is seen. - Pt given: [MASKED] 18:56 IV Ondansetron 4 mg [MASKED] 21:13 IVF LR 250 mL/hr - Vitals prior to transfer: T 74 BP 170/86 RR 18 94% 3L NC On the floor, she feels quite well. She is tired. She has [MASKED] pain. She is not dyspneic despite her O2 requirement. She has [MASKED] chest pain or heart palpitations. ROS is otherwise negative. Major Surgical or Invasive Procedure: [MASKED]: Percutaneous pinning of right femoral neck fracture History of Present Illness: This is a [MASKED] year old woman with atrial fibrillation on coumadin and metoprolol, AS s/p AVR with bioprosthetic valve on [MASKED], ascending aortic aneurysm, HTN, HLD, who presents as transfer for R femur neck fracture. She was with her husband at the [MASKED] when she fell. She reports she was accompanying him to an appointment when she tripped over some carpeting. She did not hit her head, [MASKED] LOC. She had NCHCT which revealed on bleed and plain films which revealed R femur neck fracture. She was seen by orthopedics in the ED who will surgically repair in AM. She is admitted to medicine for new O2 requirement. In the ED, initial vitals: T 97.4 HR65 BP174/84 RR18 92% RA - Exam notable for: [MASKED] systolic murmur heard best at ULSB, [MASKED] equal lengths, [MASKED] strength in feet and ankles, able to internall and externally rotate at hip bilaterally" - Labs notable for: INR: 1.7 WBC 12.4 - Imaging notable for: CTA chest: 1. [MASKED] evidence of pulmonary embolism or aortic abnormality. 2. Mild interstitial edema. 3. Multiple subpleural rule opacities throughout the lungs with the largest measures 1.3 x 1.0 cm in the right upper lobe, which may be infectious/inflammatory. Follow-up chest CT in 3 months is recommended to assess resolution. 4. T8 deformity of indeterminate chronicity, although [MASKED] definite surrounding hematoma or fracture line identified. CXR: IMPRESSION: 1. Large retrocardiac opacity likely represents known large hiatal hernia. 2. [MASKED] gross signs for pneumonia or edema. R hip plain films IMPRESSION: Right femoral neck fracture better assessed on outside hospital radiographs performed on same date. [MASKED] additional fracture is seen. - Pt given: [MASKED] 18:56 IV Ondansetron 4 mg [MASKED] 21:13 IVF LR 250 mL/hr - Vitals prior to transfer: T 74 BP 170/86 RR 18 94% 3L NC On the floor, she feels quite well. She is tired. She has [MASKED] pain. She is not dyspneic despite her O2 requirement. She has [MASKED] chest pain or heart palpitations. ROS is otherwise negative. Past Medical History: 1. Aortic stenosis, status post AVR with a bioprosthetic valve [MASKED] 2. Ascending aortic aneurysm 3. Hypertension 4. Hypercholesterolemia 5. Iron deficiency anemia: thought to be from blood loss from a hiatal hernia. 6. s/p bilateral cataracts 7. Hearing loss 8. Osteoporosis Social History: [MASKED] Family History: Mother - CHF, HTN, hearing loss Father - CHF MGM - colon cancer Physical Exam: ADMISSION PHYSICAL EXAM: ============================ VITALS: [MASKED] 0128 Temp: 98.2 PO BP: 144/86 L Lying HR: 95 RR: 17 O2 sat: 95% O2 delivery: 2L General: Pleasant, alert, oriented, [MASKED] acute distress, very hard of hearing HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, [MASKED] LAD CV: Irregular, normal S1 + S2, low pitched systolic murmur across precordium Lungs: diminished [MASKED] bases with crackles in mid lung fields Abdomen: Soft, non-tender, non-distended, bowel sounds present, [MASKED] organomegaly, [MASKED] rebound or guarding GU: [MASKED] foley Ext: Warm, well perfused, 2+ pulses, [MASKED] clubbing, cyanosis or edema. There is [MASKED] bruising or TTP over R hip or knee. Legs are equal in length. [MASKED] internal or external rotation. Skin: Warm, dry, [MASKED] rashes or notable lesions. Neuro: CNII-XII intact, [MASKED] strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally. DISCHARGE PHYSICAL EXAM: ============================ VS: [MASKED] 0126 Temp: 98.4 Axillary BP: 132/69 L Lying HR: 82 RR: 20 O2 sat: 91% O2 delivery: RA PHYSICAL EXAM: General: Pleasant, alert, [MASKED] acute distress, very hard of hearing, JVP not elevated, [MASKED] LAD CV: Irregular, normal S1 + S2, low pitched systolic murmur across precordium Lungs: CTAB Abdomen: Soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused, [MASKED] clubbing, cyanosis or edema. Dressing on R hip looks c/d/I. Mild TTP over R hip. Legs are equal in length. [MASKED] internal or external rotation. Skin: Warm, dry, [MASKED] rashes or notable lesions. Neuro: AOx1 (to name only). [MASKED] Results: ADMISSION LABS ========================= [MASKED] 07:45PM [MASKED] PO2-19* PCO2-51* PH-7.35 TOTAL CO2-29 BASE XS-0 [MASKED] 07:45PM LACTATE-2.0 [MASKED] 07:45PM O2 SAT-22 [MASKED] 07:38PM GLUCOSE-149* UREA N-20 CREAT-0.7 SODIUM-143 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15 [MASKED] 07:38PM cTropnT-<0.01 [MASKED] 07:38PM WBC-12.4* RBC-4.26 HGB-12.5 HCT-39.9 MCV-94 MCH-29.3 MCHC-31.3* RDW-15.6* RDWSD-53.1* [MASKED]:38PM NEUTS-81.0* LYMPHS-10.7* MONOS-7.2 EOS-0.3* BASOS-0.2 IM [MASKED] AbsNeut-10.01* AbsLymp-1.32 AbsMono-0.89* AbsEos-0.04 AbsBaso-0.02 [MASKED] 07:38PM PLT COUNT-234 [MASKED] 05:50PM GLUCOSE-105* UREA N-21* CREAT-0.8 SODIUM-143 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16 [MASKED] 05:50PM estGFR-Using this [MASKED] 05:50PM WBC-10.8* RBC-4.23 HGB-12.4 HCT-39.5 MCV-93 MCH-29.3 MCHC-31.4* RDW-15.5 RDWSD-52.8* [MASKED] 05:50PM NEUTS-81.6* LYMPHS-11.4* MONOS-5.5 EOS-0.7* BASOS-0.1 IM [MASKED] AbsNeut-8.78* AbsLymp-1.23 AbsMono-0.59 AbsEos-0.08 AbsBaso-0.01 [MASKED] 05:50PM PLT COUNT-234 [MASKED] 05:50PM [MASKED] PTT-30.2 [MASKED] DISCHARGE LABS =============================== [MASKED] 07:10AM BLOOD WBC-7.0 RBC-3.14* Hgb-9.3* Hct-28.9* MCV-92 MCH-29.6 MCHC-32.2 RDW-15.3 RDWSD-51.8* Plt [MASKED] [MASKED] 07:10AM BLOOD Plt [MASKED] [MASKED] 07:10AM BLOOD Glucose-119* UreaN-19 Creat-0.8 Na-141 K-4.3 Cl-102 HCO3-26 AnGap-13 [MASKED] 07:10AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.8 Brief Hospital Course: PATIENT SUMMARY: =========================== Ms. [MASKED] is a [MASKED] year old woman with atrial fibrillation on Coumadin and metoprolol, aortic stenosis s/p AVR with bioprosthetic valve on [MASKED], ascending aortic aneurysm, HTN, HLD, who presents as transfer for R femur neck fracture now s/p closed reduction and percutaneous pinning course complicated by hypoactive delirium. ACTIVE ISSUES: =========================== #R impacted femur neck fracture - Initially presented status post fall, found to have right femoral neck fracture on XR. Was evaluated by orthopedic surgery underwent right hip closed reduction and percutaneous pinning on [MASKED]. She had minimal pain post-op and received tyelnol for pain control. She was started on Vit D supplementation at 1000u daily. Please consider initiating bisphosphonate in [MASKED] weeks as an outpatient. While she remained sub-therpaeutic on warfarin for atrial fibrillation, was also started on lovenox 40 SC QD for DVT prophylxais. At rehab once therapeutic on warfarin can discontinue lovenox. Dressing to remain intact until follow-up in 2 weeks with orthopedics unless saturated. #Hypoxemic respiratory failure Initially with 2L O2 requirement thought to be secondary to IV fluids received during early admission. Patient was afebrile, [MASKED] leukocytosis and CXR with [MASKED] signs of pneumonia. Patient was diuresed with intermittent IV lasix. We were able to wean her off oxygen prior to discharge. At this point hypoxemia thought to be primarily related to atelectasis post-op. Was encouraged to use incentive spirometry. #Atrial fibrillation CHADSVASC = 4 (age, sex and HTN)- Maintained on metoprolol succinate 50 mg daily at home for rate control and warfarin and warfarin 2mg daily. Was initiallyon heparin prior to surgery, was re-started on warfarin 2mg daily. INR on discharge was 1.4 so 5mg administered on day of discharge given remains subtherapeutic. Please discontinue lovenox once warfarin is therapeutic (goal INR [MASKED]. #Hypoactive delirium Patient had waxing and weaning mentation. She was also alert and oriented x1 (to name only). She is also very hard of hearing. Infectious work-up was sent. CXR with [MASKED] consolidation, UA was bland and [MASKED] other localizing symptoms. This was felt to be hospital/post-op hypoactive delirium. Delirium precautions were put in place. #Recurrent falls Pt with listed history of gait disorder listed in chart, has recurrent falls (including one in [MASKED] which resulted in head lac requiring staples). She remains on AC for atrial fibrillation. She reports using a walker. She denies pre-syncope or LOC during these events. [MASKED] to continue working with patient and discharge to rehab. #Urinary retention - Issues with intermittent urinary retention requiring straight cath x1. Continue to monitor at rehab. CHRONIC/STABLE ISSUES ============================= #HTN - Patient was continued on home metoprolol 50XL daily, however home valsartan was initially held [MASKED] was not continued on discharge given she remained normotensive off of this. #HLD: continued home statin #AS s/p AVR #TR, MR [MASKED] specific therapy. Mild to moderate MR and moderate TR. #TRANSITIONAL ISSUES: ============================== [ ] NEW/CHANGED MEDICATIONS - Started vitamin D 1000 U QD - Started lovenox 40mg SC QD while sub-therapeutic post operatively - Held valsartan 320mg PO QD given normotensive off of this [ ] Received warfarin 2mg QD [MASKED] and 5mg on [MASKED]. Discharge INR 1.4. Continue with daily dosing until INR therapeutic [MASKED] [ ] Continue lovenox 40mg SC QD until INR therapeutic [ ] Multiple subpleural rule opacities throughout the lungs with the largest measures 1.3 x 1.0 cm in the right upper lobe, which may be infectious/inflammatory. Follow-up chest CT in 3 months is recommended to assess resolution. #CONTACT: Name of health care proxy: Dr [MASKED] Relationship: Son Phone number: [MASKED] #Code Status: Full, presumed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Simvastatin 40 mg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Valsartan 320 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Warfarin 2 mg PO DAILY16 Discharge Medications: 1. Enoxaparin Sodium 40 mg SC DAILY 2. Vitamin D 1000 UNIT PO DAILY 3. [MASKED] MD to order daily dose PO DAILY16 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Simvastatin 40 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary diagnosis -R hip fracture Secondary diagnosis -Hypoxemic respiratory failure -A fib -Hypoactive delirium -Hypertension -Hyperlipidemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure caring for you at [MASKED]. Why did you come to the hospital? -You came to the hospital because you fell and broke your right hip. What did you receive in the hospital? -While you were in the hospital, you went to the operating room to fix the hip fracture with the orthopedic surgeous. -You also had some trouble breathing requiring oxygen by nasal cannula. We think this is due to the fact that you are taking shallow breaths. Please continue using the incentive spirometry to open up your lungs. We also want you to continue working with physical therapy while at rehab What should you do once you leave the hospital? - Continue to take all of your medications as prescribed - Follow-up with your scheduled appointments as listed below We wish you all the best! Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"I4891",
"Z7901",
"I10",
"E785",
"D509",
"Z66"
] |
[
"M80851A: Other osteoporosis with current pathological fracture, right femur, initial encounter for fracture",
"J9691: Respiratory failure, unspecified with hypoxia",
"J810: Acute pulmonary edema",
"F05: Delirium due to known physiological condition",
"I4891: Unspecified atrial fibrillation",
"Z7901: Long term (current) use of anticoagulants",
"Z952: Presence of prosthetic heart valve",
"I714: Abdominal aortic aneurysm, without rupture",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"D509: Iron deficiency anemia, unspecified",
"H9190: Unspecified hearing loss, unspecified ear",
"Z9181: History of falling",
"R339: Retention of urine, unspecified",
"I081: Rheumatic disorders of both mitral and tricuspid valves",
"Z66: Do not resuscitate"
] |
10,024,120
| 28,351,361
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lipitor / oxycodone / atropine
Attending: ___.
Chief Complaint:
Shortness of Breath, Bicuspid Aortic Stenosis
Major Surgical or Invasive Procedure:
TAVR ___
History of Present Illness:
___ PMH HTN, paradoxical embolism with TIA, PFO closure (___),
OSA, and severe bicuspid AS and associated aortopathy who has
been evaluated in the structural heart disease clinic for
consideration of TAVR vs. SAVR with ascending aorta
replacement.
He follows closely with Dr. ___ and has been undergoing
active surveillance of his bicuspid aortic valve and associated
aortopathy. Earlier this year, his TTE demonstrated a mean
gradient of 60 mmHg. He did not have convincing symptoms, so he
underwent an exercise stress test which demonstrated a
hypotensive response to exercise. His most recent transthoracic
echocardiogram showed mean gradient of 71 mmHg which is
increased since his last echo in ___. Ascending aortic was
measured at 4.6 cm in diameter.
Over the past several months, he reports increased symptom
burden primarily shortness of breath on exertion. He denied any
chest pain, palpitation, dizziness, presyncope or syncope.
He notes that he has had numerous bacterial bronchitis episodes
this year and has laryngeal-pharyngeal reflux and associated
globus and thus is quite concerned about mechanical ventilation
and its potential complications associated with cardiac surgery.
He was counseled extensively, and understands the risk, benefit
and the uncertainty about progression of his ascending aortic
disease and would like to proceed with transcatheter Aortic
valve replacement. He presents today for TAVR.
Past Medical History:
PMH:
ACTINIC KERATOSIS
COLONIC ADENOMA
GERD
HYPERLIPIDEMIA
HYPERTENSION
OBESITY
SLEEP APNEA
LOW BACK PAIN
VENOUS INSUFFICIENCY
OSTEOARTHRITIS
AORTIC STENOSIS
DERMATOHELIOSIS
SEBORRHEIC KERATOSIS, OTHER
BREAST LESION
H/O PFO, TIA
PSH:
HIP REPLACEMENT (right) ___
PFO PERCUTANEOUS CLOSURE ___
Social History:
___
Family History:
Father died at age ___ related to AAA, was heavy smoker
Physical Exam:
Physical Examination on Admission:
General: Awake, pleasant lying in bed, NAD
Neuro: Alert and oriented x4. Pleasant and cooperative. PERRLA.
Speech clear, appropriate and comprehensible. Tongue midline,
smile symmetric.
HEENT: Neck supple.
CV: RRR, Normal S1 S2,
Lungs: Clear ___, anteriorly, non-labored. No use of accessory
muscles noted.
Abdomen: soft, non-tender, + BS x4
PV: WWP, + pedal pulses, No edema, Palpable Pedal pulses ___.
Access sites: Right radial TR Band in Place soft without
bleeding
or hematoma. Right and left femoral access site soft without
hematoma, bleeding, or bruit.
Physical Examination at Discharge:
Vitals:
Temp: 98.3 BP: 105/60 HR: 70 RR: 18 O2 sat: 95% O2 delivery:
RA
General/Neuro: Patient is A/O to person, place, time, and
situation. Patient does not have focal deficits and PERRLA
positive.
Cardiac: Regular heart rhythm with the presence of an S1 and S2.
Grade 1 aortic murmur appreciated, barely audible , soft, early
diastolic, not radiating to the carotids. No jugular vein
distension.
Lungs: Lung sounds are clear. Patient has no respiratory
distress.
Abd: Patient has active bowel sounds, soft abdomen,
non-distended, and non-tender.
Extremities: Patient has no edema. Pedal pulses are palpable
throughout.
Access Sites: Bilateral femoral access sites are CDI. There is
no
bleeding, ecchymosis or hematoma present. Right radial access is
CDI. There is no bleeding, ecchymosis or hematoma present
Today's Weight: 139.6 kg 307.76 lb)
Pertinent Results:
Admission Labs:
___ 10:25AM BLOOD WBC-7.9 RBC-4.49* Hgb-13.0* Hct-40.1
MCV-89 MCH-29.0 MCHC-32.4 RDW-13.3 RDWSD-43.7 Plt ___
___ 10:25AM BLOOD ___ PTT-132.2* ___
___ 10:25AM BLOOD Glucose-127* UreaN-23* Creat-0.8 Na-139
K-4.5 Cl-104 HCO3-24 AnGap-11
___ 10:25AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.5
___ TTE:(Focused study)
CONCLUSION:
Left ventricular cardiac index is normal (>2.5 L/min/m2). A
___ 3 aortic valve bioprosthesis is present. The prosthesis
is well seated with HIGH gradient. The effective orifice area
index is moderately
reduced (0.65-0.85 cm2/m2).
IMPRESSION: 1) Well seated ___ 3 valve in aortic position
with elevated gradients likely due
to moderate patient-prosthesis mismatch since aortic
acceleration time < 100 ms.
___: 39mmHg
Mean Gradient: 24mmHg
Discharge Labs:
___ 07:48AM BLOOD WBC-10.4* RBC-4.37* Hgb-12.8* Hct-38.8*
MCV-89 MCH-29.3 MCHC-33.0 RDW-13.3 RDWSD-43.8 Plt ___
___ 08:12AM BLOOD Glucose-190* UreaN-18 Creat-0.8 Na-138
K-4.2 Cl-103 HCO3-21* AnGap-14
___ 08:12AM BLOOD Mg-2.1
Brief Hospital Course:
Mr. ___ is a ___ male with severe bicuspid AS and
aortopathy who, after extensive discussion, has decided to
proceed with TAVR. He is now s/p TAVR with ___ 3 29mm valve
with sentinel protection.
#Aortic Stenosis: s/p TAVR.
Pre-TAVR gradients: ___ Gradient: 108 mmHg, Mean Gradient: 71
mmHg
Post-TAVR gradients: ___ Gradient: 44mmHg Mean Gradient:
27mmHg
- Continue Aspirin
- Start Warfarin at 5 mg for three days, then check INR.
If INR is within target, start the following schedule
5 mg on ___. & 10 mg - ___. ___. ___.
- Verapamil 120 mg daily for seven days, if patient is able to
tolerate
mediation without side affects, then increase to 240 mg
daily.
- Hold Telmisartan for stable BP
- Assess volume status daily (not on home diuretic)
- Low Na+ diet, daily weights, strict I&Os
# Transitional issues:
- Follow-up appointments
CARDIOLOGY ECHO LAB ___ at 2:30 ___
CARDIOLOGY with ___ ___ at
2:20 ___
- Management of INR and Coumadin dosing in the outpatient
setting
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. telmisartan 80 mg oral DAILY
2. GuaiFENesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough
3. Clotrimazole Cream 1 Appl TP DAILY
4. Celecoxib 200 mg oral DAILY:PRN arthritis
5. DiphenhydrAMINE 25 mg PO DAILY:PRN insomnia
6. Rosuvastatin Calcium 20 mg PO QPM
7. Multivitamins 1 TAB PO DAILY
8. Fluticasone Propionate 110mcg 2 PUFF IH DAILY:PRN as needed
for shortness of breath or wheezing
9. Naproxen 500 mg PO BID:PRN Pain - Mild
10. Omeprazole 20 mg PO BID
11. Aspirin 81 mg PO DAILY
12. albuterol sulfate 90 mcg/actuation inhalation DAILY:PRN
wheezing
13. TraZODone 25 mg PO QHS:PRN sleep
14. Vitamin D ___ UNIT PO DAILY
15. Warfarin 5 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Pantoprazole 40 mg PO BID
3. Senna 8.6 mg PO QHS
4. Verapamil 120 mg PO DAILY
5. Warfarin 5 mg PO DAILY
5 mg - ___.
10 mg - ___. ___. ___.
6. albuterol sulfate 90 mcg/actuation inhalation DAILY:PRN
wheezing
7. Aspirin 81 mg PO DAILY
8. Clotrimazole Cream 1 Appl TP DAILY
9. DiphenhydrAMINE 25 mg PO DAILY:PRN insomnia
10. Fluticasone Propionate 110mcg 2 PUFF IH DAILY:PRN as needed
for shortness of breath or wheezing
11. GuaiFENesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough
12. Multivitamins 1 TAB PO DAILY
13. Rosuvastatin Calcium 20 mg PO QPM
14. TraZODone 25 mg PO QHS:PRN sleep
15. Vitamin D ___ UNIT PO DAILY
16. HELD- Naproxen 500 mg PO BID:PRN Pain - Mild This
medication was held. Do not restart Naproxen until
recommnedations has been made by your outpatient cardiologist
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aortic Stenosis
Patent Foramen Ovale and Transient Ischemic Attack, s/p PFO
closure ___
Hyperlipidemia
Hypertension
Sleep Apnea
Gastroesophageal Reflux Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a trans catheter aortic valve replacement
(TAVR) to treat your aortic valve stenosis which was done on
___. By repairing the valve your heart can pump blood
more easily and your shortness of breath should improve.
It is very important to take all of your heart healthy
medications. In particular, you are now taking aspirin and
Warfarin. These medications help to prevent blood clots from
forming on the new valve. If you stop these medication or miss ___
dose, you risk causing a blood clot forming on your new valve.
This could cause it to malfunction and it may be life
threatening. Please do not stop taking aspirin or Warfarin
without taking to your heart doctor, even if another doctor
tells you to stop the medications.
Your target INR is between 2 and 3. Start by taking 5 mg for 3
days, then have you primary care doctor or medical provider
check your INR. If you INR is with range, we recommend you start
the following schedule 5 mg on ___. & 10 mg -
___. ___. ___. Unless otherwise changed by your medical
outpatient provider.
You will need prophylactic antibiotics prior to any dental
procedure. Please inform your dentist about your recent cardiac
procedure, and obtain a prescription from your doctor before any
procedure.
Please weigh yourself every day in the morning after you go to
the bathroom and before you get dressed. If your weight goes up
by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please
call your heart doctor or your primary care doctor and alert
them to this change. Your weight at discharge is 139.6 kg
(307.76 lbs.).
We have made changes to your medication list, so please make
sure to take your medications as directed.
You were given prescriptions for Pantoprazole, Verapamil, and
Warfarin on discharge, any future refills will need to be
authorized by your outpatient providers, primary care or
cardiologist.
You will also need to have close follow up with your heart
doctor and your primary care doctor. If you have any urgent
questions that are related to your recovery from your procedure
or are experiencing any symptoms that are concerning to you and
you think you may need to return to the hospital, please call
the ___ HeartLine at ___ to speak to a cardiologist
or cardiac nurse practitioner.
It has been a pleasure to have participated in your care and we
wish you the best with your health!
Followup Instructions:
___
|
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"I10",
"R109",
"G4733",
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"K219",
"E669",
"M1990",
"G4700",
"Z96649",
"Z8673",
"Y838",
"Y92239",
"Z006"
] |
Allergies: Lipitor / oxycodone / atropine Chief Complaint: Shortness of Breath, Bicuspid Aortic Stenosis Major Surgical or Invasive Procedure: TAVR [MASKED] History of Present Illness: [MASKED] PMH HTN, paradoxical embolism with TIA, PFO closure ([MASKED]), OSA, and severe bicuspid AS and associated aortopathy who has been evaluated in the structural heart disease clinic for consideration of TAVR vs. SAVR with ascending aorta replacement. He follows closely with Dr. [MASKED] and has been undergoing active surveillance of his bicuspid aortic valve and associated aortopathy. Earlier this year, his TTE demonstrated a mean gradient of 60 mmHg. He did not have convincing symptoms, so he underwent an exercise stress test which demonstrated a hypotensive response to exercise. His most recent transthoracic echocardiogram showed mean gradient of 71 mmHg which is increased since his last echo in [MASKED]. Ascending aortic was measured at 4.6 cm in diameter. Over the past several months, he reports increased symptom burden primarily shortness of breath on exertion. He denied any chest pain, palpitation, dizziness, presyncope or syncope. He notes that he has had numerous bacterial bronchitis episodes this year and has laryngeal-pharyngeal reflux and associated globus and thus is quite concerned about mechanical ventilation and its potential complications associated with cardiac surgery. He was counseled extensively, and understands the risk, benefit and the uncertainty about progression of his ascending aortic disease and would like to proceed with transcatheter Aortic valve replacement. He presents today for TAVR. Past Medical History: PMH: ACTINIC KERATOSIS COLONIC ADENOMA GERD HYPERLIPIDEMIA HYPERTENSION OBESITY SLEEP APNEA LOW BACK PAIN VENOUS INSUFFICIENCY OSTEOARTHRITIS AORTIC STENOSIS DERMATOHELIOSIS SEBORRHEIC KERATOSIS, OTHER BREAST LESION H/O PFO, TIA PSH: HIP REPLACEMENT (right) [MASKED] PFO PERCUTANEOUS CLOSURE [MASKED] Social History: [MASKED] Family History: Father died at age [MASKED] related to AAA, was heavy smoker Physical Exam: Physical Examination on Admission: General: Awake, pleasant lying in bed, NAD Neuro: Alert and oriented x4. Pleasant and cooperative. PERRLA. Speech clear, appropriate and comprehensible. Tongue midline, smile symmetric. HEENT: Neck supple. CV: RRR, Normal S1 S2, Lungs: Clear [MASKED], anteriorly, non-labored. No use of accessory muscles noted. Abdomen: soft, non-tender, + BS x4 PV: WWP, + pedal pulses, No edema, Palpable Pedal pulses [MASKED]. Access sites: Right radial TR Band in Place soft without bleeding or hematoma. Right and left femoral access site soft without hematoma, bleeding, or bruit. Physical Examination at Discharge: Vitals: Temp: 98.3 BP: 105/60 HR: 70 RR: 18 O2 sat: 95% O2 delivery: RA General/Neuro: Patient is A/O to person, place, time, and situation. Patient does not have focal deficits and PERRLA positive. Cardiac: Regular heart rhythm with the presence of an S1 and S2. Grade 1 aortic murmur appreciated, barely audible , soft, early diastolic, not radiating to the carotids. No jugular vein distension. Lungs: Lung sounds are clear. Patient has no respiratory distress. Abd: Patient has active bowel sounds, soft abdomen, non-distended, and non-tender. Extremities: Patient has no edema. Pedal pulses are palpable throughout. Access Sites: Bilateral femoral access sites are CDI. There is no bleeding, ecchymosis or hematoma present. Right radial access is CDI. There is no bleeding, ecchymosis or hematoma present Today's Weight: 139.6 kg 307.76 lb) Pertinent Results: Admission Labs: [MASKED] 10:25AM BLOOD WBC-7.9 RBC-4.49* Hgb-13.0* Hct-40.1 MCV-89 MCH-29.0 MCHC-32.4 RDW-13.3 RDWSD-43.7 Plt [MASKED] [MASKED] 10:25AM BLOOD [MASKED] PTT-132.2* [MASKED] [MASKED] 10:25AM BLOOD Glucose-127* UreaN-23* Creat-0.8 Na-139 K-4.5 Cl-104 HCO3-24 AnGap-11 [MASKED] 10:25AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.5 [MASKED] TTE:(Focused study) CONCLUSION: Left ventricular cardiac index is normal (>2.5 L/min/m2). A [MASKED] 3 aortic valve bioprosthesis is present. The prosthesis is well seated with HIGH gradient. The effective orifice area index is moderately reduced (0.65-0.85 cm2/m2). IMPRESSION: 1) Well seated [MASKED] 3 valve in aortic position with elevated gradients likely due to moderate patient-prosthesis mismatch since aortic acceleration time < 100 ms. [MASKED]: 39mmHg Mean Gradient: 24mmHg Discharge Labs: [MASKED] 07:48AM BLOOD WBC-10.4* RBC-4.37* Hgb-12.8* Hct-38.8* MCV-89 MCH-29.3 MCHC-33.0 RDW-13.3 RDWSD-43.8 Plt [MASKED] [MASKED] 08:12AM BLOOD Glucose-190* UreaN-18 Creat-0.8 Na-138 K-4.2 Cl-103 HCO3-21* AnGap-14 [MASKED] 08:12AM BLOOD Mg-2.1 Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with severe bicuspid AS and aortopathy who, after extensive discussion, has decided to proceed with TAVR. He is now s/p TAVR with [MASKED] 3 29mm valve with sentinel protection. #Aortic Stenosis: s/p TAVR. Pre-TAVR gradients: [MASKED] Gradient: 108 mmHg, Mean Gradient: 71 mmHg Post-TAVR gradients: [MASKED] Gradient: 44mmHg Mean Gradient: 27mmHg - Continue Aspirin - Start Warfarin at 5 mg for three days, then check INR. If INR is within target, start the following schedule 5 mg on [MASKED]. & 10 mg - [MASKED]. [MASKED]. [MASKED]. - Verapamil 120 mg daily for seven days, if patient is able to tolerate mediation without side affects, then increase to 240 mg daily. - Hold Telmisartan for stable BP - Assess volume status daily (not on home diuretic) - Low Na+ diet, daily weights, strict I&Os # Transitional issues: - Follow-up appointments CARDIOLOGY ECHO LAB [MASKED] at 2:30 [MASKED] CARDIOLOGY with [MASKED] [MASKED] at 2:20 [MASKED] - Management of INR and Coumadin dosing in the outpatient setting Medications on Admission: The Preadmission Medication list is accurate and complete. 1. telmisartan 80 mg oral DAILY 2. GuaiFENesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough 3. Clotrimazole Cream 1 Appl TP DAILY 4. Celecoxib 200 mg oral DAILY:PRN arthritis 5. DiphenhydrAMINE 25 mg PO DAILY:PRN insomnia 6. Rosuvastatin Calcium 20 mg PO QPM 7. Multivitamins 1 TAB PO DAILY 8. Fluticasone Propionate 110mcg 2 PUFF IH DAILY:PRN as needed for shortness of breath or wheezing 9. Naproxen 500 mg PO BID:PRN Pain - Mild 10. Omeprazole 20 mg PO BID 11. Aspirin 81 mg PO DAILY 12. albuterol sulfate 90 mcg/actuation inhalation DAILY:PRN wheezing 13. TraZODone 25 mg PO QHS:PRN sleep 14. Vitamin D [MASKED] UNIT PO DAILY 15. Warfarin 5 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Pantoprazole 40 mg PO BID 3. Senna 8.6 mg PO QHS 4. Verapamil 120 mg PO DAILY 5. Warfarin 5 mg PO DAILY 5 mg - [MASKED]. 10 mg - [MASKED]. [MASKED]. [MASKED]. 6. albuterol sulfate 90 mcg/actuation inhalation DAILY:PRN wheezing 7. Aspirin 81 mg PO DAILY 8. Clotrimazole Cream 1 Appl TP DAILY 9. DiphenhydrAMINE 25 mg PO DAILY:PRN insomnia 10. Fluticasone Propionate 110mcg 2 PUFF IH DAILY:PRN as needed for shortness of breath or wheezing 11. GuaiFENesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough 12. Multivitamins 1 TAB PO DAILY 13. Rosuvastatin Calcium 20 mg PO QPM 14. TraZODone 25 mg PO QHS:PRN sleep 15. Vitamin D [MASKED] UNIT PO DAILY 16. HELD- Naproxen 500 mg PO BID:PRN Pain - Mild This medication was held. Do not restart Naproxen until recommnedations has been made by your outpatient cardiologist Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Aortic Stenosis Patent Foramen Ovale and Transient Ischemic Attack, s/p PFO closure [MASKED] Hyperlipidemia Hypertension Sleep Apnea Gastroesophageal Reflux Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a trans catheter aortic valve replacement (TAVR) to treat your aortic valve stenosis which was done on [MASKED]. By repairing the valve your heart can pump blood more easily and your shortness of breath should improve. It is very important to take all of your heart healthy medications. In particular, you are now taking aspirin and Warfarin. These medications help to prevent blood clots from forming on the new valve. If you stop these medication or miss [MASKED] dose, you risk causing a blood clot forming on your new valve. This could cause it to malfunction and it may be life threatening. Please do not stop taking aspirin or Warfarin without taking to your heart doctor, even if another doctor tells you to stop the medications. Your target INR is between 2 and 3. Start by taking 5 mg for 3 days, then have you primary care doctor or medical provider check your INR. If you INR is with range, we recommend you start the following schedule 5 mg on [MASKED]. & 10 mg - [MASKED]. [MASKED]. [MASKED]. Unless otherwise changed by your medical outpatient provider. You will need prophylactic antibiotics prior to any dental procedure. Please inform your dentist about your recent cardiac procedure, and obtain a prescription from your doctor before any procedure. Please weigh yourself every day in the morning after you go to the bathroom and before you get dressed. If your weight goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please call your heart doctor or your primary care doctor and alert them to this change. Your weight at discharge is 139.6 kg (307.76 lbs.). We have made changes to your medication list, so please make sure to take your medications as directed. You were given prescriptions for Pantoprazole, Verapamil, and Warfarin on discharge, any future refills will need to be authorized by your outpatient providers, primary care or cardiologist. You will also need to have close follow up with your heart doctor and your primary care doctor. If you have any urgent questions that are related to your recovery from your procedure or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital, please call the [MASKED] HeartLine at [MASKED] to speak to a cardiologist or cardiac nurse practitioner. It has been a pleasure to have participated in your care and we wish you the best with your health! Followup Instructions: [MASKED]
|
[] |
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"Q231: Congenital insufficiency of aortic valve",
"Z6841: Body mass index [BMI]40.0-44.9, adult",
"I97190: Other postprocedural cardiac functional disturbances following cardiac surgery",
"I440: Atrioventricular block, first degree",
"I712: Thoracic aortic aneurysm, without rupture",
"J40: Bronchitis, not specified as acute or chronic",
"I10: Essential (primary) hypertension",
"R109: Unspecified abdominal pain",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"E785: Hyperlipidemia, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"E669: Obesity, unspecified",
"M1990: Unspecified osteoarthritis, unspecified site",
"G4700: Insomnia, unspecified",
"Z96649: Presence of unspecified artificial hip joint",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92239: Unspecified place in hospital as the place of occurrence of the external cause",
"Z006: Encounter for examination for normal comparison and control in clinical research program"
] |
10,024,170
| 28,956,643
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Keflex / shellfish derived / egg whites /
Pork/Porcine Containing Products
Attending: ___.
Chief Complaint:
vomiting, weight loss
Major Surgical or Invasive Procedure:
EGD
EUS
Colonoscopy
History of Present Illness:
Ms. ___ is a ___ yo woman with h/o Behcet syndrome, s/p
Roux en Y ___ years ago, who presents with several months of
abdominal pain, nausea/vomiting, and 40 lb weight loss, now
referred for inpatient GI workup.
Patient initially had Roux en Y ___ years ago, with postop course
c/b acute obstruction with frank BRBPR requiring urgent surgery
for a "kink." She required PEG with TFs for some time and
subsequently did will with about 120 lb weight loss. About ___
year ago she progressively developed her current symptoms. She
has noted difficulty tolerating POs with intermittent vomiting
of undigested food 30 min after eating. This is somewhat better
with liquids than solids but it is not obvious to her which
foods are going to trigger the vomiting. This has worsened to
the point that she is only able to tolerate 2x 6 oz cups of
yogurt daily. Over the past ___ mos she has developed
epigastric/RUQ pain. Last week she had a period of 4 days when
she had fevers to Tmax 102.7 but feels this has no resolved.
On ROS she endorses drenching night sweats. She also has cold
intolerance, pounding sensation in her chest on exertion. She
chronically has intermittent diarrhea/constipation and this has
not changed. No bloody/bilious vomiting, does endorse blood on
outside of stool that she attributes to known hemorrhoids, as
well as intermittent melenic stools.
Patient was seen previously at ___ where she reports she
had recent EGD/colonoscopy ___ mos ago. Unclear whether they
reached surgical anastomosis but they were reportedly
unremarkable. She was then referred to see ___ with GI
here who referred her to ED for further workup.
In the ED, initial vitals were: 98.4 60 139/102 20 96%RA. Exam
was notable for abdominal tenderness in RUQ, epigastrium,
without peritoneal signs. Labs were notable for very mild
transaminitis, no leukocytosis, normal lactate, normal CRP.
Abdominal CT was done which showed intra- and extraheptic
biliary dilatation as well as dilatation of pancreatic duct.
Patient was given 15 mg oxycodone x2, 4 mg IV Zofran x2, and 1L
NS bolus.
On the floor, patient is fatigued but in no NAD. She is
requesting a popsicle. Continues to have abdominal pain.
Otherwise no complaints.
Past Medical History:
Behcet's syndrome with oral/vaginal ulcers
depression
hemorrhoids
hypothyroidism
s/p Roux en Y
Social History:
___
Family History:
Mother with UC, COPD, bladder CA. Daughter with lupus. Second
daughter with UC, hidradenitis suppurativa, drug addiction.
Uncle and grandfather with early cardiac death in ___. Other fam
members with celiac disease and Crohn's disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.7 ___ 68 97%RA
___: Very thin ill appearing woman lying in bed in NAD
HEENT: Sclerae anicteric, MMM
CV: RRR, no m/r/g
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, nondistended, normoactive bowel sounds. Moderate
tenderness in RLQ and epigastrium with exquisite TTP over RUQ.
Ext: WWP, no edema
Neuro: AOx3, moving all extremities equally
DISCHARGE PHYSICAL EXAM:
VS: T 97.9, HR 54-70, BP 90-112/49-60, RR 20, SaO2 98% RA
___: Very thin woman sitting up in bed in NAD, alert and
interactive, no acute distress.
HEENT: Sclerae anicteric, MMM, poor dentition, no oropharyngeal
mucosal lesions, bilateral madarosis.
CV: RRR, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: nondistended, normoactive bowel sounds, soft in all 4
quadrants. Moderate TTP over RUQ with voluntary guarding,
moderate TTP over RLQ with pain referring to RUQ. No rebound
pain.
Ext: WWP, 2+ DPs and radial pulses b/l, no c/c/e, no calf
tenderness
Neuro: AOx3. Mild L ptosis. Muscle bulk decreased throughout
with normal tone.
Pertinent Results:
ADMISSION LABS:
---------------
___ 12:42PM BLOOD WBC-4.8 RBC-4.50 Hgb-12.6 Hct-38.4 MCV-85
MCH-28.0 MCHC-32.8 RDW-13.2 RDWSD-41.2 Plt ___
___ 12:42PM BLOOD ___ PTT-35.2 ___
___ 12:42PM BLOOD Glucose-100 UreaN-7 Creat-0.8 Na-138
K-4.7 Cl-102 HCO3-29 AnGap-12
___ 12:42PM BLOOD ALT-42* AST-47* AlkPhos-85 TotBili-0.6
DirBili-0.1 IndBili-0.5
___ 12:42PM BLOOD Lipase-41
___ 12:42PM BLOOD Albumin-3.7 Calcium-8.8 Phos-3.8 Mg-2.2
___ 12:58PM BLOOD Lactate-1.2
PERTINENT LABS:
---------------
___ 07:44AM BLOOD tTG-IgA-8
___ 12:42PM BLOOD CRP-0.3
___ 07:44AM BLOOD Cortsol-14.1
___ 07:44AM BLOOD TSH-1.3
___ 07:44AM BLOOD VitB12-764 Folate-12.6
DISCHARGE LABS:
---------------
___ 08:05AM BLOOD WBC-5.3 RBC-4.73 Hgb-13.1 Hct-40.8 MCV-86
MCH-27.7 MCHC-32.1 RDW-14.0 RDWSD-43.1 Plt ___
___ 08:05AM BLOOD ___ PTT-34.3 ___
___ 08:05AM BLOOD Glucose-183* UreaN-11 Creat-0.7 Na-140
K-3.5 Cl-104 HCO3-26 AnGap-14
___ 08:05AM BLOOD ALT-25 AST-22 AlkPhos-88 TotBili-1.0
___ 08:05AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.1
=
=
=
=
=
================================================================
RADIOLOGY:
----------
CT ABDOMEN/PELVIS ___
1. Intrahepatic and extrahepatic biliary ductal dilation.
Patient status post cholecystectomy. Please correlate
clinically as a distal obstruction is difficult to exclude.
MRCP is recommended for further evaluation.
2. Pancreas divisum.
3. No bowel obstruction in this patient status post gastric
bypass surgery.
4. Retained catheter in the right body wall extending into the
central spinal canal for which clinical correlation is advised.
CTA HEAD/NECK ___
1. Normal CTA of the head.
2. Patent vasculature in the neck with no evidence of internal
carotid artery stenosis by NASCET criteria.
3. No acute intracranial abnormality.
UPPER GI SERIES ___
No evidence of esophageal dysmotility or anastomotic stricture
to explain
symptoms.
RUQ ULTRASOUND ___ile duct stones. Ectatic common bile duct measuring
9 mm may
reflect s/p cholecystectomy.
ADDENDUM Upon further review of the the images the duodenum is
the
eccentrically thickened in the region of the ampulla which
raises concern for a periampullary mass best seen on series 1a,
image 41 and series 1b, image 263/351. Further evaluation with
ERCP or PTC if ERCP is unsuccessful is recommended.
=
=
=
=
=
================================================================
ENDOSCOPY:
----------
EGD ___
Anatomy consistent with known Roux-en-Y gastric bypass. The
stomach pouch was small. The GJ anastomosis was carefully
examined and appears intact, with no ulcers. (biopsy: normal)
Normal mucosa in the duodenum (biopsy: normal)
Otherwise normal EGD to jejunum
EUS ___
Linear EUS was performed with the Olympus enchoendoscope at
7.5mHz. A focused/limited EUS evaluation was possible given the
gastric bypass anatomy, which does not allow EUS visualization
from the duodenal bulb (for critical distal biliary and
ampullary view). The PD was measured at 2.2mm in the body, and
2.5mm in the head, which is normal diameter. The intrahepatic
biliary system was slightly dilated, and the extrahepatic
CHD/CBD was only mildly dilated (maximum diameter 7.8mm), within
the normal limits for post CCY state. The CBD cannot be traced
to the ampulla because of the gastric bypass anatomy. No filling
defects or mass is seen.
Limited eval with EUS scope notable for gastric bypass anatomy
Recommendations: Will need careful review of prior CT scans from
___ and ___. Biliary dilation is
likely benign/post CCY. This can often be more prominent after
gastric bypass ___ et al J. Gastro Surg ___. It is
important to demonstrate stability over time. If prior scans
show no biliary dilation, then can consider single balloon to
evaluate ampulla and further surveillance imaging to rule out
mass.
COLONOSCOPY ___
Polyp at 20cm in the distal sigmoid colon (polypectomy)
No bleeding seen.
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
Ms. ___ is a ___ yo woman s/p Roux-en-Y ___ years ago with
h/o nutritional deficiencies, Behcet syndrome, hypothyroidism,
depression and chronic pain, who presented with nausea,
vomiting, RUQ pain, and weight loss.
# FAILURE TO THRIVE: Presented with ongoing weight loss and very
poor ability to tolerate PO, reportedly eating only 2 6-oz
yogurts daily. Failure to thrive was thought largely nutritional
in setting of this very poor PO intake. However she is on
significant opiate regimen which was thought to contribute as
well both from standpoint of GI motility and mental status.
Opiates were downtitrated as below with some improvement.
# NAUSEA/VOMITING: Patient with chronic post-prandial
nausea/vomiting. Imaging was remarkable only for biliary
dilatation (see below) with no evidence of obstruction or other
etiology of nausea/vomiting. She underwent EGD to evaluate her
anastomosis; this was normal. Nausea/vomiting thought likely
multifactorial due in part to high dose opiate use and decreased
GI motility, as well as inability to tolerate large volumes of
food s/p Roux en Y. Opiates decreased, she was seen by
nutrition, and was tolerating POs well prior to discharge.
Recommend consideration of referral for bypass revision if
nausea/vomiting continues.
# BILIARY DILATATION: Patient presented with intermittent
postprandial RUQ pain and significant RUQ tenderness on exam.
She is s/p remote cholecystectomy. CT identified significant
biliary dilatation which could not be further elucidated with
MRCP given that patient has retained pain pump catheter in
intrathecal space. RUQ ultrasound identified area concerning for
periampullary mass. EUS was done but did not visualize any such
mass. Patient will follow up with her PCP and GI. COmparison
with prior imaging and consideration of repeat imaging to
determine if any interval change is recommended.
# NARCOTIC USE FOR CHRONIC PAIN: Patinet with long standing
chronic pain of somewhat unclear etiology as well as high dose
opioid use with recent dose increases correlating to time course
of her FTT. Fentanyl patch was decreased from 100 to 75 mcg/h.
REcommend considering further decrease on discharge, as well as
pain clinic referral.
# CONCERN FOR HORNER'S SYNDROME: Patient with left sided
Horner's syndrome on exam, also with decline of mental status.
Was seen by neurology who recommend CTA head/neck and CT of
upper chest. THese were unremarkable except for ___ cerebral
atrophy. Recommend outpatient follow up/neuropsychiatric
testing.
# S/P ROUX EN Y: Continued B vitamin, MVI. Labs here revealed
slightly low B2 and otherwise no deficiencies.
# HYPOTHYROIDISM: TSH normal here. Continued home synthroid.
# DEPRESSION: Somewhat poor mood without SI. Continued home
fluoxetine, trazodone.
# CODE: FULL
# CONTACT: Partner ___ ___, daughter ___ ___
TRANSITIONAL ISSUES:
[ ] Will need careful review of prior CT scans from ___ and ___.
[ ] Biliary dilation is likely benign post Roux-en-Y changes. If
prior scans show no biliary dilation, however, then can consider
single balloon to evaluate ampulla and further surveillance
imaging to rule out mass.
[ ] Consider repeat CT in future to trend biliary
dilatation/rule out enlarging mass lesion.
[ ] Fentanyl patch decreased to 75 mcg. Recommend considering
decreasing opioid regimen, possible pain clinic referral, to
minimize opioid dosing given c/f contribution to hypotension and
decreased motility.
[ ] Consider neuropsychiatric testing as outpatient given e/o
cerebral atrophy on CT.
[ ] Consider referral to surgery if patient still unable to
tolerate po to consider reversal of Roux en Y.
[ ] Please follow pending pathology on colonic polyp.
[ ] Consider monitoring QTc as outpatient given ongoing use of
Zofran and mildly prolonged QTc here.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Baclofen 10 mg PO BID
2. ClonazePAM 1 mg PO TID:PRN anxiety, tension
3. Fentanyl Patch 100 mcg/h TD Q72H
4. FLUoxetine 60 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. OxycoDONE (Immediate Release) 15 mg PO QID:PRN pain
7. TraZODone 150 mg PO QHS
8. Vitamin B Complex 1 CAP PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Calcium Carbonate 500 mg PO Frequency is Unknown
11. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Baclofen 10 mg PO BID
2. Calcium Carbonate 500 mg PO QID:PRN gi upset
3. ClonazePAM 1 mg PO TID:PRN anxiety, tension
4. Fentanyl Patch 75 mcg/h TD Q72H
RX *fentanyl 75 mcg/hour Apply to skin qAM Disp #*5 Patch
Refills:*0
5. FLUoxetine 60 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. OxycoDONE (Immediate Release) 15 mg PO QID:PRN pain
9. TraZODone 150 mg PO QHS
10. Vitamin B Complex 1 CAP PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % Apply to hip qAM Disp #*30 Patch
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Failure to thrive
Secondary
Vomiting
Abdominal pain
History of Roux en Y gastric bypass
Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
___ were admitted to the hospital because of your ongoing
abdominal pain, vomiting, and weight loss. ___ were followed
closely by the GI doctors. ___ had a CT of your abdomen which
showed dilation of the bile ducts. ___ had an upper endoscopy,
right upper quadrant ultrasound, endoscopic ultrasound, and
colonoscopy. These did not show anything obstructing your bile
ducts or any ulcerations at the site of your prior surgery.
There was a single polyp removed from your colonoscopy with the
pathology report still pending.
Because we were concerned that your pain medication may be
contributing to slowing of your bowels as well as low blood
pressure, your fentanyl patch was decreased. We recommend ___
follow up with your primary care doctor and ___ pain specialist to
further monitor and adjust your medications.
___ also have a follow up appointment with Dr. ___ can
continue to help ___ with your abdominal pain and vomiting.
It was a pleasure taking care of ___ during your stay in the
hospital.
- Your ___ Team
Followup Instructions:
___
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"E569"
] |
Allergies: Penicillins / Keflex / shellfish derived / egg whites / Pork/Porcine Containing Products Chief Complaint: vomiting, weight loss Major Surgical or Invasive Procedure: EGD EUS Colonoscopy History of Present Illness: Ms. [MASKED] is a [MASKED] yo woman with h/o Behcet syndrome, s/p Roux en Y [MASKED] years ago, who presents with several months of abdominal pain, nausea/vomiting, and 40 lb weight loss, now referred for inpatient GI workup. Patient initially had Roux en Y [MASKED] years ago, with postop course c/b acute obstruction with frank BRBPR requiring urgent surgery for a "kink." She required PEG with TFs for some time and subsequently did will with about 120 lb weight loss. About [MASKED] year ago she progressively developed her current symptoms. She has noted difficulty tolerating POs with intermittent vomiting of undigested food 30 min after eating. This is somewhat better with liquids than solids but it is not obvious to her which foods are going to trigger the vomiting. This has worsened to the point that she is only able to tolerate 2x 6 oz cups of yogurt daily. Over the past [MASKED] mos she has developed epigastric/RUQ pain. Last week she had a period of 4 days when she had fevers to Tmax 102.7 but feels this has no resolved. On ROS she endorses drenching night sweats. She also has cold intolerance, pounding sensation in her chest on exertion. She chronically has intermittent diarrhea/constipation and this has not changed. No bloody/bilious vomiting, does endorse blood on outside of stool that she attributes to known hemorrhoids, as well as intermittent melenic stools. Patient was seen previously at [MASKED] where she reports she had recent EGD/colonoscopy [MASKED] mos ago. Unclear whether they reached surgical anastomosis but they were reportedly unremarkable. She was then referred to see [MASKED] with GI here who referred her to ED for further workup. In the ED, initial vitals were: 98.4 60 139/102 20 96%RA. Exam was notable for abdominal tenderness in RUQ, epigastrium, without peritoneal signs. Labs were notable for very mild transaminitis, no leukocytosis, normal lactate, normal CRP. Abdominal CT was done which showed intra- and extraheptic biliary dilatation as well as dilatation of pancreatic duct. Patient was given 15 mg oxycodone x2, 4 mg IV Zofran x2, and 1L NS bolus. On the floor, patient is fatigued but in no NAD. She is requesting a popsicle. Continues to have abdominal pain. Otherwise no complaints. Past Medical History: Behcet's syndrome with oral/vaginal ulcers depression hemorrhoids hypothyroidism s/p Roux en Y Social History: [MASKED] Family History: Mother with UC, COPD, bladder CA. Daughter with lupus. Second daughter with UC, hidradenitis suppurativa, drug addiction. Uncle and grandfather with early cardiac death in [MASKED]. Other fam members with celiac disease and Crohn's disease. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.7 [MASKED] 68 97%RA [MASKED]: Very thin ill appearing woman lying in bed in NAD HEENT: Sclerae anicteric, MMM CV: RRR, no m/r/g Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, nondistended, normoactive bowel sounds. Moderate tenderness in RLQ and epigastrium with exquisite TTP over RUQ. Ext: WWP, no edema Neuro: AOx3, moving all extremities equally DISCHARGE PHYSICAL EXAM: VS: T 97.9, HR 54-70, BP 90-112/49-60, RR 20, SaO2 98% RA [MASKED]: Very thin woman sitting up in bed in NAD, alert and interactive, no acute distress. HEENT: Sclerae anicteric, MMM, poor dentition, no oropharyngeal mucosal lesions, bilateral madarosis. CV: RRR, no m/r/g Lungs: CTAB, no w/r/r Abdomen: nondistended, normoactive bowel sounds, soft in all 4 quadrants. Moderate TTP over RUQ with voluntary guarding, moderate TTP over RLQ with pain referring to RUQ. No rebound pain. Ext: WWP, 2+ DPs and radial pulses b/l, no c/c/e, no calf tenderness Neuro: AOx3. Mild L ptosis. Muscle bulk decreased throughout with normal tone. Pertinent Results: ADMISSION LABS: --------------- [MASKED] 12:42PM BLOOD WBC-4.8 RBC-4.50 Hgb-12.6 Hct-38.4 MCV-85 MCH-28.0 MCHC-32.8 RDW-13.2 RDWSD-41.2 Plt [MASKED] [MASKED] 12:42PM BLOOD [MASKED] PTT-35.2 [MASKED] [MASKED] 12:42PM BLOOD Glucose-100 UreaN-7 Creat-0.8 Na-138 K-4.7 Cl-102 HCO3-29 AnGap-12 [MASKED] 12:42PM BLOOD ALT-42* AST-47* AlkPhos-85 TotBili-0.6 DirBili-0.1 IndBili-0.5 [MASKED] 12:42PM BLOOD Lipase-41 [MASKED] 12:42PM BLOOD Albumin-3.7 Calcium-8.8 Phos-3.8 Mg-2.2 [MASKED] 12:58PM BLOOD Lactate-1.2 PERTINENT LABS: --------------- [MASKED] 07:44AM BLOOD tTG-IgA-8 [MASKED] 12:42PM BLOOD CRP-0.3 [MASKED] 07:44AM BLOOD Cortsol-14.1 [MASKED] 07:44AM BLOOD TSH-1.3 [MASKED] 07:44AM BLOOD VitB12-764 Folate-12.6 DISCHARGE LABS: --------------- [MASKED] 08:05AM BLOOD WBC-5.3 RBC-4.73 Hgb-13.1 Hct-40.8 MCV-86 MCH-27.7 MCHC-32.1 RDW-14.0 RDWSD-43.1 Plt [MASKED] [MASKED] 08:05AM BLOOD [MASKED] PTT-34.3 [MASKED] [MASKED] 08:05AM BLOOD Glucose-183* UreaN-11 Creat-0.7 Na-140 K-3.5 Cl-104 HCO3-26 AnGap-14 [MASKED] 08:05AM BLOOD ALT-25 AST-22 AlkPhos-88 TotBili-1.0 [MASKED] 08:05AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.1 = = = = = ================================================================ RADIOLOGY: ---------- CT ABDOMEN/PELVIS [MASKED] 1. Intrahepatic and extrahepatic biliary ductal dilation. Patient status post cholecystectomy. Please correlate clinically as a distal obstruction is difficult to exclude. MRCP is recommended for further evaluation. 2. Pancreas divisum. 3. No bowel obstruction in this patient status post gastric bypass surgery. 4. Retained catheter in the right body wall extending into the central spinal canal for which clinical correlation is advised. CTA HEAD/NECK [MASKED] 1. Normal CTA of the head. 2. Patent vasculature in the neck with no evidence of internal carotid artery stenosis by NASCET criteria. 3. No acute intracranial abnormality. UPPER GI SERIES [MASKED] No evidence of esophageal dysmotility or anastomotic stricture to explain symptoms. RUQ ULTRASOUND ile duct stones. Ectatic common bile duct measuring 9 mm may reflect s/p cholecystectomy. ADDENDUM Upon further review of the the images the duodenum is the eccentrically thickened in the region of the ampulla which raises concern for a periampullary mass best seen on series 1a, image 41 and series 1b, image 263/351. Further evaluation with ERCP or PTC if ERCP is unsuccessful is recommended. = = = = = ================================================================ ENDOSCOPY: ---------- EGD [MASKED] Anatomy consistent with known Roux-en-Y gastric bypass. The stomach pouch was small. The GJ anastomosis was carefully examined and appears intact, with no ulcers. (biopsy: normal) Normal mucosa in the duodenum (biopsy: normal) Otherwise normal EGD to jejunum EUS [MASKED] Linear EUS was performed with the Olympus enchoendoscope at 7.5mHz. A focused/limited EUS evaluation was possible given the gastric bypass anatomy, which does not allow EUS visualization from the duodenal bulb (for critical distal biliary and ampullary view). The PD was measured at 2.2mm in the body, and 2.5mm in the head, which is normal diameter. The intrahepatic biliary system was slightly dilated, and the extrahepatic CHD/CBD was only mildly dilated (maximum diameter 7.8mm), within the normal limits for post CCY state. The CBD cannot be traced to the ampulla because of the gastric bypass anatomy. No filling defects or mass is seen. Limited eval with EUS scope notable for gastric bypass anatomy Recommendations: Will need careful review of prior CT scans from [MASKED] and [MASKED]. Biliary dilation is likely benign/post CCY. This can often be more prominent after gastric bypass [MASKED] et al J. Gastro Surg [MASKED]. It is important to demonstrate stability over time. If prior scans show no biliary dilation, then can consider single balloon to evaluate ampulla and further surveillance imaging to rule out mass. COLONOSCOPY [MASKED] Polyp at 20cm in the distal sigmoid colon (polypectomy) No bleeding seen. Otherwise normal colonoscopy to cecum Brief Hospital Course: Ms. [MASKED] is a [MASKED] yo woman s/p Roux-en-Y [MASKED] years ago with h/o nutritional deficiencies, Behcet syndrome, hypothyroidism, depression and chronic pain, who presented with nausea, vomiting, RUQ pain, and weight loss. # FAILURE TO THRIVE: Presented with ongoing weight loss and very poor ability to tolerate PO, reportedly eating only 2 6-oz yogurts daily. Failure to thrive was thought largely nutritional in setting of this very poor PO intake. However she is on significant opiate regimen which was thought to contribute as well both from standpoint of GI motility and mental status. Opiates were downtitrated as below with some improvement. # NAUSEA/VOMITING: Patient with chronic post-prandial nausea/vomiting. Imaging was remarkable only for biliary dilatation (see below) with no evidence of obstruction or other etiology of nausea/vomiting. She underwent EGD to evaluate her anastomosis; this was normal. Nausea/vomiting thought likely multifactorial due in part to high dose opiate use and decreased GI motility, as well as inability to tolerate large volumes of food s/p Roux en Y. Opiates decreased, she was seen by nutrition, and was tolerating POs well prior to discharge. Recommend consideration of referral for bypass revision if nausea/vomiting continues. # BILIARY DILATATION: Patient presented with intermittent postprandial RUQ pain and significant RUQ tenderness on exam. She is s/p remote cholecystectomy. CT identified significant biliary dilatation which could not be further elucidated with MRCP given that patient has retained pain pump catheter in intrathecal space. RUQ ultrasound identified area concerning for periampullary mass. EUS was done but did not visualize any such mass. Patient will follow up with her PCP and GI. COmparison with prior imaging and consideration of repeat imaging to determine if any interval change is recommended. # NARCOTIC USE FOR CHRONIC PAIN: Patinet with long standing chronic pain of somewhat unclear etiology as well as high dose opioid use with recent dose increases correlating to time course of her FTT. Fentanyl patch was decreased from 100 to 75 mcg/h. REcommend considering further decrease on discharge, as well as pain clinic referral. # CONCERN FOR HORNER'S SYNDROME: Patient with left sided Horner's syndrome on exam, also with decline of mental status. Was seen by neurology who recommend CTA head/neck and CT of upper chest. THese were unremarkable except for [MASKED] cerebral atrophy. Recommend outpatient follow up/neuropsychiatric testing. # S/P ROUX EN Y: Continued B vitamin, MVI. Labs here revealed slightly low B2 and otherwise no deficiencies. # HYPOTHYROIDISM: TSH normal here. Continued home synthroid. # DEPRESSION: Somewhat poor mood without SI. Continued home fluoxetine, trazodone. # CODE: FULL # CONTACT: Partner [MASKED] [MASKED], daughter [MASKED] [MASKED] TRANSITIONAL ISSUES: [ ] Will need careful review of prior CT scans from [MASKED] and [MASKED]. [ ] Biliary dilation is likely benign post Roux-en-Y changes. If prior scans show no biliary dilation, however, then can consider single balloon to evaluate ampulla and further surveillance imaging to rule out mass. [ ] Consider repeat CT in future to trend biliary dilatation/rule out enlarging mass lesion. [ ] Fentanyl patch decreased to 75 mcg. Recommend considering decreasing opioid regimen, possible pain clinic referral, to minimize opioid dosing given c/f contribution to hypotension and decreased motility. [ ] Consider neuropsychiatric testing as outpatient given e/o cerebral atrophy on CT. [ ] Consider referral to surgery if patient still unable to tolerate po to consider reversal of Roux en Y. [ ] Please follow pending pathology on colonic polyp. [ ] Consider monitoring QTc as outpatient given ongoing use of Zofran and mildly prolonged QTc here. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Baclofen 10 mg PO BID 2. ClonazePAM 1 mg PO TID:PRN anxiety, tension 3. Fentanyl Patch 100 mcg/h TD Q72H 4. FLUoxetine 60 mg PO DAILY 5. Levothyroxine Sodium 50 mcg PO DAILY 6. OxycoDONE (Immediate Release) 15 mg PO QID:PRN pain 7. TraZODone 150 mg PO QHS 8. Vitamin B Complex 1 CAP PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Calcium Carbonate 500 mg PO Frequency is Unknown 11. Vitamin D Dose is Unknown PO DAILY Discharge Medications: 1. Baclofen 10 mg PO BID 2. Calcium Carbonate 500 mg PO QID:PRN gi upset 3. ClonazePAM 1 mg PO TID:PRN anxiety, tension 4. Fentanyl Patch 75 mcg/h TD Q72H RX *fentanyl 75 mcg/hour Apply to skin qAM Disp #*5 Patch Refills:*0 5. FLUoxetine 60 mg PO DAILY 6. Levothyroxine Sodium 50 mcg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. OxycoDONE (Immediate Release) 15 mg PO QID:PRN pain 9. TraZODone 150 mg PO QHS 10. Vitamin B Complex 1 CAP PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. Lidocaine 5% Patch 1 PTCH TD QAM RX *lidocaine [Lidoderm] 5 % Apply to hip qAM Disp #*30 Patch Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Failure to thrive Secondary Vomiting Abdominal pain History of Roux en Y gastric bypass Chronic pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], [MASKED] were admitted to the hospital because of your ongoing abdominal pain, vomiting, and weight loss. [MASKED] were followed closely by the GI doctors. [MASKED] had a CT of your abdomen which showed dilation of the bile ducts. [MASKED] had an upper endoscopy, right upper quadrant ultrasound, endoscopic ultrasound, and colonoscopy. These did not show anything obstructing your bile ducts or any ulcerations at the site of your prior surgery. There was a single polyp removed from your colonoscopy with the pathology report still pending. Because we were concerned that your pain medication may be contributing to slowing of your bowels as well as low blood pressure, your fentanyl patch was decreased. We recommend [MASKED] follow up with your primary care doctor and [MASKED] pain specialist to further monitor and adjust your medications. [MASKED] also have a follow up appointment with Dr. [MASKED] can continue to help [MASKED] with your abdominal pain and vomiting. It was a pleasure taking care of [MASKED] during your stay in the hospital. - Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"E039",
"E785",
"Z87891",
"G8929"
] |
[
"K911: Postgastric surgery syndromes",
"E43: Unspecified severe protein-calorie malnutrition",
"M352: Behçet's disease",
"I952: Hypotension due to drugs",
"F1120: Opioid dependence, uncomplicated",
"G319: Degenerative disease of nervous system, unspecified",
"K921: Melena",
"K9589: Other complications of other bariatric procedure",
"R634: Abnormal weight loss",
"R109: Unspecified abdominal pain",
"Z9884: Bariatric surgery status",
"Z980: Intestinal bypass and anastomosis status",
"E039: Hypothyroidism, unspecified",
"E785: Hyperlipidemia, unspecified",
"Z6823: Body mass index [BMI] 23.0-23.9, adult",
"R1011: Right upper quadrant pain",
"Z87891: Personal history of nicotine dependence",
"T40605A: Adverse effect of unspecified narcotics, initial encounter",
"Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause",
"G8929: Other chronic pain",
"G902: Horner's syndrome",
"R413: Other amnesia",
"Q132: Other congenital malformations of iris",
"D125: Benign neoplasm of sigmoid colon",
"E569: Vitamin deficiency, unspecified"
] |
10,024,171
| 25,047,051
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
latex
Attending: ___.
Chief Complaint:
left tibial shaft fracture
Major Surgical or Invasive Procedure:
Placement of left tibial intramedullary nail on ___
History of Present Illness:
___ w Left distal ___ tib/fib shaft fx on ___ while ice
skating presents for left heel pain x 2 days. She was seen at
___
originally but followed with Dr. ___ in clinic on ___
and had long leg cast applied and wedged. For the past 2 days
she
has had increasing pain at the heel and tightness of the toes,
enough now that the pain is waking her from sleep despite pain
meds and elevation. She called the answering service and I
advised her to come in due to the possibility of a heel sore.
The
patient is scheduled to see Dr. ___ on ___ to likely
plan IM nailing of the tibia which she is more amenable to now
given the difficulty getting around with the long leg cast. She
denies any numbness or tingling. She has not taken oxycodone
for
several days but continues to take Tylenol around-the-clock.
Otherwise feels well and denies any fevers, chills, chest pain,
or shortness of breath. Of note, patient reports that she had a
CT scan of the ankle at ___ and it was on the disc that she
brought to clinic.
The patient was evaluated in clinic on ___ and decided that
she would no longer like to pursue closed treatment and elected
for surgical intervention. The risks, benefits, indications for
surgery were thoroughly discussed with the patient, and she
elected to undergo surgery, which was scheduled for ___.
Past Medical History:
Migraines, PVCs
Social History:
___
Family History:
NC
Physical Exam:
Upon Admission:
___
General: Well-appearing female in no acute distress.
Left lower extremity:
-Long-leg cast clean dry and intact without skin breakdown at
the
edges.
-I bivalved the entire long-leg cast and reinforced the cast
with
tape. I also removed the entire heel portion of the cast,
exposing the skin to reveal a 2 x 2 cm stage I pressure ulcer
without a break in the skin or surrounding erythema or drainage.
- wiggles exposed toes
- SILT exposed toes
- Toes wwp with BCR
Upon Discharge:
General: Well-appearing, breathing comfortably on RA
Detailed examination of LLE:
-ace dsg CDI
-Fires FHL, ___, TA, GCS
-SILT ___ n distributions
-WWP distally
Pertinent Results:
please see OMR for pertinent labs and studies
___ 05:45AM BLOOD WBC-10.1* RBC-3.58* Hgb-9.3* Hct-30.1*
MCV-84 MCH-26.0 MCHC-30.9* RDW-12.9 RDWSD-39.5 Plt ___
___ 05:45AM BLOOD Glucose-100 UreaN-10 Creat-0.6 Na-144
K-4.2 Cl-108 HCO3-22 AnGap-14
___ 05:45AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1
Brief Hospital Course:
The patient presented as a same day admission for surgery. The
patient was taken to the operating room on ___ for placement
of left intramedullary nail, which the patient tolerated well.
For full details of the procedure please see the separately
dictated operative report. The patient was taken from the OR to
the PACU in stable condition and after satisfactory recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications. The patient
was given ___ antibiotics and anticoagulation per
routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the left lower extremity, and
will be discharged on aspirin 325mg daily x4weeks for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times daily
Disp #*60 Tablet Refills:*0
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl 5 mg 1 tablet(s) by mouth daily Disp #*50 Tablet
Refills:*0
4. Calcium Carbonate 1250 mg PO TID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*50 Tablet Refills:*0
6. Multivitamins 1 TAB PO DAILY
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
8. Senna 8.6 mg PO DAILY
RX *sennosides [senna] 8.6 mg 1 tab by mouth daily Disp #*50
Tablet Refills:*0
9. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Left tibial shaft fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated to the left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin 325mg 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.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
Weightbearing as tolerated to left lower extremity
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Please remain in the splint until follow-up appointment. Please
keep your splint dry. If you have concerns regarding your
splint, please call the clinic at the number provided.
Call your surgeon's office with any questions.
Followup Instructions:
___
|
[
"S82292A",
"L89621",
"W000XXA",
"Y929",
"S82402A"
] |
Allergies: latex Chief Complaint: left tibial shaft fracture Major Surgical or Invasive Procedure: Placement of left tibial intramedullary nail on [MASKED] History of Present Illness: [MASKED] w Left distal [MASKED] tib/fib shaft fx on [MASKED] while ice skating presents for left heel pain x 2 days. She was seen at [MASKED] originally but followed with Dr. [MASKED] in clinic on [MASKED] and had long leg cast applied and wedged. For the past 2 days she has had increasing pain at the heel and tightness of the toes, enough now that the pain is waking her from sleep despite pain meds and elevation. She called the answering service and I advised her to come in due to the possibility of a heel sore. The patient is scheduled to see Dr. [MASKED] on [MASKED] to likely plan IM nailing of the tibia which she is more amenable to now given the difficulty getting around with the long leg cast. She denies any numbness or tingling. She has not taken oxycodone for several days but continues to take Tylenol around-the-clock. Otherwise feels well and denies any fevers, chills, chest pain, or shortness of breath. Of note, patient reports that she had a CT scan of the ankle at [MASKED] and it was on the disc that she brought to clinic. The patient was evaluated in clinic on [MASKED] and decided that she would no longer like to pursue closed treatment and elected for surgical intervention. The risks, benefits, indications for surgery were thoroughly discussed with the patient, and she elected to undergo surgery, which was scheduled for [MASKED]. Past Medical History: Migraines, PVCs Social History: [MASKED] Family History: NC Physical Exam: Upon Admission: [MASKED] General: Well-appearing female in no acute distress. Left lower extremity: -Long-leg cast clean dry and intact without skin breakdown at the edges. -I bivalved the entire long-leg cast and reinforced the cast with tape. I also removed the entire heel portion of the cast, exposing the skin to reveal a 2 x 2 cm stage I pressure ulcer without a break in the skin or surrounding erythema or drainage. - wiggles exposed toes - SILT exposed toes - Toes wwp with BCR Upon Discharge: General: Well-appearing, breathing comfortably on RA Detailed examination of LLE: -ace dsg CDI -Fires FHL, [MASKED], TA, GCS -SILT [MASKED] n distributions -WWP distally Pertinent Results: please see OMR for pertinent labs and studies [MASKED] 05:45AM BLOOD WBC-10.1* RBC-3.58* Hgb-9.3* Hct-30.1* MCV-84 MCH-26.0 MCHC-30.9* RDW-12.9 RDWSD-39.5 Plt [MASKED] [MASKED] 05:45AM BLOOD Glucose-100 UreaN-10 Creat-0.6 Na-144 K-4.2 Cl-108 HCO3-22 AnGap-14 [MASKED] 05:45AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1 Brief Hospital Course: The patient presented as a same day admission for surgery. The patient was taken to the operating room on [MASKED] for placement of left intramedullary nail, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to home was appropriate. The [MASKED] hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the left lower extremity, and will be discharged on aspirin 325mg daily x4weeks for DVT prophylaxis. The patient will follow up with Dr. [MASKED] routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 500 mg 2 tablet(s) by mouth three times daily Disp #*60 Tablet Refills:*0 2. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*28 Tablet Refills:*0 3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation RX *bisacodyl 5 mg 1 tablet(s) by mouth daily Disp #*50 Tablet Refills:*0 4. Calcium Carbonate 1250 mg PO TID RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #*50 Tablet Refills:*0 6. Multivitamins 1 TAB PO DAILY 7. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 8. Senna 8.6 mg PO DAILY RX *sennosides [senna] 8.6 mg 1 tab by mouth daily Disp #*50 Tablet Refills:*0 9. Vitamin D 800 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] [MASKED] Diagnosis: Left tibial shaft fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Weightbearing as tolerated to the left lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take aspirin 325mg 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. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB Physical Therapy: Weightbearing as tolerated to left lower extremity Treatments Frequency: Any staples or superficial sutures you have are to remain in place for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound, but please refrain from bathing for at least 4 weeks postoperatively. Please remain in the splint until follow-up appointment. Please keep your splint dry. If you have concerns regarding your splint, please call the clinic at the number provided. Call your surgeon's office with any questions. Followup Instructions: [MASKED]
|
[] |
[
"Y929"
] |
[
"S82292A: Other fracture of shaft of left tibia, initial encounter for closed fracture",
"L89621: Pressure ulcer of left heel, stage 1",
"W000XXA: Fall on same level due to ice and snow, initial encounter",
"Y929: Unspecified place or not applicable",
"S82402A: Unspecified fracture of shaft of left fibula, initial encounter for closed fracture"
] |
10,024,451
| 20,199,878
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zetia / simvastatin
Attending: ___.
Chief Complaint:
CC: ___ Pain, ___
Major Surgical or Invasive Procedure:
ERCP with stent exchange
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
Mr. ___ is a ___ male with history of CAD
s/p
CABG, sarcoidosis, atrial fibrillation not on anticoagulation,
and recent diagnosis of pancreatic adenocarcinoma who presents
with abdominal pain and fever and now s/p ERCP with stent
exchange.
Patient reports that he developed severe diffuse abdominal pain
the morning of admission. He describes the pain as sharp and
constant. The pain progressively got worse. Since diagnosis of
pancreatic cancer he has had chronic abdominal pain for which he
has been taking round the clock Tylenol. He notes a fever to
102.4 this morning. He also had nausea without vomiting. He also
endorses 25 pound weight loss since ___ and poor PO intake.
He initially presented to ___ this morning. Vitals were
Temp 102.4, BP 152/102, HR 112, RR 16, O2 sat 96% RA. Labs were
notable for WBC 12.3 and Tbili 3.7. He had a CXR without acute
process. RUQ US showed gallbladder sludge and small gallstones
without definite evidence of acute cholecystitis. He was given
Tylenol 1g IV, ertapenem 1g IV, morphine 4mg V, Zofran 4mg IV,
and 3L NS. Blood cultures were taken. Patient was transferred to
___ ED for further evaluation.
On arrival to the ED, initial vitals were 99.2 92 83/53 16 94%
RA. Labs were notable for WBC 11.0, H/H 13.0, Plt 220, INR 1.2,
Na 139, K 5.0, BUN/Cr ___, Mg 1.5, ALT 101, AST 135, ALP 395,
Tbili 3.8, lactate 1.5, and UA negative. Patient was given
Tylenol 1g IV and Zofran 4mg IV. ERCP was consulted and patient
was taken directly to ERCP from the ED. Prior to transfer vitals
were 101.0 95 124/66 16 97% RA.
Patient taken for ERCP which per report was uncomplicated. His
plastic stent was removed and a metal stent was placed across
the
CBD.
On arrival to the floor, patient reports feeling much better.
His
abdominal pain is improved, currently ___. His headache is also
better. He denies vision changes, dizziness/lightheadedness,
weakness/numbness, shortness of breath, cough, hemoptysis, chest
pain, palpitations, 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:
PAST ONCOLOGIC HISTORY:
- ___: RUQ abdominal pain and itching.
- ___: ERCP/EUS 2.5 cm x 1.9 cm ill-defined mass in the head
of the pancreas; FNB was performed which was benign. CA ___ 46
(mildly elevated), IgG4 normal.
- ___: Presented with cholangitis, ERCP/EUS for biliary
stenting, similar pancreatic head mass noted, cytology benign.
CT
A/P showed likely reactive lymph nodes, biliary dilation, no
clear mass.
- ___: EUS with FNB of pancreatic mass, FNA porta hepatis
lymph node, cyst cytology. Pathology from the cyst aspiration
showed mucinous neoplasm, FNB of the pancreatic head mass
adenocarcinoma, and the porta hepatis lymph node was benign.
PAST MEDICAL HISTORY:
- CAD s/p stent in ___, CABG ___
- HLD
- Hypertension
- R knee replacement
- Atrial fibrillation, s/p cardioversion now in NSR, previously
on anti-coagulation now d/c
- ___ esophagus without dysplasia
- Iron deficiency anemia
- Shingles with neuropathy
- Sarcoidosis (Dx ___ ___
- Anal fissure s/p repair ___ (Dr ___)
Social History:
___
Family History:
FAMILY HISTORY: Father with CAD. No family history of
malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98.7, BP 145/84, HR 81, RR 18, O2 sat 94% 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, positive bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
Discharge physical exam:
ADMISSION PHYSICAL EXAM:
VS: 98.1, BP: 123/69, HR: 74, RR: 20, O2: 94% 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, positive bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No rashes
Pertinent Results:
___ 07:13AM BLOOD WBC-7.5 RBC-4.17* Hgb-12.1* Hct-36.0*
MCV-86 MCH-29.0 MCHC-33.6 RDW-13.3 RDWSD-41.7 Plt ___
___ 07:45AM BLOOD WBC-7.3 RBC-3.90* Hgb-11.4* Hct-34.2*
MCV-88 MCH-29.2 MCHC-33.3 RDW-13.4 RDWSD-42.8 Plt ___
___ 02:40PM BLOOD WBC-11.0* RBC-4.56* Hgb-13.0* Hct-40.5
MCV-89 MCH-28.5 MCHC-32.1 RDW-13.4 RDWSD-43.8 Plt ___
___ 02:40PM BLOOD Neuts-89.4* Lymphs-2.3* Monos-7.7
Eos-0.0* Baso-0.1 Im ___ AbsNeut-9.86* AbsLymp-0.25*
AbsMono-0.85* AbsEos-0.00* AbsBaso-0.01
___ 07:13AM BLOOD Plt ___
___ 07:45AM BLOOD Plt ___
___ 02:40PM BLOOD Plt ___
___ 02:40PM BLOOD ___ PTT-29.4 ___
___ 07:13AM BLOOD Glucose-114* UreaN-6 Creat-0.6 Na-137
K-3.9 Cl-96 HCO3-28 AnGap-13
___ 07:45AM BLOOD Glucose-111* UreaN-8 Creat-0.6 Na-137
K-4.0 Cl-99 HCO3-27 AnGap-11
___ 02:40PM BLOOD Glucose-106* UreaN-10 Creat-0.8 Na-139
K-5.0 Cl-102 HCO3-22 AnGap-15
___ 07:13AM BLOOD ALT-48* AST-37 AlkPhos-280* TotBili-1.1
___ 07:45AM BLOOD ALT-70* AST-73* AlkPhos-309* TotBili-1.8*
___ 02:40PM BLOOD ALT-101* AST-135* AlkPhos-395*
TotBili-3.8*
___ 02:40PM BLOOD Lipase-22
___ 07:13AM BLOOD Calcium-9.0 Phos-2.5* Mg-1.8
___ 07:45AM BLOOD Calcium-8.8 Phos-2.4* Mg-1.9
___ 02:40PM BLOOD Albumin-3.4* Calcium-8.9 Phos-3.0 Mg-1.5*
___ 03:05PM BLOOD Lactate-1.5
___ 3:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 2:40 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
ERCP ___
Impression: The scout film showed a plastic stent in the RUQ. A
plastic stent placed in the biliary duct was found in the major
papilla. The stent was removed with a 20mm snare. Evidence of a
previous biliary sphincterotomy was seen. The bile duct was
successfully cannulated using a Rx sphincterotome preloaded with
0.035in guidewire. Contrast was injected and there was brisk
flow
through the ducts. Contrast extended to the entire biliary tree.
Contrast injection revealed no filling defects in the CBD. A
10mm
x 60mm Wallflex biliary Rx Fully covered metal stent (ref
___, lot ___ was placed across the CBD. Excellent
bile and contrast drainage was seen endoscopically and
fluoroscopically.
CXR ___ at ___
1. No acute findings.
2. Right lung nodule suspicious for lung cancer as noted on
recent CT scan. Further investigation is recommended if not
already performed.
RUQ US ___ at ___
Impression: Gallbladder sludge and small gallstones. No definite
evidence of acute cholecystitis. Prominent extrahepatic bile
ducts, possibly containing some sludge or small stones. Mild
pneumobilia, likely related to recent instrumentation.
Brief Hospital Course:
Mr. ___ is a ___ male with history of CAD
s/p CABG, sarcoidosis, atrial fibrillation not on
anticoagulation, and recent diagnosis of pancreatic
adenocarcinoma who presents with abdominal pain and fever and
now
s/p ERCP with stent exchange. He was observed post ERCP with
stent exchange and had abdominal pain and nausea on day post
procedure. His diet was slowly advanced from clear to full
liquid and he was tolerating PO diet on day of discharge. He was
discharged to continue a total course of Augmentin for 5 days.
He will follow-up with oncology as an outpatient.
# Cholangitis:
# Abdominal Pain:
# Elevated Bilirubin:
# Fevers: Patient with likely stent malfunction. He is now s/p
ERCP with stent exchange and now has metal stent. His abdominal
pain is improved.
- Patient's diet advanced to regular
- Monitored for abdominal pain, fever
- Antibiotics with plan to complete ___ day course, initially
plan to start cipro/flagyl however patient declines cipro as had
side effects previously so will give augmentin which was also
given during recent admission, given rx on discharge
- Morphine PRN abdominal pain
- Zofran PRN nausea requested on discharge (he reports he was
taking expired Zofran pills in past)
- Trend LFTs as outpatient
- Follow-up cultures
# Pancreatic Adenocarcinoma: Plan for neoadjuvant chemotherapy
following by possible surgery.
- Follow-up with outpatient Oncologist
# CAD: Cardiologist is ___ in ___.
- Continue home aspirin
- Continue home metoprolol and atorvastatin
# Hypertension
- Continue home metoprolol, imdur, and lisinopril
# Atrial Fibrillation: Prior history of AFib, per patient s/p
cardioversion. Previously on anti-coagulation, now discontinued.
Currently in sinus rhythm.
- Continue home metoprolol
# Insomnia
- Continue home alprazolam
EMERGENCY CONTACT HCP: ___ (wife/HCP) ___
___ issues:
-Follow-up with oncology as an outpatient
-Follow-up with outpatient CBC and chemistries and LFTs
-Follow-up with outpatient CT chest if not already performed for
lung nodule noted on Chest X-ray
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 3 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*6 Tablet Refills:*0
2. Ondansetron 4 mg PO Q8H:PRN nausea Duration: 7 Days
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours as
needed for nausea Disp #*21 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Lisinopril 5 mg PO DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Stent malfunction, now s/p
ERCP with stent exchange and now has metal stent
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were with abdominal pain and fever and now
s/p ERCP with stent exchange. Please continue course of
antibiotics. Please follow-up with your oncologist as an
outpatient. We wish you best wishes in your recovery.
Best wishes,
Your ___ team
Followup Instructions:
___
|
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Allergies: Zetia / simvastatin Chief Complaint: CC: [MASKED] Pain, [MASKED] Major Surgical or Invasive Procedure: ERCP with stent exchange History of Present Illness: HISTORY OF PRESENTING ILLNESS: Mr. [MASKED] is a [MASKED] male with history of CAD s/p CABG, sarcoidosis, atrial fibrillation not on anticoagulation, and recent diagnosis of pancreatic adenocarcinoma who presents with abdominal pain and fever and now s/p ERCP with stent exchange. Patient reports that he developed severe diffuse abdominal pain the morning of admission. He describes the pain as sharp and constant. The pain progressively got worse. Since diagnosis of pancreatic cancer he has had chronic abdominal pain for which he has been taking round the clock Tylenol. He notes a fever to 102.4 this morning. He also had nausea without vomiting. He also endorses 25 pound weight loss since [MASKED] and poor PO intake. He initially presented to [MASKED] this morning. Vitals were Temp 102.4, BP 152/102, HR 112, RR 16, O2 sat 96% RA. Labs were notable for WBC 12.3 and Tbili 3.7. He had a CXR without acute process. RUQ US showed gallbladder sludge and small gallstones without definite evidence of acute cholecystitis. He was given Tylenol 1g IV, ertapenem 1g IV, morphine 4mg V, Zofran 4mg IV, and 3L NS. Blood cultures were taken. Patient was transferred to [MASKED] ED for further evaluation. On arrival to the ED, initial vitals were 99.2 92 83/53 16 94% RA. Labs were notable for WBC 11.0, H/H 13.0, Plt 220, INR 1.2, Na 139, K 5.0, BUN/Cr [MASKED], Mg 1.5, ALT 101, AST 135, ALP 395, Tbili 3.8, lactate 1.5, and UA negative. Patient was given Tylenol 1g IV and Zofran 4mg IV. ERCP was consulted and patient was taken directly to ERCP from the ED. Prior to transfer vitals were 101.0 95 124/66 16 97% RA. Patient taken for ERCP which per report was uncomplicated. His plastic stent was removed and a metal stent was placed across the CBD. On arrival to the floor, patient reports feeling much better. His abdominal pain is improved, currently [MASKED]. His headache is also better. He denies vision changes, dizziness/lightheadedness, weakness/numbness, shortness of breath, cough, hemoptysis, chest pain, palpitations, 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: PAST ONCOLOGIC HISTORY: - [MASKED]: RUQ abdominal pain and itching. - [MASKED]: ERCP/EUS 2.5 cm x 1.9 cm ill-defined mass in the head of the pancreas; FNB was performed which was benign. CA [MASKED] 46 (mildly elevated), IgG4 normal. - [MASKED]: Presented with cholangitis, ERCP/EUS for biliary stenting, similar pancreatic head mass noted, cytology benign. CT A/P showed likely reactive lymph nodes, biliary dilation, no clear mass. - [MASKED]: EUS with FNB of pancreatic mass, FNA porta hepatis lymph node, cyst cytology. Pathology from the cyst aspiration showed mucinous neoplasm, FNB of the pancreatic head mass adenocarcinoma, and the porta hepatis lymph node was benign. PAST MEDICAL HISTORY: - CAD s/p stent in [MASKED], CABG [MASKED] - HLD - Hypertension - R knee replacement - Atrial fibrillation, s/p cardioversion now in NSR, previously on anti-coagulation now d/c - [MASKED] esophagus without dysplasia - Iron deficiency anemia - Shingles with neuropathy - Sarcoidosis (Dx [MASKED] [MASKED] - Anal fissure s/p repair [MASKED] (Dr [MASKED]) Social History: [MASKED] Family History: FAMILY HISTORY: Father with CAD. No family history of malignancy. Physical Exam: ADMISSION PHYSICAL EXAM: VS: Temp 98.7, BP 145/84, HR 81, RR 18, O2 sat 94% 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, positive bowel sounds. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Strength full throughout. Sensation to light touch intact. SKIN: No significant rashes. Discharge physical exam: ADMISSION PHYSICAL EXAM: VS: 98.1, BP: 123/69, HR: 74, RR: 20, O2: 94% 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, positive bowel sounds. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Strength full throughout. Sensation to light touch intact. SKIN: No rashes Pertinent Results: [MASKED] 07:13AM BLOOD WBC-7.5 RBC-4.17* Hgb-12.1* Hct-36.0* MCV-86 MCH-29.0 MCHC-33.6 RDW-13.3 RDWSD-41.7 Plt [MASKED] [MASKED] 07:45AM BLOOD WBC-7.3 RBC-3.90* Hgb-11.4* Hct-34.2* MCV-88 MCH-29.2 MCHC-33.3 RDW-13.4 RDWSD-42.8 Plt [MASKED] [MASKED] 02:40PM BLOOD WBC-11.0* RBC-4.56* Hgb-13.0* Hct-40.5 MCV-89 MCH-28.5 MCHC-32.1 RDW-13.4 RDWSD-43.8 Plt [MASKED] [MASKED] 02:40PM BLOOD Neuts-89.4* Lymphs-2.3* Monos-7.7 Eos-0.0* Baso-0.1 Im [MASKED] AbsNeut-9.86* AbsLymp-0.25* AbsMono-0.85* AbsEos-0.00* AbsBaso-0.01 [MASKED] 07:13AM BLOOD Plt [MASKED] [MASKED] 07:45AM BLOOD Plt [MASKED] [MASKED] 02:40PM BLOOD Plt [MASKED] [MASKED] 02:40PM BLOOD [MASKED] PTT-29.4 [MASKED] [MASKED] 07:13AM BLOOD Glucose-114* UreaN-6 Creat-0.6 Na-137 K-3.9 Cl-96 HCO3-28 AnGap-13 [MASKED] 07:45AM BLOOD Glucose-111* UreaN-8 Creat-0.6 Na-137 K-4.0 Cl-99 HCO3-27 AnGap-11 [MASKED] 02:40PM BLOOD Glucose-106* UreaN-10 Creat-0.8 Na-139 K-5.0 Cl-102 HCO3-22 AnGap-15 [MASKED] 07:13AM BLOOD ALT-48* AST-37 AlkPhos-280* TotBili-1.1 [MASKED] 07:45AM BLOOD ALT-70* AST-73* AlkPhos-309* TotBili-1.8* [MASKED] 02:40PM BLOOD ALT-101* AST-135* AlkPhos-395* TotBili-3.8* [MASKED] 02:40PM BLOOD Lipase-22 [MASKED] 07:13AM BLOOD Calcium-9.0 Phos-2.5* Mg-1.8 [MASKED] 07:45AM BLOOD Calcium-8.8 Phos-2.4* Mg-1.9 [MASKED] 02:40PM BLOOD Albumin-3.4* Calcium-8.9 Phos-3.0 Mg-1.5* [MASKED] 03:05PM BLOOD Lactate-1.5 [MASKED] 3:00 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 2:40 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. IMAGING: ERCP [MASKED] Impression: The scout film showed a plastic stent in the RUQ. A plastic stent placed in the biliary duct was found in the major papilla. The stent was removed with a 20mm snare. Evidence of a previous biliary sphincterotomy was seen. The bile duct was successfully cannulated using a Rx sphincterotome preloaded with 0.035in guidewire. Contrast was injected and there was brisk flow through the ducts. Contrast extended to the entire biliary tree. Contrast injection revealed no filling defects in the CBD. A 10mm x 60mm Wallflex biliary Rx Fully covered metal stent (ref [MASKED], lot [MASKED] was placed across the CBD. Excellent bile and contrast drainage was seen endoscopically and fluoroscopically. CXR [MASKED] at [MASKED] 1. No acute findings. 2. Right lung nodule suspicious for lung cancer as noted on recent CT scan. Further investigation is recommended if not already performed. RUQ US [MASKED] at [MASKED] Impression: Gallbladder sludge and small gallstones. No definite evidence of acute cholecystitis. Prominent extrahepatic bile ducts, possibly containing some sludge or small stones. Mild pneumobilia, likely related to recent instrumentation. Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with history of CAD s/p CABG, sarcoidosis, atrial fibrillation not on anticoagulation, and recent diagnosis of pancreatic adenocarcinoma who presents with abdominal pain and fever and now s/p ERCP with stent exchange. He was observed post ERCP with stent exchange and had abdominal pain and nausea on day post procedure. His diet was slowly advanced from clear to full liquid and he was tolerating PO diet on day of discharge. He was discharged to continue a total course of Augmentin for 5 days. He will follow-up with oncology as an outpatient. # Cholangitis: # Abdominal Pain: # Elevated Bilirubin: # Fevers: Patient with likely stent malfunction. He is now s/p ERCP with stent exchange and now has metal stent. His abdominal pain is improved. - Patient's diet advanced to regular - Monitored for abdominal pain, fever - Antibiotics with plan to complete [MASKED] day course, initially plan to start cipro/flagyl however patient declines cipro as had side effects previously so will give augmentin which was also given during recent admission, given rx on discharge - Morphine PRN abdominal pain - Zofran PRN nausea requested on discharge (he reports he was taking expired Zofran pills in past) - Trend LFTs as outpatient - Follow-up cultures # Pancreatic Adenocarcinoma: Plan for neoadjuvant chemotherapy following by possible surgery. - Follow-up with outpatient Oncologist # CAD: Cardiologist is [MASKED] in [MASKED]. - Continue home aspirin - Continue home metoprolol and atorvastatin # Hypertension - Continue home metoprolol, imdur, and lisinopril # Atrial Fibrillation: Prior history of AFib, per patient s/p cardioversion. Previously on anti-coagulation, now discontinued. Currently in sinus rhythm. - Continue home metoprolol # Insomnia - Continue home alprazolam EMERGENCY CONTACT HCP: [MASKED] (wife/HCP) [MASKED] [MASKED] issues: -Follow-up with oncology as an outpatient -Follow-up with outpatient CBC and chemistries and LFTs -Follow-up with outpatient CT chest if not already performed for lung nodule noted on Chest X-ray Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.5 mg PO QHS:PRN insomnia 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 5. Lisinopril 5 mg PO DAILY 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 8. Docusate Sodium 100 mg PO BID:PRN constipation 9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild Discharge Medications: 1. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H Duration: 3 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0 2. Ondansetron 4 mg PO Q8H:PRN nausea Duration: 7 Days RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours as needed for nausea Disp #*21 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. ALPRAZolam 0.5 mg PO QHS:PRN insomnia 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Docusate Sodium 100 mg PO BID:PRN constipation 8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 9. Lisinopril 5 mg PO DAILY 10. Metoprolol Succinate XL 100 mg PO DAILY 11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain Discharge Disposition: Home Discharge Diagnosis: Stent malfunction, now s/p ERCP with stent exchange and now has metal stent Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], You were with abdominal pain and fever and now s/p ERCP with stent exchange. Please continue course of antibiotics. Please follow-up with your oncologist as an outpatient. We wish you best wishes in your recovery. Best wishes, Your [MASKED] team Followup Instructions: [MASKED]
|
[] |
[
"I4891",
"Z951",
"E785",
"I10",
"D509",
"Z87891",
"G4700"
] |
[
"T85590A: Other mechanical complication of bile duct prosthesis, initial encounter",
"K830: Cholangitis",
"I4891: Unspecified atrial fibrillation",
"C250: Malignant neoplasm of head of pancreas",
"K8681: Exocrine pancreatic insufficiency",
"B0229: Other postherpetic nervous system involvement",
"R911: Solitary pulmonary nodule",
"Z951: Presence of aortocoronary bypass graft",
"D869: Sarcoidosis, unspecified",
"G893: Neoplasm related pain (acute) (chronic)",
"R634: Abnormal weight loss",
"Z6832: Body mass index [BMI] 32.0-32.9, adult",
"E785: Hyperlipidemia, unspecified",
"I10: Essential (primary) hypertension",
"Z96651: Presence of right artificial knee joint",
"K2270: Barrett's esophagus without dysplasia",
"D509: Iron deficiency anemia, unspecified",
"Z87891: Personal history of nicotine dependence",
"G4700: Insomnia, unspecified"
] |
10,024,451
| 21,654,679
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Zetia / simvastatin / adhesive tape
Attending: ___.
Chief Complaint:
Pancreatic adenocarcinoma
Major Surgical or Invasive Procedure:
___: Staging laparoscopy and pylorus-preserving
pancreaticoduodenectomy as well as fiducial placement.
History of Present Illness:
The patient is a ___ y.o. male with a history of pancreatic head
cancer, which was diagnosed this past ___. He has
completed neoadjuvant chemotherapy, and presents today for a
diagnostic laparoscopy with Whipple Procedure.
Past Medical History:
PAST MEDICAL HISTORY:
- Pancreatic adenocarcinoma
- CAD s/p stent in ___, CABG ___
- HLD
- Hypertension
- R knee replacement
- Atrial fibrillation, s/p cardioversion now in NSR, previously
on anti-coagulation now d/c
- ___ esophagus without dysplasia
- Iron deficiency anemia
- Shingles with neuropathy
- Sarcoidosis (Dx ___ ___
- Anal fissure s/p repair ___ (Dr ___)
Social History:
___
Family History:
FAMILY HISTORY: Father with CAD. No family history of
malignancy.
Physical Exam:
Prior to Discharge:
VS: 98.1, 65, 115/70, 93% RA
GEN: Pleasant with NAD
HEENT: No scleral icterus
CV: RRR
PULM: CTAB
ABD: Bilateral subcostal incision open to air with staples,
blanching erythema around incision marked, no evidence of
drainage. RLQ JP drain to bulb suction with moderated amount
serous fluid, site with drain sponge and c/d/I.
EXTR: Warm, no c/c/e
Pertinent Results:
RECENT LABS:
___ 03:41AM BLOOD WBC-9.9 RBC-4.32* Hgb-12.8* Hct-38.8*
MCV-90 MCH-29.6 MCHC-33.0 RDW-14.4 RDWSD-47.7* Plt ___
___ 03:41AM BLOOD Glucose-142* UreaN-5* Creat-0.5 Na-141
K-3.5 Cl-103 HCO3-25 AnGap-13
___ 03:41AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.9
___ 10:01AM ASCITES Amylase-15 Triglyc-234
PATHOLOGY: Locally advanced pancreatic adenocarcinoma
Brief Hospital Course:
The patient with biopsy proven pancreatic head carcinoma was
admitted to the HPB Surgical Service on ___ for elective
resection. On ___, the patient underwent pylorus-preserving
pancreaticoduodenectomy (Whipple) and open cholecystectomy,
which went well without complication (reader referred to the
Operative Note for details). After a brief, uneventful stay in
the PACU, the patient arrived on the floor NPO with an NG tube,
on IV fluids, with a foley catheter and a JP drain x 2 in place,
and epidural catheter for pain control. The patient was
hemodynamically stable.
The ___ hospital course was uneventful and followed the
Whipple Clinical Pathway with minimal deviation. Post-operative
pain was initially well controlled with epidural analgesia,
which was converted to oral pain medication when tolerating
clear liquids. The NG tube was discontinued on POD# 4, and the
foley catheter discontinued at midnight of POD# 5. The patient
subsequently voided without problem. The patient was started on
sips of clears on POD# 5, which was progressively advanced as
tolerated to a regular diet by POD#7. JP amylase was sent in
the evening of POD#6, amylase was low in both JPs, and JP 1 was
removed. The JP 2 was remained in place on discharge secondary
to chylous leak.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. Prior to discharge patient was
transitioned to prophylactic Lovenox. The patient's blood sugar
was monitored regularly throughout the stay; sliding scale
insulin was administered when indicated, no insulin was required
on discharge. Patient was started on Keflex x 5 days secondary
to wound erythema.
At the time of discharge on ___, the patient was doing
well, afebrile with stable vital signs. The patient was
tolerating a regular low fat diet, ambulating, voiding without
assistance, and pain was well controlled. The patient was
discharged home with services to continue JP drain care, wound
care and Lovenox teaching. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
Xanax 0.5', atorvastatin 40', imdur XR 30', toprol XL 100', ASA
81', nitro PRN
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
do not exceed more then 3000 mg/day
2. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*12 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*30
Syringe Refills:*0
5. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tab by mouth QIDACHS Disp #*56
Tablet Refills:*0
6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*28 Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Senna 8.6 mg PO BID
9. ALPRAZolam 0.5 mg PO QHS:PRN insomnia
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 40 mg PO QPM
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Pancreatic ductal adenocarcinoma
2. Severe malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to the surgery service at ___ for surgical
resection of your pancreatic mass. Your recovery was complicated
by chylous JP drain output, and you were transitioned to low fat
diet. You have done well in the post operative period and are
now safe to return home to complete your recovery with the
following instructions:
.
Please call Dr. ___ office at ___ or Office Nurses
at ___ if you have any questions or concerns.
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
[
"C250",
"E43",
"C772",
"I4891",
"C3411",
"D7389",
"B0229",
"L03311",
"T814XXA",
"K8681",
"B9689",
"Y832",
"Y92230",
"Z6829",
"K2270",
"Z9221",
"Z951",
"E785",
"I10",
"Z96651",
"D509",
"D8689",
"Z87891",
"Z006",
"N400",
"F419",
"K811"
] |
Allergies: Zetia / simvastatin / adhesive tape Chief Complaint: Pancreatic adenocarcinoma Major Surgical or Invasive Procedure: [MASKED]: Staging laparoscopy and pylorus-preserving pancreaticoduodenectomy as well as fiducial placement. History of Present Illness: The patient is a [MASKED] y.o. male with a history of pancreatic head cancer, which was diagnosed this past [MASKED]. He has completed neoadjuvant chemotherapy, and presents today for a diagnostic laparoscopy with Whipple Procedure. Past Medical History: PAST MEDICAL HISTORY: - Pancreatic adenocarcinoma - CAD s/p stent in [MASKED], CABG [MASKED] - HLD - Hypertension - R knee replacement - Atrial fibrillation, s/p cardioversion now in NSR, previously on anti-coagulation now d/c - [MASKED] esophagus without dysplasia - Iron deficiency anemia - Shingles with neuropathy - Sarcoidosis (Dx [MASKED] [MASKED] - Anal fissure s/p repair [MASKED] (Dr [MASKED]) Social History: [MASKED] Family History: FAMILY HISTORY: Father with CAD. No family history of malignancy. Physical Exam: Prior to Discharge: VS: 98.1, 65, 115/70, 93% RA GEN: Pleasant with NAD HEENT: No scleral icterus CV: RRR PULM: CTAB ABD: Bilateral subcostal incision open to air with staples, blanching erythema around incision marked, no evidence of drainage. RLQ JP drain to bulb suction with moderated amount serous fluid, site with drain sponge and c/d/I. EXTR: Warm, no c/c/e Pertinent Results: RECENT LABS: [MASKED] 03:41AM BLOOD WBC-9.9 RBC-4.32* Hgb-12.8* Hct-38.8* MCV-90 MCH-29.6 MCHC-33.0 RDW-14.4 RDWSD-47.7* Plt [MASKED] [MASKED] 03:41AM BLOOD Glucose-142* UreaN-5* Creat-0.5 Na-141 K-3.5 Cl-103 HCO3-25 AnGap-13 [MASKED] 03:41AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.9 [MASKED] 10:01AM ASCITES Amylase-15 Triglyc-234 PATHOLOGY: Locally advanced pancreatic adenocarcinoma Brief Hospital Course: The patient with biopsy proven pancreatic head carcinoma was admitted to the HPB Surgical Service on [MASKED] for elective resection. On [MASKED], the patient underwent pylorus-preserving pancreaticoduodenectomy (Whipple) and open cholecystectomy, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO with an NG tube, on IV fluids, with a foley catheter and a JP drain x 2 in place, and epidural catheter for pain control. The patient was hemodynamically stable. The [MASKED] hospital course was uneventful and followed the Whipple Clinical Pathway with minimal deviation. Post-operative pain was initially well controlled with epidural analgesia, which was converted to oral pain medication when tolerating clear liquids. The NG tube was discontinued on POD# 4, and the foley catheter discontinued at midnight of POD# 5. The patient subsequently voided without problem. The patient was started on sips of clears on POD# 5, which was progressively advanced as tolerated to a regular diet by POD#7. JP amylase was sent in the evening of POD#6, amylase was low in both JPs, and JP 1 was removed. The JP 2 was remained in place on discharge secondary to chylous leak. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. Prior to discharge patient was transitioned to prophylactic Lovenox. The patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated, no insulin was required on discharge. Patient was started on Keflex x 5 days secondary to wound erythema. At the time of discharge on [MASKED], the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular low fat diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home with services to continue JP drain care, wound care and Lovenox teaching. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Xanax 0.5', atorvastatin 40', imdur XR 30', toprol XL 100', ASA 81', nitro PRN Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild do not exceed more then 3000 mg/day 2. Cephalexin 500 mg PO Q6H RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours Disp #*12 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 4. Enoxaparin Sodium 40 mg SC DAILY RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*30 Syringe Refills:*0 5. Metoclopramide 10 mg PO QIDACHS RX *metoclopramide HCl 10 mg 1 tab by mouth QIDACHS Disp #*56 Tablet Refills:*0 6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*28 Tablet Refills:*0 7. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 8. Senna 8.6 mg PO BID 9. ALPRAZolam 0.5 mg PO QHS:PRN insomnia 10. Aspirin 81 mg PO DAILY 11. Atorvastatin 40 mg PO QPM 12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 13. Metoprolol Succinate XL 100 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: 1. Pancreatic ductal adenocarcinoma 2. Severe malnutrition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], You were admitted to the surgery service at [MASKED] for surgical resection of your pancreatic mass. Your recovery was complicated by chylous JP drain output, and you were transitioned to low fat diet. You have done well in the post operative period and are now safe to return home to complete your recovery with the following instructions: . Please call Dr. [MASKED] office at [MASKED] or Office Nurses at [MASKED] if you have any questions or concerns. . Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Incision Care: *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. . JP Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb. *Note color, consistency, and amount of fluid in the drain. Call the doctor, [MASKED], or [MASKED] nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *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. Followup Instructions: [MASKED]
|
[] |
[
"I4891",
"Y92230",
"Z951",
"E785",
"I10",
"D509",
"Z87891",
"N400",
"F419"
] |
[
"C250: Malignant neoplasm of head of pancreas",
"E43: Unspecified severe protein-calorie malnutrition",
"C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes",
"I4891: Unspecified atrial fibrillation",
"C3411: Malignant neoplasm of upper lobe, right bronchus or lung",
"D7389: Other diseases of spleen",
"B0229: Other postherpetic nervous system involvement",
"L03311: Cellulitis of abdominal wall",
"T814XXA: Infection following a procedure",
"K8681: Exocrine pancreatic insufficiency",
"B9689: Other specified bacterial agents as the cause of diseases classified elsewhere",
"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",
"Y92230: Patient room in hospital as the place of occurrence of the external cause",
"Z6829: Body mass index [BMI] 29.0-29.9, adult",
"K2270: Barrett's esophagus without dysplasia",
"Z9221: Personal history of antineoplastic chemotherapy",
"Z951: Presence of aortocoronary bypass graft",
"E785: Hyperlipidemia, unspecified",
"I10: Essential (primary) hypertension",
"Z96651: Presence of right artificial knee joint",
"D509: Iron deficiency anemia, unspecified",
"D8689: Sarcoidosis of other sites",
"Z87891: Personal history of nicotine dependence",
"Z006: Encounter for examination for normal comparison and control in clinical research program",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"F419: Anxiety disorder, unspecified",
"K811: Chronic cholecystitis"
] |
10,024,451
| 24,547,411
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zetia / simvastatin
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with Hx CAD s/p CABG,
sarcoidosis, prior AFib not on anti-coagulation, recently
discharged after being treated for cholangitis and s/p biliary
stent placement for biliary stricture currently with ongoing
workup for newly diagnosed tumor involving the head of the
pancreas now representing a week after discharge with recurrent
severe abdominal pain L > R.
Patient completed a course of cipro/flagyll on ___ for
treatment
of cholangitis. He underwent EUS on ___ with repeat FNB of
subtle ill-defined pancreatic mass. CBD was found to be dilated
at 1cm. Previously placed stent was visible, no intrinsic sludge
or stones were visible. Patient reports that he was at work
yesterday feeling reasonably okay but may have had long hours of
fasting in the setting post-prandial nausea and abdominal pain
and subsequent loss of appetite. he went home and had an omelet
after which he developed moderate to severe abdominal pain that
started in the left side of the abdomen and started to make its
way across to the other side. The pain persisted and became
progressively worse so he presented to ___ at which
time it had reached about a 12 or more out 10. The pain resolved
soon after he received 0.5mg IV dilaudid. He notes that he was
called by Dr. ___ who asked him if he could come to
___ tomorrow for the tumor board meeting which he declined
stating that he couldn't do so at such short notice. Over tha
past few weeks he thinks he has probably had some weight loss
but
hasn't weighed himself recently. Since recent discharge, he has
not had any jaundice, fevers, chills, or vomiting. He continues
to have poor po intake with early satiety, increased belching
and
increased reflux / heartburn symptoms. He denies diarrhea or
constipation.
For his newly diagnosed pancreatic tumor. Workup so far has been
notable for negative FNB on initial ERCP. Biopsies from the most
recent EUS (___) are still pending. ___ is mildly elevated
at
46. IgG subclasses have been normal.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
CAD, stent in ___, CABG ___
- HLD
- Hypertension
- R knee replacement
- Atrial fibrillation, s/p cardioversion now in NSR, previously
on anti-coagulation now d/c
- ___ esophagus without dysplasia
- Iron deficiency anemia
- Shingles with neuropathy
- Sarcoidosis
Social History:
___
Family History:
+ CAD (father)
Physical Exam:
EXAM(8)
VITALS: 97.9
PO 113 / 71 74 18 94 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Discharge physical exam:
VITALS: Per eflowsheet. Reviewed and stable
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 11:55PM BLOOD WBC-9.0 RBC-4.55* Hgb-13.7 Hct-40.3
MCV-89 MCH-30.1 MCHC-34.0 RDW-12.7 RDWSD-40.9 Plt ___
___ 09:25AM BLOOD Neuts-84.8* Lymphs-5.0* Monos-7.7 Eos-1.0
Baso-0.2 Im ___ AbsNeut-8.82* AbsLymp-0.52* AbsMono-0.80
AbsEos-0.10 AbsBaso-0.02
___ 09:25AM BLOOD Glucose-106* UreaN-7 Creat-0.7 Na-136
K-4.8 Cl-96 HCO3-27 AnGap-13
___ 06:55AM BLOOD Glucose-101* UreaN-7 Creat-0.6 Na-138
K-4.6 Cl-99 HCO3-21* AnGap-18*
___ 11:55PM BLOOD Glucose-133* UreaN-10 Creat-0.7 Na-138
K-4.8 Cl-98 HCO3-25 AnGap-15
___ 09:25AM BLOOD ALT-123* AST-190* AlkPhos-394* Amylase-53
TotBili-3.0*
___ 11:55PM BLOOD ALT-94* AST-162* AlkPhos-325*
TotBili-1.9*
___ 09:25AM BLOOD Lipase-30
___ 06:55AM BLOOD Lipase-35
___ 11:55PM BLOOD Lipase-125*
EUS
Impression: EUS was performed using a linear echoendoscope at
7.5 and ___ MHz frequency.
The head and uncinate pancreas were imaged from the duodenal
bulb and the second / third duodenum.
The body and tail were imaged from the gastric body and fundus.
Mass: A very subtle 1cm ill-defined mass was noted at the
junction of CBD and the pancreas.
The mass was hypoechoic and heterogenous in echotexture.
The borders of the mass were irregular and poorly defined.
FNB was performed of the mass. Color doppler was used to
determine an avascular path for needle biopsy.
A 22-gauge SharkCore needle with a stylet was used to perform
biopsy. Three needle passes were made into the mass
Bile duct: The bile duct was imaged at the level of the
porta-hepatis, head of the pancreas and ampulla.
The CBD was dilated up to 1cm in diameter with abrupt
termination at the hypoechoic mass in the head of the pancreas.
The previously placed stent was visible. No intrinsic stones or
sludge were noted.
Cyst: A discrete anechoic lesion, consistent with a cyst was
noted in the neck of the pancreas.
The diameter of the cyst was 1.1cm. The walls of the cysts were
thin and well-defined. No intrinsic mass, septations or debris
were noted within the cyst.
A 22-gauge needle with a stylet was used to perform aspiration.
One needle pass was made into the cyst. 1 cc of clear thick
viscous fluid was aspirated from the cyst.
Aspirate was sent for cytology.
A lymph node was noted in the portahepatis. The lymph node was
hypoechoic and homogenous in echotexture. The borders were
well-defined. No central intra-nodal vessels were seen.
FNA was performed of the lymph node. Color doppler was used to
determine an avascular path for needle aspiration. A 25-gauge
needle with a stylet was used to perform aspiration. Two needle
passes were made.
Discharge labs
___ 08:00AM BLOOD WBC-8.0 RBC-4.60 Hgb-13.4* Hct-40.1
MCV-87 MCH-29.1 MCHC-33.4 RDW-12.8 RDWSD-40.3 Plt ___
___ 09:25AM BLOOD Neuts-84.8* Lymphs-5.0* Monos-7.7 Eos-1.0
Baso-0.2 Im ___ AbsNeut-8.82* AbsLymp-0.52* AbsMono-0.80
AbsEos-0.10 AbsBaso-0.02
___ 08:00AM BLOOD Glucose-120* UreaN-7 Creat-0.7 Na-138
K-4.6 Cl-99 HCO3-26 AnGap-13
___ 08:00AM BLOOD ALT-63* AST-39 AlkPhos-346* TotBili-1.1
DirBili-0.5* IndBili-0.6
___ 08:00AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.8
Brief Hospital Course:
Mr. ___ is a ___ male with Hx CAD s/p CABG, sarcoidosis,
prior AFib not on anti-coagulation, recently discharged after
being treated for cholangitis ___ last dose) and s/p biliary
stent placement for biliary stricture currently with ongoing
workup for newly diagnosed tumor involving the head of the
pancreas now representing a week after discharge with recurrent
severe abdominal pain L > R, poor po tolerance and weight loss,
found to have mildly elevated lipase, ALP and Tbili concerning
for pancreatitis versus stent displacement / blockage or due to
underlying tumor.
#Abdominal pain
#Pancreatic mass
#Hyperbilirubinemia: This improved as he was initiated on
antibiotics. It is unclear what caused this abdominal pain and
elevated liver enzymes. He represented with severe abdominal
pain 1 day after EUS. He had no fever, leukocytosis or sepsis
physiology. However given LFT were not downtrending, he was
started on antibiotics per ERCP recs. Lipase was mildly
elevated. Interval worsening in T bili was initially concerning
for either recurrent biliary obstruction versus stent
displacement versus underlying ??tumor.
He was discharged on augmentin (to be completed ___ for ___s he reported cipro/flagyl PO had caused significant
nausea. He tolerated PO prior to discharge.
#CAD - continued ASA, BB, ACE, Isosorbide. Restarted statin
given improvement in LFTS prior to discharge
#Anxiety / insomnia - continued home alprazolam
Transitional issues
=====================
- Augmentin for 7 days course (end date ___
- Needs follow up in pancreas clinic. Has appointment with
heme-onc ___ already
- ___ pancreas biopsy from ___ results not back yet. Will need
follow up for this.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth Twice a day. End date ___ Disp #*10 Tablet Refills:*0
2. ALPRAZolam 0.5 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
- Transaminitis
- Pancreatic mass
- Hyperbilirubinemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
You were admitted due to abdominal pain and your liver enzymes
were found to be elevated. This reassuringly improved and you
did not require a second ERCP. You were started on antibiotics
in case your symptoms were due to an infection and you will
complete this on ___.
Your biopsy results of your pancreas from the previous admission
were still pending and you will need to follow up with your
doctors.
It was a pleasure being part of your care.
Your ___ team
Followup Instructions:
___
|
[
"C250",
"K862",
"I4891",
"B0223",
"G8918",
"E785",
"R740",
"R634",
"Z6833",
"I2510",
"Z955",
"D869",
"I10",
"Z96651",
"K2270",
"D509",
"F419",
"G4700"
] |
Allergies: Zetia / simvastatin Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] male with Hx CAD s/p CABG, sarcoidosis, prior AFib not on anti-coagulation, recently discharged after being treated for cholangitis and s/p biliary stent placement for biliary stricture currently with ongoing workup for newly diagnosed tumor involving the head of the pancreas now representing a week after discharge with recurrent severe abdominal pain L > R. Patient completed a course of cipro/flagyll on [MASKED] for treatment of cholangitis. He underwent EUS on [MASKED] with repeat FNB of subtle ill-defined pancreatic mass. CBD was found to be dilated at 1cm. Previously placed stent was visible, no intrinsic sludge or stones were visible. Patient reports that he was at work yesterday feeling reasonably okay but may have had long hours of fasting in the setting post-prandial nausea and abdominal pain and subsequent loss of appetite. he went home and had an omelet after which he developed moderate to severe abdominal pain that started in the left side of the abdomen and started to make its way across to the other side. The pain persisted and became progressively worse so he presented to [MASKED] at which time it had reached about a 12 or more out 10. The pain resolved soon after he received 0.5mg IV dilaudid. He notes that he was called by Dr. [MASKED] who asked him if he could come to [MASKED] tomorrow for the tumor board meeting which he declined stating that he couldn't do so at such short notice. Over tha past few weeks he thinks he has probably had some weight loss but hasn't weighed himself recently. Since recent discharge, he has not had any jaundice, fevers, chills, or vomiting. He continues to have poor po intake with early satiety, increased belching and increased reflux / heartburn symptoms. He denies diarrhea or constipation. For his newly diagnosed pancreatic tumor. Workup so far has been notable for negative FNB on initial ERCP. Biopsies from the most recent EUS ([MASKED]) are still pending. [MASKED] is mildly elevated at 46. IgG subclasses have been normal. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: CAD, stent in [MASKED], CABG [MASKED] - HLD - Hypertension - R knee replacement - Atrial fibrillation, s/p cardioversion now in NSR, previously on anti-coagulation now d/c - [MASKED] esophagus without dysplasia - Iron deficiency anemia - Shingles with neuropathy - Sarcoidosis Social History: [MASKED] Family History: + CAD (father) Physical Exam: EXAM(8) VITALS: 97.9 PO 113 / 71 74 18 94 RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Discharge physical exam: VITALS: Per eflowsheet. Reviewed and stable GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: [MASKED] 11:55PM BLOOD WBC-9.0 RBC-4.55* Hgb-13.7 Hct-40.3 MCV-89 MCH-30.1 MCHC-34.0 RDW-12.7 RDWSD-40.9 Plt [MASKED] [MASKED] 09:25AM BLOOD Neuts-84.8* Lymphs-5.0* Monos-7.7 Eos-1.0 Baso-0.2 Im [MASKED] AbsNeut-8.82* AbsLymp-0.52* AbsMono-0.80 AbsEos-0.10 AbsBaso-0.02 [MASKED] 09:25AM BLOOD Glucose-106* UreaN-7 Creat-0.7 Na-136 K-4.8 Cl-96 HCO3-27 AnGap-13 [MASKED] 06:55AM BLOOD Glucose-101* UreaN-7 Creat-0.6 Na-138 K-4.6 Cl-99 HCO3-21* AnGap-18* [MASKED] 11:55PM BLOOD Glucose-133* UreaN-10 Creat-0.7 Na-138 K-4.8 Cl-98 HCO3-25 AnGap-15 [MASKED] 09:25AM BLOOD ALT-123* AST-190* AlkPhos-394* Amylase-53 TotBili-3.0* [MASKED] 11:55PM BLOOD ALT-94* AST-162* AlkPhos-325* TotBili-1.9* [MASKED] 09:25AM BLOOD Lipase-30 [MASKED] 06:55AM BLOOD Lipase-35 [MASKED] 11:55PM BLOOD Lipase-125* EUS Impression: EUS was performed using a linear echoendoscope at 7.5 and [MASKED] MHz frequency. The head and uncinate pancreas were imaged from the duodenal bulb and the second / third duodenum. The body and tail were imaged from the gastric body and fundus. Mass: A very subtle 1cm ill-defined mass was noted at the junction of CBD and the pancreas. The mass was hypoechoic and heterogenous in echotexture. The borders of the mass were irregular and poorly defined. FNB was performed of the mass. Color doppler was used to determine an avascular path for needle biopsy. A 22-gauge SharkCore needle with a stylet was used to perform biopsy. Three needle passes were made into the mass Bile duct: The bile duct was imaged at the level of the porta-hepatis, head of the pancreas and ampulla. The CBD was dilated up to 1cm in diameter with abrupt termination at the hypoechoic mass in the head of the pancreas. The previously placed stent was visible. No intrinsic stones or sludge were noted. Cyst: A discrete anechoic lesion, consistent with a cyst was noted in the neck of the pancreas. The diameter of the cyst was 1.1cm. The walls of the cysts were thin and well-defined. No intrinsic mass, septations or debris were noted within the cyst. A 22-gauge needle with a stylet was used to perform aspiration. One needle pass was made into the cyst. 1 cc of clear thick viscous fluid was aspirated from the cyst. Aspirate was sent for cytology. A lymph node was noted in the portahepatis. The lymph node was hypoechoic and homogenous in echotexture. The borders were well-defined. No central intra-nodal vessels were seen. FNA was performed of the lymph node. Color doppler was used to determine an avascular path for needle aspiration. A 25-gauge needle with a stylet was used to perform aspiration. Two needle passes were made. Discharge labs [MASKED] 08:00AM BLOOD WBC-8.0 RBC-4.60 Hgb-13.4* Hct-40.1 MCV-87 MCH-29.1 MCHC-33.4 RDW-12.8 RDWSD-40.3 Plt [MASKED] [MASKED] 09:25AM BLOOD Neuts-84.8* Lymphs-5.0* Monos-7.7 Eos-1.0 Baso-0.2 Im [MASKED] AbsNeut-8.82* AbsLymp-0.52* AbsMono-0.80 AbsEos-0.10 AbsBaso-0.02 [MASKED] 08:00AM BLOOD Glucose-120* UreaN-7 Creat-0.7 Na-138 K-4.6 Cl-99 HCO3-26 AnGap-13 [MASKED] 08:00AM BLOOD ALT-63* AST-39 AlkPhos-346* TotBili-1.1 DirBili-0.5* IndBili-0.6 [MASKED] 08:00AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.8 Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with Hx CAD s/p CABG, sarcoidosis, prior AFib not on anti-coagulation, recently discharged after being treated for cholangitis [MASKED] last dose) and s/p biliary stent placement for biliary stricture currently with ongoing workup for newly diagnosed tumor involving the head of the pancreas now representing a week after discharge with recurrent severe abdominal pain L > R, poor po tolerance and weight loss, found to have mildly elevated lipase, ALP and Tbili concerning for pancreatitis versus stent displacement / blockage or due to underlying tumor. #Abdominal pain #Pancreatic mass #Hyperbilirubinemia: This improved as he was initiated on antibiotics. It is unclear what caused this abdominal pain and elevated liver enzymes. He represented with severe abdominal pain 1 day after EUS. He had no fever, leukocytosis or sepsis physiology. However given LFT were not downtrending, he was started on antibiotics per ERCP recs. Lipase was mildly elevated. Interval worsening in T bili was initially concerning for either recurrent biliary obstruction versus stent displacement versus underlying ??tumor. He was discharged on augmentin (to be completed [MASKED] for s he reported cipro/flagyl PO had caused significant nausea. He tolerated PO prior to discharge. #CAD - continued ASA, BB, ACE, Isosorbide. Restarted statin given improvement in LFTS prior to discharge #Anxiety / insomnia - continued home alprazolam Transitional issues ===================== - Augmentin for 7 days course (end date [MASKED] - Needs follow up in pancreas clinic. Has appointment with heme-onc [MASKED] already - [MASKED] pancreas biopsy from [MASKED] results not back yet. Will need follow up for this. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.5 mg PO QHS 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 5. Metoprolol Succinate XL 100 mg PO DAILY 6. Lisinopril 5 mg PO DAILY 7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain Discharge Medications: 1. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth Twice a day. End date [MASKED] Disp #*10 Tablet Refills:*0 2. ALPRAZolam 0.5 mg PO QHS 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 6. Lisinopril 5 mg PO DAILY 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis - Transaminitis - Pancreatic mass - Hyperbilirubinemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [MASKED], You were admitted due to abdominal pain and your liver enzymes were found to be elevated. This reassuringly improved and you did not require a second ERCP. You were started on antibiotics in case your symptoms were due to an infection and you will complete this on [MASKED]. Your biopsy results of your pancreas from the previous admission were still pending and you will need to follow up with your doctors. It was a pleasure being part of your care. Your [MASKED] team Followup Instructions: [MASKED]
|
[] |
[
"I4891",
"E785",
"I2510",
"Z955",
"I10",
"D509",
"F419",
"G4700"
] |
[
"C250: Malignant neoplasm of head of pancreas",
"K862: Cyst of pancreas",
"I4891: Unspecified atrial fibrillation",
"B0223: Postherpetic polyneuropathy",
"G8918: Other acute postprocedural pain",
"E785: Hyperlipidemia, unspecified",
"R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]",
"R634: Abnormal weight loss",
"Z6833: Body mass index [BMI] 33.0-33.9, adult",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z955: Presence of coronary angioplasty implant and graft",
"D869: Sarcoidosis, unspecified",
"I10: Essential (primary) hypertension",
"Z96651: Presence of right artificial knee joint",
"K2270: Barrett's esophagus without dysplasia",
"D509: Iron deficiency anemia, unspecified",
"F419: Anxiety disorder, unspecified",
"G4700: Insomnia, unspecified"
] |
10,024,451
| 25,378,230
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zetia / simvastatin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
___ y.o M with history of CAD s/p CABG, HLD, HTN, atrial
fibrillation, sarcoidosis s/p ERCP on ___, notable for biliary
strictures, presenting to ___ with worsening RUQ and
itching, found to have elevated WBC and t. bilirubin, admitted
for concern for cholangitis, now s/p ERCP with sphincterotomy.
The patient reported severe RUQ abdominal pain since his ERCP on
___. He reports that the pain has been worsening and is now
radiating diffusely throughout the abdomen. He describes the
pain
as intermittent, however, some of the attacks of pain can last
for greater than 10 hours. His pain is worse with food and
movement. HE also endorses anorexia, nausea, and darker colored
urine, as well as decreased urinary output. He reports
subjective
fever x 1 day. He otherwise denies shortness of breath, chest
pain, cough, or swelling.
Pt's initial symptoms began 3 weeks a ago with severe RUQ pain
radiating to the back and severe itching. Workup as outpatient
revealed elevated bilirubin and imaging was notable for
gallbladder strictures, but no stones. No gallbladder/liver
issues before this. He was referred to ___ at this time.
___ ERCP procedure + FNA biopsies were benign. No stents
were placed, however pt received call from GI this week that
stenting procedure is planned.
At ___, patient received 500 mL NS, zosyn, and morphine.
In the ED, initial VS were 97 170/52 16 93% RA.
PHysical exam notable for uncomfortable appearing, with scleral
icterus.
Labs notable for a WBC of 21.7, H/H of 16.3/49.1, Plt 165. LFTS
with ALT 211, AST 66, alk phos 302, t. bili 3.9. BMP with Na
131,
Cl 95, HCO3 21. Lactate 1.5. UA showed moderate bacteria and
negative leukesterase and nitrates.
He received IV morphine, IV Zofran, NS, IV zosyn, IV dilaudid
RUQ ultrasound showed moderate intrahepatic biliary dilatation,
with common bile duct measured up to 17 mm.
He was taken from the ED to ERCP. Per signout, it was difficult.
Cholangiogram with tight stricture with a stent with brushing,
as
well as sphincterotomy.
Upon my evaluation, the patient appears well. He reports some
mild abdominal pain which is significantly improved from prior.
He confirms the story as detailed above, describing severe
abdominal pain at home, worsened by movement and eating,
decreased appetite, nausea, fevers, chills. He endorses dark
urine and significant pruritus. He otherwise denies chest pain,
dyspnea, dysuria.
Past Medical History:
- CAD, stent in ___, CABG ___
- HLD
- Hypertension
- History of CABG
- R knee replacement
- Atrial fibrillation
- ___ esophagus without dysplasia
- Iron deficiency anemia
- Shingles with neuropathy
- Sarcoidosis
Social History:
___
Family History:
+ CAD (father)
Physical Exam:
Admission Physical Exam:
========================
VITALS: 99.4 PO 135 / 75 85 18 95 RA
GENERAL: Alert and in no apparent distress
EYES: pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Discharge Physical Exam:
========================
VITALS: Reviewed in E flowsheets
GENERAL: Alert and in no apparent distress
EYES: pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission Labs:
===============
___ 02:45AM BLOOD WBC-21.7* RBC-5.59 Hgb-16.3 Hct-49.1
MCV-88 MCH-29.2 MCHC-33.2 RDW-13.2 RDWSD-41.9 Plt ___
___ 02:45AM BLOOD Neuts-88.9* Lymphs-2.4* Monos-7.3
Eos-0.0* Baso-0.2 Im ___ AbsNeut-19.31* AbsLymp-0.53*
AbsMono-1.58* AbsEos-0.01* AbsBaso-0.04
___ 02:45AM BLOOD ___ PTT-28.9 ___
___ 02:45AM BLOOD Glucose-150* UreaN-20 Creat-0.9 Na-131*
K-4.5 Cl-95* HCO3-21* AnGap-15
___ 02:45AM BLOOD ALT-211* AST-66* AlkPhos-302*
TotBili-3.9*
___ 02:53AM BLOOD Lactate-1.5
Imaging:
========
ERCP ___
We ordered ___ and Igg4.
EUS/FNB samples sent with rush request.
Further management will depend on path, lab and CT results.
Clear fluids when awake then advance diet as tolerated.
Follow-up with Dr. ___ as previously scheduled.
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call Advanced
Endoscopy Fellow on call ___
Repeat ERCP with possible EUS rendez-vous when tissue diagnosis
is confirmed.
ERCP ___
Impression: The scout film was normal. The procedure was
started
in a short position. The papilla was difficult to localise.
Multiple unsuccessfull attempts were made to cannulate with the
sphincterotome followed by the ___ cannula. At this point, it
was decided to switch to the linear EUS.
EUS was performed using a linear echoendoscope at ___ MHz
frequency. The head and uncinate pancreas were imaged from the
duodenal bulb and the second / third duodenum. The ill defined
previously described mass was briefly seen. As we advanced the
scope in the D2 position, the major papilla with oozing bile was
clearly identified.
It was decided to switch back to an ERCP scope. The major
papilla was seen in a distal position in D2, on the lateral rim
of a large ___ diverticulum. The procedure was done
in
a long position.
The bile duct was successfully cannulated using a Rx
sphincterotome preloaded with a 0.035in guidewire. Contrast was
injected and there was brisk flow through the ducts.
Contrast injection showed a single 2 cm long tight stricture at
the level of the middle third CBD. There was significant
post-obstructive dilation of the CBD. The CHD, right and left
main hepatic ducts were not injected. Complete opacification was
not possible because of a very unstable scope position. The CBD
measured up to 12 mm in diameter.
A biliary sphincterotomy was successfully performed with the
sphincterotome. There was no post-sphincterotomy bleeding.
A cytology brush was then inserted to obtain specimen from the
mid third CBD stricture which was sent for cytology.
Subsequently, a ___ x 9cm biliary strait plastic stent (Cotton
___ was successfully placed in the CBD using a preloaded
OASIS
stent introducer kit.
Excellent bile and contrast drainage was seen endoscopically and
fluoroscopically.
Recommendations:
Return to ward for on going care.
NPO overnight with aggressive IV hydration with LR at 200 cc/hr
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
Continue with antibiotics - to complete atleast 5 days
Follow up with cytology reports. Please call Dr. ___
___
___ in 10 days for the pathology results.
Patients case will be discussed in ___ and will arrange for
___ pancreas tumor clinic.
If any abdominal pain, fever, jaundice, gastrointestinal
bleeding please call Advanced Endoscopy Fellow on call
___
CT A/P Second Opinoin ___
1. Moderate intrahepatic and extrahepatic biliary dilation
extending from the proximal common bile duct without evidence of
obstructive lesion in the head of the pancreas, compatible with
known stricture seen on previous MRCP & EUS. No CT signs of
malignancy seen.
2. Several borderline mesenteric lymph nodes, nonspecific,
likely reactive. Multiple retroperitoneal and mesenteric
lymphadenopathy.
2. 1.4 x 1 cm h cystic lesion in the body of the pancreas and
other multiple hypoattenuating subcentimeter lesions within the
tail, of them causing obstruction of the pancreatic duct, likely
benign.
3. Nonspecific multiple hypodense lesions in the splenic
parenchyma.
4. Multiple cortical renal cysts, the largest measures up to
5.6
cm in the lower left pole. Multiple nonobstructive millimetric
renal stones in the left pelvis.
Discharge Labs:
===============
___ 08:40AM BLOOD WBC-14.3* RBC-4.50* Hgb-13.3* Hct-41.1
MCV-91 MCH-29.6 MCHC-32.4 RDW-13.1 RDWSD-43.3 Plt ___
___ 08:40AM BLOOD Glucose-147* UreaN-15 Creat-0.7 Na-138
K-3.7 Cl-98 HCO3-28 AnGap-12
___ 08:40AM BLOOD ALT-84* AST-38 AlkPhos-179* TotBili-1.___ y.o M with history of CAD s/p CABG, HLD, HTN,
atrialfibrillation, sarcoidosis s/p ERCP on ___ (5 days ago),
notable for biliary strictures, presenting to ___ with
worsening RUQ and itching, found to have elevated WBC and
bilirubin, admitted for concern for cholangitis and underwent
ERCP with sphincterotomy and stone extraction.
ACUTE/ACTIVE PROBLEMS:
# Acute cholangitis:
# Biliary stricture: presented to ___ with worsening RUQ
pain and itching, found to have elevated WBC and bilirubin, and
transferred due to concern for cholangitis. He underwent ERCP
with sphincterotomy with improvement in LFTs. He remained
hemodynamically stable without evidence of sepsis, and blood
cultures were preliminarily negative at time of discharge. He
was initially treated with IV antibiotics and transitioned to PO
cipro/flagyl at discharge with plans for ___nding on
___. He will need follow up in pancreas clinic for likely
pancreatic malignancy
# Possible pancreatic mass: Patient with recent EUS showing a
2.5cm X 1.9cm ill-defined mass in the head of the pancreas.
Subsequent biopsies without evidence of malignancy. ___ 46
(elevated), IgGs normal. CBD brushings performed during an ERCP
on ___. He will follow up in pancreas clinic as an outpatient
CHRONIC/STABLE PROBLEMS:
# CAD: No acute issues. Continued home atorvastatin 40 mg PO
QPM, metoprolol succinate XL 100 mg PO daily, Aspirin 81 mg PO
DAILY, Isosorbide Mononitrate (Extended Release) 30 mg PO daily
# HTN: Continued home metoprolol. Home lisinopril initially held
due to concerns for developing sepsis and restarted at discharge
# Atrial fibrillation: Patient with a chart history of atrial
fibrillation. Does not appear to be on anticoagulation. EKG on
admission showed normal sinus rhythm. He reports that his atrial
fibrillation was attributed to excessive alcohol use. He is s/p
cardioversion and has not had any known recurrence of atrial
fibrillation. He was previously on xarelto but this was
reportedly discontinued by his cardiologist due to concerns
about bleeding risk
# Insomnia: continued home alprazolam
Transitional Issues:
====================
- discharged on PO cipro/flagyl with plans for ___nding on ___
- blood cultures pending at discharge
- needs follow up in pancreas clinic, appointment planned for
___ but not officially scheduled at time of discharge. Patient
aware of appointment
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. ALPRAZolam 0.5 mg PO QHS
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*11 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*16 Tablet Refills:*0
3. ALPRAZolam 0.5 mg PO QHS
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Biliary Obstruction
Cholangitis
Leukocytosis
Pancreatic Mass
Secondary:
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came in with abdominal pain. You had a blockage in your bile
duct. You had a procedure to place a stent to open the blockage.
Your liver tests improved after the stent was placed.
You are going home on antibiotics, which you should continue for
five more days after today (last day ___. It will also be very
important to follow up in the pancreas clinic. Dr. ___
office is working on making you an appointment to be seen on
___. If you do not hear from anyone, please call his office
at ___.
It was a pleasure taking care of you, and we're happy that
you're feeling better!
Followup Instructions:
___
|
[
"K830",
"K831",
"I4891",
"K862",
"K8689",
"B0229",
"I10",
"E785",
"Z951",
"D869",
"Z96651",
"K2270",
"D509",
"G4700",
"F519",
"Z87891"
] |
Allergies: Zetia / simvastatin Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ERCP History of Present Illness: [MASKED] y.o M with history of CAD s/p CABG, HLD, HTN, atrial fibrillation, sarcoidosis s/p ERCP on [MASKED], notable for biliary strictures, presenting to [MASKED] with worsening RUQ and itching, found to have elevated WBC and t. bilirubin, admitted for concern for cholangitis, now s/p ERCP with sphincterotomy. The patient reported severe RUQ abdominal pain since his ERCP on [MASKED]. He reports that the pain has been worsening and is now radiating diffusely throughout the abdomen. He describes the pain as intermittent, however, some of the attacks of pain can last for greater than 10 hours. His pain is worse with food and movement. HE also endorses anorexia, nausea, and darker colored urine, as well as decreased urinary output. He reports subjective fever x 1 day. He otherwise denies shortness of breath, chest pain, cough, or swelling. Pt's initial symptoms began 3 weeks a ago with severe RUQ pain radiating to the back and severe itching. Workup as outpatient revealed elevated bilirubin and imaging was notable for gallbladder strictures, but no stones. No gallbladder/liver issues before this. He was referred to [MASKED] at this time. [MASKED] ERCP procedure + FNA biopsies were benign. No stents were placed, however pt received call from GI this week that stenting procedure is planned. At [MASKED], patient received 500 mL NS, zosyn, and morphine. In the ED, initial VS were 97 170/52 16 93% RA. PHysical exam notable for uncomfortable appearing, with scleral icterus. Labs notable for a WBC of 21.7, H/H of 16.3/49.1, Plt 165. LFTS with ALT 211, AST 66, alk phos 302, t. bili 3.9. BMP with Na 131, Cl 95, HCO3 21. Lactate 1.5. UA showed moderate bacteria and negative leukesterase and nitrates. He received IV morphine, IV Zofran, NS, IV zosyn, IV dilaudid RUQ ultrasound showed moderate intrahepatic biliary dilatation, with common bile duct measured up to 17 mm. He was taken from the ED to ERCP. Per signout, it was difficult. Cholangiogram with tight stricture with a stent with brushing, as well as sphincterotomy. Upon my evaluation, the patient appears well. He reports some mild abdominal pain which is significantly improved from prior. He confirms the story as detailed above, describing severe abdominal pain at home, worsened by movement and eating, decreased appetite, nausea, fevers, chills. He endorses dark urine and significant pruritus. He otherwise denies chest pain, dyspnea, dysuria. Past Medical History: - CAD, stent in [MASKED], CABG [MASKED] - HLD - Hypertension - History of CABG - R knee replacement - Atrial fibrillation - [MASKED] esophagus without dysplasia - Iron deficiency anemia - Shingles with neuropathy - Sarcoidosis Social History: [MASKED] Family History: + CAD (father) Physical Exam: Admission Physical Exam: ======================== VITALS: 99.4 PO 135 / 75 85 18 95 RA GENERAL: Alert and in no apparent distress EYES: pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect Discharge Physical Exam: ======================== VITALS: Reviewed in E flowsheets GENERAL: Alert and in no apparent distress EYES: pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect Pertinent Results: Admission Labs: =============== [MASKED] 02:45AM BLOOD WBC-21.7* RBC-5.59 Hgb-16.3 Hct-49.1 MCV-88 MCH-29.2 MCHC-33.2 RDW-13.2 RDWSD-41.9 Plt [MASKED] [MASKED] 02:45AM BLOOD Neuts-88.9* Lymphs-2.4* Monos-7.3 Eos-0.0* Baso-0.2 Im [MASKED] AbsNeut-19.31* AbsLymp-0.53* AbsMono-1.58* AbsEos-0.01* AbsBaso-0.04 [MASKED] 02:45AM BLOOD [MASKED] PTT-28.9 [MASKED] [MASKED] 02:45AM BLOOD Glucose-150* UreaN-20 Creat-0.9 Na-131* K-4.5 Cl-95* HCO3-21* AnGap-15 [MASKED] 02:45AM BLOOD ALT-211* AST-66* AlkPhos-302* TotBili-3.9* [MASKED] 02:53AM BLOOD Lactate-1.5 Imaging: ======== ERCP [MASKED] We ordered [MASKED] and Igg4. EUS/FNB samples sent with rush request. Further management will depend on path, lab and CT results. Clear fluids when awake then advance diet as tolerated. Follow-up with Dr. [MASKED] as previously scheduled. Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call Advanced Endoscopy Fellow on call [MASKED] Repeat ERCP with possible EUS rendez-vous when tissue diagnosis is confirmed. ERCP [MASKED] Impression: The scout film was normal. The procedure was started in a short position. The papilla was difficult to localise. Multiple unsuccessfull attempts were made to cannulate with the sphincterotome followed by the [MASKED] cannula. At this point, it was decided to switch to the linear EUS. EUS was performed using a linear echoendoscope at [MASKED] MHz frequency. The head and uncinate pancreas were imaged from the duodenal bulb and the second / third duodenum. The ill defined previously described mass was briefly seen. As we advanced the scope in the D2 position, the major papilla with oozing bile was clearly identified. It was decided to switch back to an ERCP scope. The major papilla was seen in a distal position in D2, on the lateral rim of a large [MASKED] diverticulum. The procedure was done in a long position. The bile duct was successfully cannulated using a Rx sphincterotome preloaded with a 0.035in guidewire. Contrast was injected and there was brisk flow through the ducts. Contrast injection showed a single 2 cm long tight stricture at the level of the middle third CBD. There was significant post-obstructive dilation of the CBD. The CHD, right and left main hepatic ducts were not injected. Complete opacification was not possible because of a very unstable scope position. The CBD measured up to 12 mm in diameter. A biliary sphincterotomy was successfully performed with the sphincterotome. There was no post-sphincterotomy bleeding. A cytology brush was then inserted to obtain specimen from the mid third CBD stricture which was sent for cytology. Subsequently, a [MASKED] x 9cm biliary strait plastic stent (Cotton [MASKED] was successfully placed in the CBD using a preloaded OASIS stent introducer kit. Excellent bile and contrast drainage was seen endoscopically and fluoroscopically. Recommendations: Return to ward for on going care. NPO overnight with aggressive IV hydration with LR at 200 cc/hr If no abdominal pain in the morning, advance diet to clear liquids and then advance as tolerated Continue with antibiotics - to complete atleast 5 days Follow up with cytology reports. Please call Dr. [MASKED] [MASKED] [MASKED] in 10 days for the pathology results. Patients case will be discussed in [MASKED] and will arrange for [MASKED] pancreas tumor clinic. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call Advanced Endoscopy Fellow on call [MASKED] CT A/P Second Opinoin [MASKED] 1. Moderate intrahepatic and extrahepatic biliary dilation extending from the proximal common bile duct without evidence of obstructive lesion in the head of the pancreas, compatible with known stricture seen on previous MRCP & EUS. No CT signs of malignancy seen. 2. Several borderline mesenteric lymph nodes, nonspecific, likely reactive. Multiple retroperitoneal and mesenteric lymphadenopathy. 2. 1.4 x 1 cm h cystic lesion in the body of the pancreas and other multiple hypoattenuating subcentimeter lesions within the tail, of them causing obstruction of the pancreatic duct, likely benign. 3. Nonspecific multiple hypodense lesions in the splenic parenchyma. 4. Multiple cortical renal cysts, the largest measures up to 5.6 cm in the lower left pole. Multiple nonobstructive millimetric renal stones in the left pelvis. Discharge Labs: =============== [MASKED] 08:40AM BLOOD WBC-14.3* RBC-4.50* Hgb-13.3* Hct-41.1 MCV-91 MCH-29.6 MCHC-32.4 RDW-13.1 RDWSD-43.3 Plt [MASKED] [MASKED] 08:40AM BLOOD Glucose-147* UreaN-15 Creat-0.7 Na-138 K-3.7 Cl-98 HCO3-28 AnGap-12 [MASKED] 08:40AM BLOOD ALT-84* AST-38 AlkPhos-179* TotBili-1.[MASKED] y.o M with history of CAD s/p CABG, HLD, HTN, atrialfibrillation, sarcoidosis s/p ERCP on [MASKED] (5 days ago), notable for biliary strictures, presenting to [MASKED] with worsening RUQ and itching, found to have elevated WBC and bilirubin, admitted for concern for cholangitis and underwent ERCP with sphincterotomy and stone extraction. ACUTE/ACTIVE PROBLEMS: # Acute cholangitis: # Biliary stricture: presented to [MASKED] with worsening RUQ pain and itching, found to have elevated WBC and bilirubin, and transferred due to concern for cholangitis. He underwent ERCP with sphincterotomy with improvement in LFTs. He remained hemodynamically stable without evidence of sepsis, and blood cultures were preliminarily negative at time of discharge. He was initially treated with IV antibiotics and transitioned to PO cipro/flagyl at discharge with plans for nding on [MASKED]. He will need follow up in pancreas clinic for likely pancreatic malignancy # Possible pancreatic mass: Patient with recent EUS showing a 2.5cm X 1.9cm ill-defined mass in the head of the pancreas. Subsequent biopsies without evidence of malignancy. [MASKED] 46 (elevated), IgGs normal. CBD brushings performed during an ERCP on [MASKED]. He will follow up in pancreas clinic as an outpatient CHRONIC/STABLE PROBLEMS: # CAD: No acute issues. Continued home atorvastatin 40 mg PO QPM, metoprolol succinate XL 100 mg PO daily, Aspirin 81 mg PO DAILY, Isosorbide Mononitrate (Extended Release) 30 mg PO daily # HTN: Continued home metoprolol. Home lisinopril initially held due to concerns for developing sepsis and restarted at discharge # Atrial fibrillation: Patient with a chart history of atrial fibrillation. Does not appear to be on anticoagulation. EKG on admission showed normal sinus rhythm. He reports that his atrial fibrillation was attributed to excessive alcohol use. He is s/p cardioversion and has not had any known recurrence of atrial fibrillation. He was previously on xarelto but this was reportedly discontinued by his cardiologist due to concerns about bleeding risk # Insomnia: continued home alprazolam Transitional Issues: ==================== - discharged on PO cipro/flagyl with plans for nding on [MASKED] - blood cultures pending at discharge - needs follow up in pancreas clinic, appointment planned for [MASKED] but not officially scheduled at time of discharge. Patient aware of appointment Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. ALPRAZolam 0.5 mg PO QHS 3. Metoprolol Succinate XL 100 mg PO DAILY 4. Lisinopril 5 mg PO DAILY 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 7. Aspirin 81 mg PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*11 Tablet Refills:*0 2. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*16 Tablet Refills:*0 3. ALPRAZolam 0.5 mg PO QHS 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 7. Lisinopril 5 mg PO DAILY 8. Metoprolol Succinate XL 100 mg PO DAILY 9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain Discharge Disposition: Home Discharge Diagnosis: Primary: Biliary Obstruction Cholangitis Leukocytosis Pancreatic Mass Secondary: Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You came in with abdominal pain. You had a blockage in your bile duct. You had a procedure to place a stent to open the blockage. Your liver tests improved after the stent was placed. You are going home on antibiotics, which you should continue for five more days after today (last day [MASKED]. It will also be very important to follow up in the pancreas clinic. Dr. [MASKED] office is working on making you an appointment to be seen on [MASKED]. If you do not hear from anyone, please call his office at [MASKED]. It was a pleasure taking care of you, and we're happy that you're feeling better! Followup Instructions: [MASKED]
|
[] |
[
"I4891",
"I10",
"E785",
"Z951",
"D509",
"G4700",
"Z87891"
] |
[
"K830: Cholangitis",
"K831: Obstruction of bile duct",
"I4891: Unspecified atrial fibrillation",
"K862: Cyst of pancreas",
"K8689: Other specified diseases of pancreas",
"B0229: Other postherpetic nervous system involvement",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"Z951: Presence of aortocoronary bypass graft",
"D869: Sarcoidosis, unspecified",
"Z96651: Presence of right artificial knee joint",
"K2270: Barrett's esophagus without dysplasia",
"D509: Iron deficiency anemia, unspecified",
"G4700: Insomnia, unspecified",
"F519: Sleep disorder not due to a substance or known physiological condition, unspecified",
"Z87891: Personal history of nicotine dependence"
] |
10,024,982
| 24,190,442
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zoloft
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Dr. ___ is a ___ Surgeon at ___ with past medical history
notable for coronary artery disease CAD s/p CABG and several
PCI's since then (most recent balloon angioplasty SVG-OM ___
who presents with ___ days of chest pain.
Exam in the ED notable for bilateral lower extremity edema. ECG
showed V-pacing at 59 bpm, intermittent ectopy, Sgarbossa
negative.
POCUS TTE showed EF 50%, no apparent RWMA.
In the ED initial vitals were:
Temp. 97.9, HR 60, BP 159/67, RR 22, 100% RA
ECG showed V-pacing at 59 bpm, intermittent ectopy, Sgarbossa
negative. POCUS TTE showed EF 50%, no apparent wall motion
abnormality
Labs/studies notable for:
WBC 7.1, Hg 8.7, Hct 30.7, platelets 205, MCV 74. Chemistry
notable for Na 148, K 4.2, Cl 109, Bicarb 27, BUN 32, Cr 1.1,
glucose 111. Trop < 0.01, MB 3, CK 74, Pro-BNP 2323, INR 1.4.
CXR showed small right pleural effusion with patchy bibasilar
airspace opacities, possibly atelectasis though infection is not
excluded. Mild pulmonary vascular congestion.
Patient was given: 243 mg aspirin, 0.4 mg nitro, 4000 unit
heparin.
Evaluated by Cardiology consult who recommended:
Treatment as unstable angina with initiation of heparin gtt
without bolus (already on apixaban.) Recommendation to hold
apixaban, make NPO after midnight. Recommendation for nuclear
stress test in AM. If chest pain overnight start sublingual
nitro or nitro gtt and consider cardiac cath at that time.
Vitals on transfer: HR 69, BP 143/98, RR 19, 100% RA
On the floor, Dr. ___ that he has had ongoing chest
pressure in his mid-chest for ___ days both with exertion and at
rest. The pressure also radiates to his left wrist with
associated numbness/tingling. He denies any associated dyspnea,
diaphoresis, feeling lightheaded or dizziness. He notes that his
chest pressure has improved with nitroglycerin. He is currently
chest pain free. He does endorse a few episodes of vomiting
without diarrhea, abdominal pain, or fevers unrelated to his
chest pressure over the last few days. Of note, he has not taken
his eliquis the past 2 days as he has planned injection on
___ for chronic back pain.
Past Medical History:
ANGINA PECTORIS --post CABG ___ and post multiple stents/PTCA
ATRIAL FIBRILLATION
BENIGN PROSTATIC HYPERTROPHY
GASTROESOPHAGEAL REFLUX
OSTEOARTHRITIS
PACEMAKER
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
BACK AND NECK PAIN
TURP
Knee surgery
Social History:
___
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
ADMISSION EXAM
VS: T= 98.7 BP= 139/80 HR=108, manual recheck 70's RR= 16 O2
sat= 100% RA
GENERAL: In NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple without JVD
CARDIAC: Normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
CHEST: raised erythematous papule (stable from baseline),
well-healed surgical scar
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Lipoma on right
lower quadrant.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE EXAM
VS - Temp 98.7, HR 56-108, BP 131-150/71-94, RR ___, 99-100%
RA
Tele: Paced, occ PVC's
General: NAD, A+Ox3, pleasant, laying down in bed
HEENT: Sclera anicteric, oropharynx clear
Neck: No JVD
CV: RRR, no murmurs, normal PMI
Lungs: Clear bilaterally
Abdomen: NTND, +BS
Ext: Warm and well perfused, no ___ edema
Neuro: Grossly normal
Pertinent Results:
ADMISSION LABS
___ 06:06PM BLOOD WBC-7.1 RBC-4.16* Hgb-8.7* Hct-30.7*
MCV-74* MCH-20.9* MCHC-28.3* RDW-17.5* RDWSD-46.3 Plt ___
___ 08:04PM BLOOD ___ PTT-33.2 ___
___ 06:06PM BLOOD Neuts-60.1 ___ Monos-14.9*
Eos-3.1 Baso-0.3 Im ___ AbsNeut-4.25 AbsLymp-1.50
AbsMono-1.05* AbsEos-0.22 AbsBaso-0.02
___ 06:06PM BLOOD Glucose-111* UreaN-32* Creat-1.1 Na-148*
K-4.2 Cl-109* HCO3-27 AnGap-16
___ 06:06PM BLOOD CK-MB-3 proBNP-2323*
___ 06:06PM BLOOD cTropnT-<0.01
___ 01:25AM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:00AM BLOOD CK-MB-3 cTropnT-0.01
___ 06:06PM BLOOD Calcium-8.6 Phos-3.4 Mg-2.2
DISCHARGE LABS
___ 06:00AM BLOOD WBC-8.5 RBC-4.34* Hgb-9.0* Hct-32.0*
MCV-74* MCH-20.7* MCHC-28.1* RDW-17.7* RDWSD-46.9* Plt ___
___ 06:00AM BLOOD ___ PTT-64.6* ___
___ 06:00AM BLOOD Glucose-88 UreaN-30* Creat-1.2 Na-143
K-3.8 Cl-105 HCO3-27 AnGap-15
___ 06:00AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.2
REPORTS
PHARMACOLOGIC STRESS TEST ___. Normal myocardial perfusion.
2. Increased left ventricular cavity size with mild global
systolic
dysfunction.
Compared with prior study of ___, the prior apical defect
is no longer present, left ventricular cavity size has
increased, and systolic function has decreased.
CXR ___
Small right pleural effusion with patchy bibasilar airspace
opacities,
possibly atelectasis though infection is not excluded. Mild
pulmonary
vascular congestion.
Brief Hospital Course:
___ y/o M Cardiac Surgeon with a h/o CAD s/p CABG and PCI's,
A-Fib, PPM, COPD, GERD, presenting with several days of chest
pain concerning for unstable angina.
ACTIVE ISSUES
# Chest pain: Presented with ___t rest, relieved by
nitro. Given his significant cardiac history there was concern
for unstable angina. He was started on a heparin drip and given
full dose ASA on arrival, and his home apixaban was held. He was
chest pain free after admission. There were no ischemic EKG
changes. Troponin and CK-MB were negative x3. Stress MIBI was
done, showing normal perfusion, and a decrease in systolic
function (to 40%) vs his prior study. He was discharged home
with plan for an outpatient catheterization in 5 days. Home
Imdur was increased from 60mg daily to 120mg daily. Continued
home metoprolol succinate 25mg daily, ASA 81mg, and Atorvastatin
40mg daily.
CHRONIC ISSUES
# H/o A-Fib: s/p pacemaker for Tachy-Brady. Takes apixaban for
anticoag as outpatient, but this has been held in anticipation
of a pain injection procedure on ___. Heparin drip was used
for anticoag while inpatient.
# COPD: Lung exam unremarkable. Normal RR and O2 sats. Continued
home Symbicort BID, tiotropium, albuterol inhaler PRN
# Anemia: Microcytic, stable during this admission, stable vs
prior labs earlier this year. Prior workup c/w Iron Deficiency.
# Back/neck pain: Continued home Duloxetine 30mg daily,
Hydrocodone-Acetaminophen PRN
# GERD: Pantoprazole 40mg daily
# Hypothyroidism: Levothyroxine 75 mcg daily
TRANSITIONAL ISSUES
# Imdur increased from 60 mg daily to 120 mg daily at discharge
# Will follow up with Dr. ___ likely receive an
angiogram in 5 days. Request was sent and timing being finalized
with Dr. ___.
# Apixiban held on discharge, as it had been held prior to
admission, in anticipation of upcoming back procedure on
___ it will also be held in anticipation of upcoming
angiogram, to be determined by Dr. ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH BID PRN SOB
2. Apixaban 5 mg PO BID
3. Atorvastatin 40 mg PO QPM
4. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
5. Duloxetine 30 mg PO DAILY
6. Isosorbide Mononitrate 60 mg PO DAILY
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Endocet (oxyCODONE-acetaminophen) ___ mg oral Q6 PRN pain
10. Pantoprazole 40 mg PO Q24H
11. Tiotropium Bromide 1 CAP IH DAILY
12. Aspirin 81 mg PO DAILY
13. Nitromist (nitroglycerin) 400 mcg/spray translingual ___
sprays Q5 minutes PRN chest pain
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH BID PRN SOB
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Duloxetine 30 mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Nitromist (nitroglycerin) 400 mcg/spray translingual ___
sprays Q5 minutes PRN chest pain
8. Pantoprazole 40 mg PO Q24H
9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
10. Tiotropium Bromide 1 CAP IH DAILY
11. Endocet (oxyCODONE-acetaminophen) ___ mg oral Q6 PRN pain
12. Isosorbide Mononitrate 60 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
==========
Unstable angina
Secondary:
============
coronary artery disease
atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ was a pleasure participating in your care at ___. You were
admitted to our hospital because of chest pain. We checked your
troponins, which we negative three times, ruling out a heart
attack. A pharmacologic cardiac perfusion study showed normal
perfusion and a mild decrease in systolic function. Dr. ___
___ about these results, and will follow-up with you as an
outpatient. He may recommend an angiogram.
We wish you all the best,
Your ___ Care Team
Followup Instructions:
___
|
[
"I25110",
"Z951",
"I4891",
"J449",
"Z87891",
"D509",
"M549",
"M542",
"K219",
"E039",
"Z950"
] |
Allergies: Zoloft Chief Complaint: Chest pain Major Surgical or Invasive Procedure: none History of Present Illness: Dr. [MASKED] is a [MASKED] Surgeon at [MASKED] with past medical history notable for coronary artery disease CAD s/p CABG and several PCI's since then (most recent balloon angioplasty SVG-OM [MASKED] who presents with [MASKED] days of chest pain. Exam in the ED notable for bilateral lower extremity edema. ECG showed V-pacing at 59 bpm, intermittent ectopy, Sgarbossa negative. POCUS TTE showed EF 50%, no apparent RWMA. In the ED initial vitals were: Temp. 97.9, HR 60, BP 159/67, RR 22, 100% RA ECG showed V-pacing at 59 bpm, intermittent ectopy, Sgarbossa negative. POCUS TTE showed EF 50%, no apparent wall motion abnormality Labs/studies notable for: WBC 7.1, Hg 8.7, Hct 30.7, platelets 205, MCV 74. Chemistry notable for Na 148, K 4.2, Cl 109, Bicarb 27, BUN 32, Cr 1.1, glucose 111. Trop < 0.01, MB 3, CK 74, Pro-BNP 2323, INR 1.4. CXR showed small right pleural effusion with patchy bibasilar airspace opacities, possibly atelectasis though infection is not excluded. Mild pulmonary vascular congestion. Patient was given: 243 mg aspirin, 0.4 mg nitro, 4000 unit heparin. Evaluated by Cardiology consult who recommended: Treatment as unstable angina with initiation of heparin gtt without bolus (already on apixaban.) Recommendation to hold apixaban, make NPO after midnight. Recommendation for nuclear stress test in AM. If chest pain overnight start sublingual nitro or nitro gtt and consider cardiac cath at that time. Vitals on transfer: HR 69, BP 143/98, RR 19, 100% RA On the floor, Dr. [MASKED] that he has had ongoing chest pressure in his mid-chest for [MASKED] days both with exertion and at rest. The pressure also radiates to his left wrist with associated numbness/tingling. He denies any associated dyspnea, diaphoresis, feeling lightheaded or dizziness. He notes that his chest pressure has improved with nitroglycerin. He is currently chest pain free. He does endorse a few episodes of vomiting without diarrhea, abdominal pain, or fevers unrelated to his chest pressure over the last few days. Of note, he has not taken his eliquis the past 2 days as he has planned injection on [MASKED] for chronic back pain. Past Medical History: ANGINA PECTORIS --post CABG [MASKED] and post multiple stents/PTCA ATRIAL FIBRILLATION BENIGN PROSTATIC HYPERTROPHY GASTROESOPHAGEAL REFLUX OSTEOARTHRITIS PACEMAKER CHRONIC OBSTRUCTIVE PULMONARY DISEASE BACK AND NECK PAIN TURP Knee surgery Social History: [MASKED] Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: ADMISSION EXAM VS: T= 98.7 BP= 139/80 HR=108, manual recheck 70's RR= 16 O2 sat= 100% RA GENERAL: In NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple without JVD CARDIAC: Normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. CHEST: raised erythematous papule (stable from baseline), well-healed surgical scar LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Lipoma on right lower quadrant. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric DISCHARGE EXAM VS - Temp 98.7, HR 56-108, BP 131-150/71-94, RR [MASKED], 99-100% RA Tele: Paced, occ PVC's General: NAD, A+Ox3, pleasant, laying down in bed HEENT: Sclera anicteric, oropharynx clear Neck: No JVD CV: RRR, no murmurs, normal PMI Lungs: Clear bilaterally Abdomen: NTND, +BS Ext: Warm and well perfused, no [MASKED] edema Neuro: Grossly normal Pertinent Results: ADMISSION LABS [MASKED] 06:06PM BLOOD WBC-7.1 RBC-4.16* Hgb-8.7* Hct-30.7* MCV-74* MCH-20.9* MCHC-28.3* RDW-17.5* RDWSD-46.3 Plt [MASKED] [MASKED] 08:04PM BLOOD [MASKED] PTT-33.2 [MASKED] [MASKED] 06:06PM BLOOD Neuts-60.1 [MASKED] Monos-14.9* Eos-3.1 Baso-0.3 Im [MASKED] AbsNeut-4.25 AbsLymp-1.50 AbsMono-1.05* AbsEos-0.22 AbsBaso-0.02 [MASKED] 06:06PM BLOOD Glucose-111* UreaN-32* Creat-1.1 Na-148* K-4.2 Cl-109* HCO3-27 AnGap-16 [MASKED] 06:06PM BLOOD CK-MB-3 proBNP-2323* [MASKED] 06:06PM BLOOD cTropnT-<0.01 [MASKED] 01:25AM BLOOD CK-MB-3 cTropnT-<0.01 [MASKED] 06:00AM BLOOD CK-MB-3 cTropnT-0.01 [MASKED] 06:06PM BLOOD Calcium-8.6 Phos-3.4 Mg-2.2 DISCHARGE LABS [MASKED] 06:00AM BLOOD WBC-8.5 RBC-4.34* Hgb-9.0* Hct-32.0* MCV-74* MCH-20.7* MCHC-28.1* RDW-17.7* RDWSD-46.9* Plt [MASKED] [MASKED] 06:00AM BLOOD [MASKED] PTT-64.6* [MASKED] [MASKED] 06:00AM BLOOD Glucose-88 UreaN-30* Creat-1.2 Na-143 K-3.8 Cl-105 HCO3-27 AnGap-15 [MASKED] 06:00AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.2 REPORTS PHARMACOLOGIC STRESS TEST [MASKED]. Normal myocardial perfusion. 2. Increased left ventricular cavity size with mild global systolic dysfunction. Compared with prior study of [MASKED], the prior apical defect is no longer present, left ventricular cavity size has increased, and systolic function has decreased. CXR [MASKED] Small right pleural effusion with patchy bibasilar airspace opacities, possibly atelectasis though infection is not excluded. Mild pulmonary vascular congestion. Brief Hospital Course: [MASKED] y/o M Cardiac Surgeon with a h/o CAD s/p CABG and PCI's, A-Fib, PPM, COPD, GERD, presenting with several days of chest pain concerning for unstable angina. ACTIVE ISSUES # Chest pain: Presented with t rest, relieved by nitro. Given his significant cardiac history there was concern for unstable angina. He was started on a heparin drip and given full dose ASA on arrival, and his home apixaban was held. He was chest pain free after admission. There were no ischemic EKG changes. Troponin and CK-MB were negative x3. Stress MIBI was done, showing normal perfusion, and a decrease in systolic function (to 40%) vs his prior study. He was discharged home with plan for an outpatient catheterization in 5 days. Home Imdur was increased from 60mg daily to 120mg daily. Continued home metoprolol succinate 25mg daily, ASA 81mg, and Atorvastatin 40mg daily. CHRONIC ISSUES # H/o A-Fib: s/p pacemaker for Tachy-Brady. Takes apixaban for anticoag as outpatient, but this has been held in anticipation of a pain injection procedure on [MASKED]. Heparin drip was used for anticoag while inpatient. # COPD: Lung exam unremarkable. Normal RR and O2 sats. Continued home Symbicort BID, tiotropium, albuterol inhaler PRN # Anemia: Microcytic, stable during this admission, stable vs prior labs earlier this year. Prior workup c/w Iron Deficiency. # Back/neck pain: Continued home Duloxetine 30mg daily, Hydrocodone-Acetaminophen PRN # GERD: Pantoprazole 40mg daily # Hypothyroidism: Levothyroxine 75 mcg daily TRANSITIONAL ISSUES # Imdur increased from 60 mg daily to 120 mg daily at discharge # Will follow up with Dr. [MASKED] likely receive an angiogram in 5 days. Request was sent and timing being finalized with Dr. [MASKED]. # Apixiban held on discharge, as it had been held prior to admission, in anticipation of upcoming back procedure on [MASKED] it will also be held in anticipation of upcoming angiogram, to be determined by Dr. [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler [MASKED] PUFF IH BID PRN SOB 2. Apixaban 5 mg PO BID 3. Atorvastatin 40 mg PO QPM 4. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 5. Duloxetine 30 mg PO DAILY 6. Isosorbide Mononitrate 60 mg PO DAILY 7. Levothyroxine Sodium 75 mcg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Endocet (oxyCODONE-acetaminophen) [MASKED] mg oral Q6 PRN pain 10. Pantoprazole 40 mg PO Q24H 11. Tiotropium Bromide 1 CAP IH DAILY 12. Aspirin 81 mg PO DAILY 13. Nitromist (nitroglycerin) 400 mcg/spray translingual [MASKED] sprays Q5 minutes PRN chest pain Discharge Medications: 1. Albuterol Inhaler [MASKED] PUFF IH BID PRN SOB 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Duloxetine 30 mg PO DAILY 5. Levothyroxine Sodium 75 mcg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Nitromist (nitroglycerin) 400 mcg/spray translingual [MASKED] sprays Q5 minutes PRN chest pain 8. Pantoprazole 40 mg PO Q24H 9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 10. Tiotropium Bromide 1 CAP IH DAILY 11. Endocet (oxyCODONE-acetaminophen) [MASKED] mg oral Q6 PRN pain 12. Isosorbide Mononitrate 60 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Primary: ========== Unstable angina Secondary: ============ coronary artery disease atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Dr. [MASKED], [MASKED] was a pleasure participating in your care at [MASKED]. You were admitted to our hospital because of chest pain. We checked your troponins, which we negative three times, ruling out a heart attack. A pharmacologic cardiac perfusion study showed normal perfusion and a mild decrease in systolic function. Dr. [MASKED] [MASKED] about these results, and will follow-up with you as an outpatient. He may recommend an angiogram. We wish you all the best, Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"Z951",
"I4891",
"J449",
"Z87891",
"D509",
"K219",
"E039"
] |
[
"I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris",
"Z951: Presence of aortocoronary bypass graft",
"I4891: Unspecified atrial fibrillation",
"J449: Chronic obstructive pulmonary disease, unspecified",
"Z87891: Personal history of nicotine dependence",
"D509: Iron deficiency anemia, unspecified",
"M549: Dorsalgia, unspecified",
"M542: Cervicalgia",
"K219: Gastro-esophageal reflux disease without esophagitis",
"E039: Hypothyroidism, unspecified",
"Z950: Presence of cardiac pacemaker"
] |
10,024,982
| 25,154,057
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catherization ___
___ L3-L4 arterial embolization ___
History of Present Illness:
Dr. ___ is a ___ year old cardiac surgeon with past history of
CAD s/p CABG and several PCI's, and most recently balloon
angioplasty (SVG-OM ___ presents with increased chest
pain. Patient was recently admitted on ___ to medicine and
discharged on ___. Patient re-presented to the ED for recurrent
chest pain symptoms.
Over the past 3 days patient has been having increased chest
pain, and reports that this has been increased with exertion. He
also had radiation of this chest pain to the left hand, with
associated numbness/tingling. He denies any dyspnea, orthopnea,
lightheaded or dizziness. He did have some episodes several days
ago of chest pain with vomiting, however none currently. He felt
nauseous in the ED with no vomiting.
Notably, patient does take apixiban for atrial fibrillation
anticoagulation, and patient has not been taking this medication
due to a planned steroid injection on ___ for back pain.
During patient's prior hospitalization, he was initially started
on heparin gtt and given aspirin full dose. Patient was found to
be chest pain free after SL Nitro, and EKG at that time was not
notable for any ischemic change. Patient underwent a stress MIBI
which did show normal perfusion, a decrease in EF to 40%, and
therefore was then discharged for outpatient follow up.
Patient's home medications were also changed to imdur 120 mg
from 60 mg, given his home metoprolol.
ED COURSE:
In the ED, patient had initial labs that were notable for a
Trop-T <0.01, Sodium 141, Potassium 4.3, Chloride 104, BUN 32,
Createinine 1.5. Patient was then found to have LFTs ALT 44, AST
53, AP 164. Patient also had Hgb 9.2, Hct 32.6 with MCV 74, and
WBC 8.6.
Patient was then taken to the cardiac cath lab for urgent
evaluation of unstable angina. There, it was visualized that the
graft to the OM was down, and collaterals looked good. There was
further discussion regarding further revascularization, and
possible medical vs operative treatment.
Past Medical History:
ANGINA PECTORIS --post CABG ___ and post multiple stents/PTCA
ATRIAL FIBRILLATION
BENIGN PROSTATIC HYPERTROPHY
GASTROESOPHAGEAL REFLUX
OSTEOARTHRITIS
PACEMAKER
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
BACK AND NECK PAIN
TURP
Knee surgery
Social History:
___
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=======================
VS: 97.9 ___ 53-61 18 99%2L
GENERAL: NAD. Very sleepy after catherization.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple. No JVD
CARDIAC: RRR. No murmurs/rubs/gallops. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, occasional
wheezes in left lower base, no rhonchi.
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 EXAMINATION:
=======================
DECEASED
Pertinent Results:
ADMISSION LABS:
===========
___ 06:00AM ___ PTT-64.6* ___
___ 06:00AM PLT COUNT-205
___ 06:00AM WBC-8.5 RBC-4.34* HGB-9.0* HCT-32.0* MCV-74*
MCH-20.7* MCHC-28.1* RDW-17.7* RDWSD-46.9*
___ 06:00AM CALCIUM-8.5 PHOSPHATE-3.5 MAGNESIUM-2.2
___ 06:00AM CK-MB-3 cTropnT-0.01
___ 06:00AM GLUCOSE-88 UREA N-30* CREAT-1.2 SODIUM-143
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-27 ANION GAP-15
___ 08:00AM cTropnT-<0.01
___ 08:00AM GLUCOSE-115* UREA N-32* CREAT-1.5* SODIUM-141
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-16
___ 03:09PM ___ PTT-32.3 ___
___ 03:09PM PLT COUNT-206
___ 03:09PM WBC-8.7 RBC-4.53* HGB-9.3* HCT-33.6* MCV-74*
MCH-20.5* MCHC-27.7* RDW-17.8* RDWSD-47.0*
___ 03:09PM CALCIUM-8.8 PHOSPHATE-4.4 MAGNESIUM-2.3
IMAGING:
======
ECHO ___
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. Overall
left ventricular systolic function is low normal (LVEF 50-55%)
secondary to septal dyssynchrony. Doppler parameters are
indeterminate for left ventricular diastolic function. The right
ventricular cavity is mildly dilated with focal hypokinesis of
the apical free wall. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
number of aortic valve leaflets cannot be determined. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Moderate to
severe [3+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___,
the right ventricle is now dilated with evidence of apical
hypokinesis. There is more tricuspid regurgitation and pulmonary
artery systolic pressure is severely increased. Left ventricular
regional/global systolic function and other findings are
similar.
CTA CHEST W&W/O C&RECON ___
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. Small consolidations in the right upper lobe and right lower
lobe in a
dependent location with a moderate right pleural effusion.
Underlying
infection not excluded. Left basilar atelectasis.
3. Pooling of secretions above the ETT balloon.
Head CT ___
1. No evidence of acute intracranial process.
CHEST (PORTABLE AP)Study Date of ___
Mild pulmonary edema has increased since ___. Slight
increase in severe cardiomegaly could be due to differences in
cardiac cycle. Small right pleural effusion is likely. There
is no pneumothorax. New ET tube is in standard placement.
Esophageal drainage tube ends in the
upper portion of a nondistended stomach. Transvenous right
atrial right ventricular pacer leads follow their expected
courses from the left pectoral generator.
CTA CHEST W&W/O C&RECONS, NON-CORONARYStudy Date of ___
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. Small consolidations in the right upper lobe and right lower
lobe in a dependent location with a moderate right pleural
effusion. Underlying infection not excluded. Left basilar
atelectasis.
3. Pooling of secretions above the ETT balloon.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORTStudy Date of
___
1. Normal liver echotexture with patent flow of the portal
vein. No concerning liver mass. No morphologic features of
cirrhosis.
2. Trace left lower quadrant ascites.
3. Cholelithiasis with trace pericholecystic fluid but no wall
thickening.
4. Partially visualized right pleural effusion.
CHEST (PORTABLE AP)Study Date of ___
Increased opacity at the right lung base likely reflects a
layering pleural effusion. Severe cardiomegaly and pulmonary
vascular congestion, similar when compared to the prior study.
Asymmetric pulmonary edema predominately affecting the right
lung.
EEGStudy Date of ___
This is an abnormal continuous ICU EEG monitoring because of 1)
frontally predominant sharp waves with a triphasic morphology at
times appear in periodic runs embedded on a diffusely slow
background. This is indicative of a moderate encephalopathy,
which is non-specific but may be due to metabolic or electrolyte
disturbances, infection or medications. There no definite
epileptiform discharges. There are no electrographic seizures.
MR HEAD W/O CONTRASTStudy Date of ___
1. Few scattered punctate foci of slow diffusion in the left
frontal centrum semiovale, right occipital lobe and right
cerebellum in keeping with acute infarcts, likely embolic in
etiology.
2. Diffuse age-related volume loss.
CAROTID SERIES COMPLETEStudy Date of ___
1. Mild heterogeneous calcified plaque involving bifurcations
bilaterally.
2. No hemodynamically significant stenoses on either side (less
than 40%).
3. Normal antegrade flow both vertebral arteries.
CT HEAD W/O CONTRASTStudy Date of ___
1. Study is moderately degraded by motion.
2. Within limits of study no evidence of acute intracranial
hemorrhage hemorrhage or infarct.
CHEST (PORTABLE AP)Study Date of ___
Moderate edema with new asymmetric increased edema in the right
upper lobe which can be seen in the setting of mitral
regurgitation. Correlate with clinical history.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of ___
1. Active bleeding into a large left retroperitoneal hematoma
most likely
arising from the psoas muscle.
2. Acute anterior fractures of the left fourth- seventh and
right
fifth-seventh ribs.
3. Moderate right and small left pleural effusions with
adjacent atelectasis.
Ground-glass opacities in the bilateral upper lobes may reflect
aspiration.
4. Chronic findings of colon diverticulosis and cholelithiasis.
CHEST (PORTABLE AP) Study Date of ___
Since most recent radiograph, there is no significant interval
change. Again seen is bilateral pleural effusion and
atelectasis, not significantly changed from prior. The ET tube
now terminates approximately 2.5 cm from the carina, which may
be due to patient positioning. Otherwise, there is no
appreciable change in support lines. Sternotomy wires and
surgical clips are in place.
IMPRESSION:
No significant interval change.
MICRO
====
___ 6:06 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
___ 11:03 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
___ 6:47 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
~3000/ML Commensal Respiratory Flora.
YEAST. 10,000-100,000 ORGANISMS/ML..
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Preliminary):
___ 6:47 pm Rapid Respiratory Viral Screen & Culture
BRONCHIAL LAVAGE.
Respiratory Viral Culture (Preliminary):
Respiratory Viral Antigen Screen (Final ___:
Greater than 400 polymorphonuclear leukocytes;.
Inadequate specimen for DFA detection of respiratory
viruses..
Interpret all negative DFA and/or culture results from
this specimen
with caution..
Urine Culture (___): Negative
Blood Culture ___, 13, 14, 17, 19, 22, 24, 25): Negative
MRSA (___): Negative
Sputum Culture (___): Negative
Sputum Culture (___): RP
Stool C Diff (___): Negative
___ 5:00 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS EPIDERMIDIS.
Isolated from only one set in the previous five days.
WORK UP PER ___ ___.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
STAPHYLOCOCCUS EPIDERMIDIS. ___ MORPHOLOGY.
Isolated from only one set in the previous five days.
WORK UP PER ___. ___ ___.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
| STAPHYLOCOCCUS
EPIDERMIDIS
| |
CLINDAMYCIN----------- =>8 R <=0.25 S
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ 8 I <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R =>4 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
VANCOMYCIN------------ 1 S 1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
DISCHARGE LABS
==========
___ 06:15AM BLOOD WBC-7.9 RBC-2.84* Hgb-7.6* Hct-25.3*
MCV-89 MCH-26.8 MCHC-30.0* RDW-21.5* RDWSD-67.5* Plt ___
___ 06:15AM BLOOD Glucose-90 UreaN-45* Creat-1.2 Na-147*
K-4.2 Cl-113* HCO3-27 AnGap-11
___ 06:15AM BLOOD Calcium-7.4* Phos-3.9 Mg-2.3
___ 04:44AM BLOOD Lactate-1.3
___ 04:44AM BLOOD freeCa-1.02*
___ 03:55PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
Brief Hospital Course:
Dr. ___ is an ___ year old male, with past history of CAD s/p
CABG, and multiple stenting, nd most recently balloon
angioplasty (SVG-OM ___ and atrial fibrillation, who
presented with increased chest pain concerning for unstable
angina.
# Unstable Angina: Patient has now had another presentation of
unstable angina at home, with increased chest pain at rest.
Patient was recently admitted and underwent stress test which
was negative for ischemic area of disease. Patient was placed on
heparin gtt for cardiac catherization which revealed that the
SVG to OM1 was completed occluded proximally. The decision was
made not to place a stent since it appeared to be an old
occlusion (>3 days) and his initial troponions and MB were
negative and there were no ischemic changes on EKG. The plan was
to optimize medical management with Imdur 120, Renexa 1000 BID,
atorvastatin, metoprolol, aspirin and then continue to have
discussion with outpatient cardiologist regarding further
management. However, the patient began to have rising troponins
on ___, several hours after the catherization and then went
into PEA arrest and required intubation and transfer to the CCU
for management.
CCU COURSE:
==============
Patient underwent PEA Arrest In the evening of ___ the patient
developed sudden onset respiratory distress and AMS. He
subsequently suffered a PEA arrest with CPR performed and ROSC
after 5min. CTA ruled out PE but showed small RUL consolidation
vs compressive atelectasis and a moderate R pleural effusion. At
the time of transfer to the CCU the pt was on levophed for
hypotension.
In the evening of ___eveloped fever 100.1 and was
ordered for CTX to treat UTI due to a positive urinalysis. The
urine culture eventually grew Enterococcus sensitive to vanc and
unasyn. On ___ the pt remained febrile and vancomycin was
added. Unasyn was added on ___ for possible aspiration
pneumonia. He continued to spike fevers up to 102 daily, so he
also received a dose of cefepime on ___ and a dose of
azithromycin on ___. On ___, ID was consulted and
recommended discontinuation of all antibiotics given likelihood
of drug fever rather than an infectious etiology. The patient
had no further fevers after ___.
The pt was increasing agitated on the vent and unable to arouse
when sedation weaned so he underwent evaluation by neurology
with concern for anoxic injury. An MRI showed evidence of
several foci of small embolic strokes, EEG c/w toxic metabolic
encephalopathy.
The pt was noted to have bloody secretions on ___ during
suctioning. At this time the pt's fever curve increased with a
Tm of 102. Sputum cx revealed GPCs on gram stain and given
concern for aspiration, CTX was d/c and unasyn was initiated.
Bloody secretions increased in quantity on ___ and ___ and
the pt was evaluated by pulmonology, who felt that they were
related to irritation by the ET tube, compounded by
anticoagulation, and possible pneumonia. On ___, unasyn was
broadened to cefepime.
The CCU team was unable to wean him from mechanical ventilation
for several days due to the patient's inability to follow
commands even off sedation, as well as periods of agitation and
tachypnea with low tidal volumes. On ___ he was noted to be
alert and following commands. He was eventually able to be
extubated on ___. Post-extubation the patient was awake,
talking and mostly responding to commands and interacting with
his family. The following day (___), he was talking to his
family members and calling them by name, talking about distant
past events appropriately. Overall he appeared to be
dramatically improved. Towards the evening of ___, however, he
was restless, agitated, more paranoid, would not sleep despite
his family urging. By ___ his agitation had worsened
and the CCU team needed to give frequent doses of antipsychotics
to help control this. They discontinued his foley on ___.
Overnight, he required ongoing antipyschotics (olanzapine,
Haldol and Seroquel) and was even tried on Precedex between 6pm
and 6am without good effect.
Of note, the patient had a fever to 100.7 in the AM of ___
(his last fever prior to this was ___ when antibiotics were
discontinued) and was straight catheterized yielding 300cc with
a UA that was abnormal (95 WBCs, 0 Epi), though UCx was
negative. He also was hypoxemic to mid-80s off nasal cannula
(mid-90s on NC). Lastly, at 9:30AM his pupils were noted to be
unequal so a STAT neuro consult was obtained. Their assessment
was that this was most likely due to medication effect from
ipratropium (anticholinergic) and albuterol (beta 2 agonist)
nebulizers this morning, as well as precedex (alpha 2 agonist).
CT head was ordered which did not reveal any acute intracranial
hemorrhage or infarct, pt was given Cogentin for possible
Parksinonian side effects from antipsychotics, which may have
been contributing to his fevers. Duloxetine and all
anti-psychotics were DC'd.
On ___, pt was noted to be increasingly tachypneic and
agitated, and had a PEA arrest w/ROSC after 5min of CPR, 2 amps
of bicarb. A crash femoral line was placed and levophed was
started for BP support, and Aline was later placed after pt
stabilized. No hypothermia was done per pt's family decision. Pt
was noted to have a lactate of 8 after the arrest which quickly
downtrended later in the day. Pt's hypernatremia noted to have
worsened, was started on increasing IVF and FWF with lasix for
fluid overload as needed. Ampillicin and Flagyl was started for
possible PNA/UTI coverage, later broadened to Meropenem for
increased coverage, Meropenem DC'd on ___ negative
cultures and pt w/o sig fevers. Pulm was c/s for BAL, study
noted not to find any significant findings for acute lung
process. Pt remained tachypneic while intubated, was weaned off
propofol to precedex, tried using ativan to control tachypnea
though was unsuccessful, had to be placed on rate control as
wasn't tolerating pressure support. Pt failed SBT on ___.
In the early AM of ___, pt developed significant hypotension,
large abdominal mass was palpated, pt got stat CT-A showing
significant brisk RP bleed, went to ___ stat for emergent
embolization of L3-L4 arteries. Heparin gtt was stopped, got
protamine and blood product transfusions (5u PRBCs, 2x FFP).
___ d/w family that day, pt was made DNR if he were to arrest.
Pt continued to spike fevers, there was concern for infected
hematoma and was started on dapto/meropenem. Pt passed his RSBI
on ___ though there was continued concern for agitation after
potential extubation, which occurred on ___. Palliative care
was consulted, after extubation pt was made DNI in addition to
prior DNR, Abx and PO meds were DC'd. Pt was made comfortable
w/precedex and fentanyl boluses and levophed was stopped. In the
evening of ___, pt was noted to have worsening respirations
and be increasingly hypotensive and expired at ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler ___ PUFF IH BID PRN SOB
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Duloxetine 30 mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Nitromist (nitroglycerin) 400 mcg/spray translingual ___
sprays Q5 minutes PRN chest pain
8. Pantoprazole 40 mg PO Q24H
9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
10. Tiotropium Bromide 1 CAP IH DAILY
11. Endocet (oxyCODONE-acetaminophen) ___ mg oral Q6 PRN pain
12. Isosorbide Mononitrate 60 mg PO BID
Discharge Medications:
DECEASED
Discharge Disposition:
Expired
Discharge Diagnosis:
PRIMARY:
NSTEMI
s/p 2x PEA/RESPIRATORY ARREST
RP BLEED
Hyperactive Toxic Metabolic Encephalopathy
Afib
UTI
SECONDARY:
COPD
GERD
Hypothyroidism
Discharge Condition:
DECEASED
Discharge Instructions:
DECEASED
Followup Instructions:
___
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Allergies: [MASKED] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catherization [MASKED] [MASKED] L3-L4 arterial embolization [MASKED] History of Present Illness: Dr. [MASKED] is a [MASKED] year old cardiac surgeon with past history of CAD s/p CABG and several PCI's, and most recently balloon angioplasty (SVG-OM [MASKED] presents with increased chest pain. Patient was recently admitted on [MASKED] to medicine and discharged on [MASKED]. Patient re-presented to the ED for recurrent chest pain symptoms. Over the past 3 days patient has been having increased chest pain, and reports that this has been increased with exertion. He also had radiation of this chest pain to the left hand, with associated numbness/tingling. He denies any dyspnea, orthopnea, lightheaded or dizziness. He did have some episodes several days ago of chest pain with vomiting, however none currently. He felt nauseous in the ED with no vomiting. Notably, patient does take apixiban for atrial fibrillation anticoagulation, and patient has not been taking this medication due to a planned steroid injection on [MASKED] for back pain. During patient's prior hospitalization, he was initially started on heparin gtt and given aspirin full dose. Patient was found to be chest pain free after SL Nitro, and EKG at that time was not notable for any ischemic change. Patient underwent a stress MIBI which did show normal perfusion, a decrease in EF to 40%, and therefore was then discharged for outpatient follow up. Patient's home medications were also changed to imdur 120 mg from 60 mg, given his home metoprolol. ED COURSE: In the ED, patient had initial labs that were notable for a Trop-T <0.01, Sodium 141, Potassium 4.3, Chloride 104, BUN 32, Createinine 1.5. Patient was then found to have LFTs ALT 44, AST 53, AP 164. Patient also had Hgb 9.2, Hct 32.6 with MCV 74, and WBC 8.6. Patient was then taken to the cardiac cath lab for urgent evaluation of unstable angina. There, it was visualized that the graft to the OM was down, and collaterals looked good. There was further discussion regarding further revascularization, and possible medical vs operative treatment. Past Medical History: ANGINA PECTORIS --post CABG [MASKED] and post multiple stents/PTCA ATRIAL FIBRILLATION BENIGN PROSTATIC HYPERTROPHY GASTROESOPHAGEAL REFLUX OSTEOARTHRITIS PACEMAKER CHRONIC OBSTRUCTIVE PULMONARY DISEASE BACK AND NECK PAIN TURP Knee surgery Social History: [MASKED] Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: ADMISSION PHYSICAL EXAMINATION: ======================= VS: 97.9 [MASKED] 53-61 18 99%2L GENERAL: NAD. Very sleepy after catherization. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. No JVD CARDIAC: RRR. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, occasional wheezes in left lower base, no rhonchi. 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 EXAMINATION: ======================= DECEASED Pertinent Results: ADMISSION LABS: =========== [MASKED] 06:00AM [MASKED] PTT-64.6* [MASKED] [MASKED] 06:00AM PLT COUNT-205 [MASKED] 06:00AM WBC-8.5 RBC-4.34* HGB-9.0* HCT-32.0* MCV-74* MCH-20.7* MCHC-28.1* RDW-17.7* RDWSD-46.9* [MASKED] 06:00AM CALCIUM-8.5 PHOSPHATE-3.5 MAGNESIUM-2.2 [MASKED] 06:00AM CK-MB-3 cTropnT-0.01 [MASKED] 06:00AM GLUCOSE-88 UREA N-30* CREAT-1.2 SODIUM-143 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-27 ANION GAP-15 [MASKED] 08:00AM cTropnT-<0.01 [MASKED] 08:00AM GLUCOSE-115* UREA N-32* CREAT-1.5* SODIUM-141 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-16 [MASKED] 03:09PM [MASKED] PTT-32.3 [MASKED] [MASKED] 03:09PM PLT COUNT-206 [MASKED] 03:09PM WBC-8.7 RBC-4.53* HGB-9.3* HCT-33.6* MCV-74* MCH-20.5* MCHC-27.7* RDW-17.8* RDWSD-47.0* [MASKED] 03:09PM CALCIUM-8.8 PHOSPHATE-4.4 MAGNESIUM-2.3 IMAGING: ====== ECHO [MASKED] The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is low normal (LVEF 50-55%) secondary to septal dyssynchrony. Doppler parameters are indeterminate for left ventricular diastolic function. The right ventricular cavity is mildly dilated with focal hypokinesis of the apical free wall. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The number of aortic valve leaflets cannot be determined. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [MASKED], the right ventricle is now dilated with evidence of apical hypokinesis. There is more tricuspid regurgitation and pulmonary artery systolic pressure is severely increased. Left ventricular regional/global systolic function and other findings are similar. CTA CHEST W&W/O C&RECON [MASKED] 1. No evidence of pulmonary embolism or acute aortic syndrome. 2. Small consolidations in the right upper lobe and right lower lobe in a dependent location with a moderate right pleural effusion. Underlying infection not excluded. Left basilar atelectasis. 3. Pooling of secretions above the ETT balloon. Head CT [MASKED] 1. No evidence of acute intracranial process. CHEST (PORTABLE AP)Study Date of [MASKED] Mild pulmonary edema has increased since [MASKED]. Slight increase in severe cardiomegaly could be due to differences in cardiac cycle. Small right pleural effusion is likely. There is no pneumothorax. New ET tube is in standard placement. Esophageal drainage tube ends in the upper portion of a nondistended stomach. Transvenous right atrial right ventricular pacer leads follow their expected courses from the left pectoral generator. CTA CHEST W&W/O C&RECONS, NON-CORONARYStudy Date of [MASKED] 1. No evidence of pulmonary embolism or acute aortic syndrome. 2. Small consolidations in the right upper lobe and right lower lobe in a dependent location with a moderate right pleural effusion. Underlying infection not excluded. Left basilar atelectasis. 3. Pooling of secretions above the ETT balloon. LIVER OR GALLBLADDER US (SINGLE ORGAN) PORTStudy Date of [MASKED] 1. Normal liver echotexture with patent flow of the portal vein. No concerning liver mass. No morphologic features of cirrhosis. 2. Trace left lower quadrant ascites. 3. Cholelithiasis with trace pericholecystic fluid but no wall thickening. 4. Partially visualized right pleural effusion. CHEST (PORTABLE AP)Study Date of [MASKED] Increased opacity at the right lung base likely reflects a layering pleural effusion. Severe cardiomegaly and pulmonary vascular congestion, similar when compared to the prior study. Asymmetric pulmonary edema predominately affecting the right lung. EEGStudy Date of [MASKED] This is an abnormal continuous ICU EEG monitoring because of 1) frontally predominant sharp waves with a triphasic morphology at times appear in periodic runs embedded on a diffusely slow background. This is indicative of a moderate encephalopathy, which is non-specific but may be due to metabolic or electrolyte disturbances, infection or medications. There no definite epileptiform discharges. There are no electrographic seizures. MR HEAD W/O CONTRASTStudy Date of [MASKED] 1. Few scattered punctate foci of slow diffusion in the left frontal centrum semiovale, right occipital lobe and right cerebellum in keeping with acute infarcts, likely embolic in etiology. 2. Diffuse age-related volume loss. CAROTID SERIES COMPLETEStudy Date of [MASKED] 1. Mild heterogeneous calcified plaque involving bifurcations bilaterally. 2. No hemodynamically significant stenoses on either side (less than 40%). 3. Normal antegrade flow both vertebral arteries. CT HEAD W/O CONTRASTStudy Date of [MASKED] 1. Study is moderately degraded by motion. 2. Within limits of study no evidence of acute intracranial hemorrhage hemorrhage or infarct. CHEST (PORTABLE AP)Study Date of [MASKED] Moderate edema with new asymmetric increased edema in the right upper lobe which can be seen in the setting of mitral regurgitation. Correlate with clinical history. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [MASKED] 1. Active bleeding into a large left retroperitoneal hematoma most likely arising from the psoas muscle. 2. Acute anterior fractures of the left fourth- seventh and right fifth-seventh ribs. 3. Moderate right and small left pleural effusions with adjacent atelectasis. Ground-glass opacities in the bilateral upper lobes may reflect aspiration. 4. Chronic findings of colon diverticulosis and cholelithiasis. CHEST (PORTABLE AP) Study Date of [MASKED] Since most recent radiograph, there is no significant interval change. Again seen is bilateral pleural effusion and atelectasis, not significantly changed from prior. The ET tube now terminates approximately 2.5 cm from the carina, which may be due to patient positioning. Otherwise, there is no appreciable change in support lines. Sternotomy wires and surgical clips are in place. IMPRESSION: No significant interval change. MICRO ==== [MASKED] 6:06 am URINE Source: Catheter. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S [MASKED] 11:03 am SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [MASKED]: Commensal Respiratory Flora Absent. YEAST. SPARSE GROWTH. [MASKED] 6:47 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. GRAM STAIN (Final [MASKED]: 3+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [MASKED]: ~3000/ML Commensal Respiratory Flora. YEAST. 10,000-100,000 ORGANISMS/ML.. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [MASKED]: NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): [MASKED] 6:47 pm Rapid Respiratory Viral Screen & Culture BRONCHIAL LAVAGE. Respiratory Viral Culture (Preliminary): Respiratory Viral Antigen Screen (Final [MASKED]: Greater than 400 polymorphonuclear leukocytes;. Inadequate specimen for DFA detection of respiratory viruses.. Interpret all negative DFA and/or culture results from this specimen with caution.. Urine Culture ([MASKED]): Negative Blood Culture [MASKED], 13, 14, 17, 19, 22, 24, 25): Negative MRSA ([MASKED]): Negative Sputum Culture ([MASKED]): Negative Sputum Culture ([MASKED]): RP Stool C Diff ([MASKED]): Negative [MASKED] 5:00 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS EPIDERMIDIS. Isolated from only one set in the previous five days. WORK UP PER [MASKED] [MASKED]. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. STAPHYLOCOCCUS EPIDERMIDIS. [MASKED] MORPHOLOGY. Isolated from only one set in the previous five days. WORK UP PER [MASKED]. [MASKED] [MASKED]. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] STAPHYLOCOCCUS EPIDERMIDIS | STAPHYLOCOCCUS EPIDERMIDIS | | CLINDAMYCIN----------- =>8 R <=0.25 S ERYTHROMYCIN---------- =>8 R =>8 R GENTAMICIN------------ 8 I <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R =>4 R RIFAMPIN-------------- <=0.5 S <=0.5 S VANCOMYCIN------------ 1 S 1 S Aerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN CLUSTERS. DISCHARGE LABS ========== [MASKED] 06:15AM BLOOD WBC-7.9 RBC-2.84* Hgb-7.6* Hct-25.3* MCV-89 MCH-26.8 MCHC-30.0* RDW-21.5* RDWSD-67.5* Plt [MASKED] [MASKED] 06:15AM BLOOD Glucose-90 UreaN-45* Creat-1.2 Na-147* K-4.2 Cl-113* HCO3-27 AnGap-11 [MASKED] 06:15AM BLOOD Calcium-7.4* Phos-3.9 Mg-2.3 [MASKED] 04:44AM BLOOD Lactate-1.3 [MASKED] 04:44AM BLOOD freeCa-1.02* [MASKED] 03:55PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM Brief Hospital Course: Dr. [MASKED] is an [MASKED] year old male, with past history of CAD s/p CABG, and multiple stenting, nd most recently balloon angioplasty (SVG-OM [MASKED] and atrial fibrillation, who presented with increased chest pain concerning for unstable angina. # Unstable Angina: Patient has now had another presentation of unstable angina at home, with increased chest pain at rest. Patient was recently admitted and underwent stress test which was negative for ischemic area of disease. Patient was placed on heparin gtt for cardiac catherization which revealed that the SVG to OM1 was completed occluded proximally. The decision was made not to place a stent since it appeared to be an old occlusion (>3 days) and his initial troponions and MB were negative and there were no ischemic changes on EKG. The plan was to optimize medical management with Imdur 120, Renexa 1000 BID, atorvastatin, metoprolol, aspirin and then continue to have discussion with outpatient cardiologist regarding further management. However, the patient began to have rising troponins on [MASKED], several hours after the catherization and then went into PEA arrest and required intubation and transfer to the CCU for management. CCU COURSE: ============== Patient underwent PEA Arrest In the evening of [MASKED] the patient developed sudden onset respiratory distress and AMS. He subsequently suffered a PEA arrest with CPR performed and ROSC after 5min. CTA ruled out PE but showed small RUL consolidation vs compressive atelectasis and a moderate R pleural effusion. At the time of transfer to the CCU the pt was on levophed for hypotension. In the evening of eveloped fever 100.1 and was ordered for CTX to treat UTI due to a positive urinalysis. The urine culture eventually grew Enterococcus sensitive to vanc and unasyn. On [MASKED] the pt remained febrile and vancomycin was added. Unasyn was added on [MASKED] for possible aspiration pneumonia. He continued to spike fevers up to 102 daily, so he also received a dose of cefepime on [MASKED] and a dose of azithromycin on [MASKED]. On [MASKED], ID was consulted and recommended discontinuation of all antibiotics given likelihood of drug fever rather than an infectious etiology. The patient had no further fevers after [MASKED]. The pt was increasing agitated on the vent and unable to arouse when sedation weaned so he underwent evaluation by neurology with concern for anoxic injury. An MRI showed evidence of several foci of small embolic strokes, EEG c/w toxic metabolic encephalopathy. The pt was noted to have bloody secretions on [MASKED] during suctioning. At this time the pt's fever curve increased with a Tm of 102. Sputum cx revealed GPCs on gram stain and given concern for aspiration, CTX was d/c and unasyn was initiated. Bloody secretions increased in quantity on [MASKED] and [MASKED] and the pt was evaluated by pulmonology, who felt that they were related to irritation by the ET tube, compounded by anticoagulation, and possible pneumonia. On [MASKED], unasyn was broadened to cefepime. The CCU team was unable to wean him from mechanical ventilation for several days due to the patient's inability to follow commands even off sedation, as well as periods of agitation and tachypnea with low tidal volumes. On [MASKED] he was noted to be alert and following commands. He was eventually able to be extubated on [MASKED]. Post-extubation the patient was awake, talking and mostly responding to commands and interacting with his family. The following day ([MASKED]), he was talking to his family members and calling them by name, talking about distant past events appropriately. Overall he appeared to be dramatically improved. Towards the evening of [MASKED], however, he was restless, agitated, more paranoid, would not sleep despite his family urging. By [MASKED] his agitation had worsened and the CCU team needed to give frequent doses of antipsychotics to help control this. They discontinued his foley on [MASKED]. Overnight, he required ongoing antipyschotics (olanzapine, Haldol and Seroquel) and was even tried on Precedex between 6pm and 6am without good effect. Of note, the patient had a fever to 100.7 in the AM of [MASKED] (his last fever prior to this was [MASKED] when antibiotics were discontinued) and was straight catheterized yielding 300cc with a UA that was abnormal (95 WBCs, 0 Epi), though UCx was negative. He also was hypoxemic to mid-80s off nasal cannula (mid-90s on NC). Lastly, at 9:30AM his pupils were noted to be unequal so a STAT neuro consult was obtained. Their assessment was that this was most likely due to medication effect from ipratropium (anticholinergic) and albuterol (beta 2 agonist) nebulizers this morning, as well as precedex (alpha 2 agonist). CT head was ordered which did not reveal any acute intracranial hemorrhage or infarct, pt was given Cogentin for possible Parksinonian side effects from antipsychotics, which may have been contributing to his fevers. Duloxetine and all anti-psychotics were DC'd. On [MASKED], pt was noted to be increasingly tachypneic and agitated, and had a PEA arrest w/ROSC after 5min of CPR, 2 amps of bicarb. A crash femoral line was placed and levophed was started for BP support, and Aline was later placed after pt stabilized. No hypothermia was done per pt's family decision. Pt was noted to have a lactate of 8 after the arrest which quickly downtrended later in the day. Pt's hypernatremia noted to have worsened, was started on increasing IVF and FWF with lasix for fluid overload as needed. Ampillicin and Flagyl was started for possible PNA/UTI coverage, later broadened to Meropenem for increased coverage, Meropenem DC'd on [MASKED] negative cultures and pt w/o sig fevers. Pulm was c/s for BAL, study noted not to find any significant findings for acute lung process. Pt remained tachypneic while intubated, was weaned off propofol to precedex, tried using ativan to control tachypnea though was unsuccessful, had to be placed on rate control as wasn't tolerating pressure support. Pt failed SBT on [MASKED]. In the early AM of [MASKED], pt developed significant hypotension, large abdominal mass was palpated, pt got stat CT-A showing significant brisk RP bleed, went to [MASKED] stat for emergent embolization of L3-L4 arteries. Heparin gtt was stopped, got protamine and blood product transfusions (5u PRBCs, 2x FFP). [MASKED] d/w family that day, pt was made DNR if he were to arrest. Pt continued to spike fevers, there was concern for infected hematoma and was started on dapto/meropenem. Pt passed his RSBI on [MASKED] though there was continued concern for agitation after potential extubation, which occurred on [MASKED]. Palliative care was consulted, after extubation pt was made DNI in addition to prior DNR, Abx and PO meds were DC'd. Pt was made comfortable w/precedex and fentanyl boluses and levophed was stopped. In the evening of [MASKED], pt was noted to have worsening respirations and be increasingly hypotensive and expired at [MASKED]. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler [MASKED] PUFF IH BID PRN SOB 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Duloxetine 30 mg PO DAILY 5. Levothyroxine Sodium 75 mcg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Nitromist (nitroglycerin) 400 mcg/spray translingual [MASKED] sprays Q5 minutes PRN chest pain 8. Pantoprazole 40 mg PO Q24H 9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 10. Tiotropium Bromide 1 CAP IH DAILY 11. Endocet (oxyCODONE-acetaminophen) [MASKED] mg oral Q6 PRN pain 12. Isosorbide Mononitrate 60 mg PO BID Discharge Medications: DECEASED Discharge Disposition: Expired Discharge Diagnosis: PRIMARY: NSTEMI s/p 2x PEA/RESPIRATORY ARREST RP BLEED Hyperactive Toxic Metabolic Encephalopathy Afib UTI SECONDARY: COPD GERD Hypothyroidism Discharge Condition: DECEASED Discharge Instructions: DECEASED Followup Instructions: [MASKED]
|
[] |
[
"J449",
"Z951",
"Z87891",
"N400",
"E039",
"D509",
"K219",
"Z955",
"I4891"
] |
[
"I214: Non-ST elevation (NSTEMI) myocardial infarction",
"N170: Acute kidney failure with tubular necrosis",
"I469: Cardiac arrest, cause unspecified",
"J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia",
"K7200: Acute and subacute hepatic failure without coma",
"J690: Pneumonitis due to inhalation of food and vomit",
"E870: Hyperosmolality and hypernatremia",
"G92: Toxic encephalopathy",
"I6310: Cerebral infarction due to embolism of unspecified precerebral artery",
"E874: Mixed disorder of acid-base balance",
"D684: Acquired coagulation factor deficiency",
"J449: Chronic obstructive pulmonary disease, unspecified",
"Z951: Presence of aortocoronary bypass graft",
"Z87891: Personal history of nicotine dependence",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"E039: Hypothyroidism, unspecified",
"Z950: Presence of cardiac pacemaker",
"R502: Drug induced fever",
"D509: Iron deficiency anemia, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"Z955: Presence of coronary angioplasty implant and graft",
"I4891: Unspecified atrial fibrillation"
] |
10,025,268
| 26,726,393
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Clindamycin / Bactrim DS /
Sulfa(Sulfonamide Antibiotics) / Nitrofurantoin / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / aspirin / Levaquin
Attending: ___.
Chief Complaint:
Fever, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
FROM ADMISSION NOTE
Ms. ___ is a ___ with history of
migraines (w/ pain protocol), MS, CKD, hyperparathyroidism,
depression, presenting with 1 day of fever and generalized
malaise and fatigue.
She states that she was feeling well up to the day prior to
admission. Fairly quickly she started to feel generally unwell,
with chills in the afternoon. She had sore throat, nasal
congestion, cough. No emesis, diarrhea, abdominal pain.
In the ED, initial VS were: 103.3 120 101/70 20 96% 4L NC
Exam notable for:
Fatigued, sleeping. Easily arousable and conversant, interacting
per baseline.
Lungs: Clear to auscultation bilaterally.
Abd: Soft, nontender.
Back: No cva tenderness.
Ext: No swelling, no pitting edema.
Labs showed: WBC 8.9, 88.9% PMNs, creatinine 1.8 (baseline 1.5),
lactate 1.6
Imaging showed:
CXR
IMPRESSION:
Chronic bibasilar atelectasis without definite focal
consolidation.
Consults: None
Patient received:
___ 01:06 PO/NG OSELTAMivir 75 mg
___ 01:06 IV CefTRIAXone Started
___ 01:11 IV CefTRIAXone Stopped (___)
___ 03:45 IV Promethazine 12.5 mg
___ 03:45 IV DiphenhydrAMINE 12.5 mg
___ 04:02 IV HYDROmorphone (Dilaudid) .5 mg
___ 06:28 IV HYDROmorphone (Dilaudid) .5 mg
___ 06:37 IV Ondansetron 4 mg
___ 12:09 PO/NG OSELTAMivir 75 mg
___ 12:09 IV Ondansetron 4 mg
___ 14:16 IM Promethazine 12.5 mg
___ 14:16 PO/NG DiphenhydrAMINE 25 mg
___ 14:16 IV HYDROmorphone (Dilaudid) .5 mg
___ 16:14 IV Ondansetron 4 mg
___ 16:30 IM Promethazine 25 mg
___ 16:30 IV HYDROmorphone (Dilaudid) .5 mg
___ 22:13 PO/NG OSELTAMivir 75 mg
___ 22:13 IV HYDROmorphone (Dilaudid) .5 mg
___ 22:13 IV Ondansetron 4 mg
Transfer VS were: 98.9 77 115/75 15 98% RA
Flu A came back positive in the ED and the patient was given
OSELTAMivir. There was initially some question of super imposed
bacterial pneumonia and ceftriaxone was started, but given
equivocal CXR this was stopped.
The patient also developed a migraine in the ED. This was
managed
w/ existing pain protocol (IV dilaudid) + additional Zofran.
On arrival to the floor, patient reports the pain has improved
somewhat, now ___ down from ___. Significant nausea. Moderate
cough. No visual symptoms. No chest pain, dyspnea, dizziness.
Past Medical History:
FROM ADMISSION NOTE
Multiple Sclerosis - in remission, not on treatment
Hyperparathyroid
Migraine Headache
Chronic Renal Insufficency ___ to hx lithium use (baseline Cr
1.5)
Hypercholesterolemia
Hypothyroid ___ lithium
___
Depression
S/p TAH/BSO
Social History:
___
Family History:
FROM ADMISSION NOTE
Heart Disease: Father died age ___, paternal grandfather
___ Heart ___: Mother at age ___ died.
CVA: Mother
___ brother
___: Father since age ___
___: Paternal Aunt, paternal grandmother.
Suicide: Two distant paternal family members and paternal aunt.
Lung ___ Grandfather
Physical ___:
ADMISSION PHYSICAL EXAM:
======================
VS: 98.5 BP: 110/77 HR: 75 RR: 18 O2 sat: 93% on RA
GENERAL: NAD
HEENT: AT/NC, EOMI
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB
ABDOMEN: Nondistended, nontender in all quadrants
EXTREMITIES: No cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose, quite
sleepy but not somnolent
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
DISCHARE PHYSICAL EXAM:
=====================
T 97.7 BP 130/70 HR 75 RR 18 O2 92% RA
GENERAL: NAD, lying in bed
HEENT: anicteric, oropharynx clear
NECK: supple, no LAD
HEART: RRR, S1/S2, no m/r/g
LUNGS: unlabored, rare late inspiratory crackle
ABDOMEN: soft, nondistended, nontender
EXT: WWP without edema
NEURO: non-focal
Pertinent Results:
ADMSSION LABS
=============
___ 08:47PM BLOOD WBC-8.9# RBC-3.40* Hgb-10.5* Hct-33.2*
MCV-98 MCH-30.9 MCHC-31.6* RDW-13.6 RDWSD-48.9* Plt ___
___ 08:47PM BLOOD Neuts-88.9* Lymphs-5.3* Monos-5.2
Eos-0.0* Baso-0.1 Im ___ AbsNeut-7.58*# AbsLymp-0.45*
AbsMono-0.44 AbsEos-0.00* AbsBaso-0.01
___ 08:47PM BLOOD Glucose-143* UreaN-24* Creat-1.8* Na-138
K-4.3 Cl-106 HCO3-17* AnGap-15
___ 08:54PM BLOOD Lactate-1.6
___ 10:12PM OTHER BODY FLUID FluAPCR-POSITIVE*
FluBPCR-NEGATIVE
DISCHARGE LABS
=============
___ 06:05AM BLOOD WBC-5.0 RBC-3.07* Hgb-9.5* Hct-30.3*
MCV-99* MCH-30.9 MCHC-31.4* RDW-13.6 RDWSD-49.4* Plt ___
___ 06:05AM BLOOD Glucose-74 UreaN-19 Creat-1.2* Na-143
K-4.2 Cl-112* HCO3-17* AnGap-14
___ 06:05AM BLOOD Calcium-7.3* Phos-2.7 Mg-2.1
IMAGING
=======
CXR (___)
IMPRESSION:
Chronic bibasilar atelectasis without definite focal
consolidation.
Brief Hospital Course:
___ female with history of CKD, stage IIIB and migraine
disorder presenting with fever 103 Fahrenheit and generalized
malaise of one-day duration found to be influenza A positive.
#) Influenza: fever on background constitutional symptoms, as
above, of less than 48-hour duration. Oseltamivir 75 mg BID thus
initiated on ___ in the emergency department. Empiric
ceftriaxone likewise initiated for possible bacterial
superinfection, which was then discontinued at admission, in the
absence of fever, leukocytosis, or hemodynamic instability. No
respiratory distress or hypoxemia noted. CXR also reassuring.
Patient quickly tolerated oral intake and was overall well
enough for discharge by end of hospital day 1. Discharged on
oseltamivir 30 mg BID, given GFR <60, for completion of five-day
course (end date = ___.
#) Migraine disorder: intermittent, typical migraine symptoms on
the order of days, prompting initiation of established pain
protocol in the emergency department. This was discontinued at
admission for excessive sedation. Many of her sedating home
medications were also held.
#) Acute on chronic kidney disease: secondary to lithium
toxicity. Creatinine 1.8 at presentation (from baseline
creatinine 1.5), which rapidly declined with intravenous
hydration and improved oral intake.
TRANSITIONAL ISSUES
[ ]Confirm completion of five-day course of oseltamivir (end
date = ___
[ ]Consider de-escalation of psychoactive medications, and
amending emergency migraine pain protocol (from ___, given
excessive sedation
Greater than 30 minutes spent in care coordination and
counseling on the day of discharge.
#CONTACT: ___, husband (___)
#CODE: Full, presumed
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Sodium Bicarbonate 650 mg PO BID
2. Gabapentin 600 mg PO QHS
3. Topiramate (Topamax) 100 mg PO QHS
4. BuPROPion 100 mg PO BID
5. ARIPiprazole 5 mg PO DAILY
6. QUEtiapine Fumarate 200 mg PO QHS
7. ClonazePAM 3 mg PO QHS
8. ALPRAZolam 1 mg PO BID:PRN anxiety
9. Simvastatin 40 mg PO QPM
10. Multivitamins 1 TAB PO DAILY
11. Promethazine ___ID:PRN migraine
12. Nystatin Cream 1 Appl TP TID
13. Calcitriol 0.25 mcg PO 1X/WEEK (FR)
14. Tamsulosin 0.4 mg PO QHS
15. ZOLMitriptan 5 mg oral DAILY:PRN
16. Levothyroxine Sodium 125 mcg PO DAILY
Discharge Medications:
1. OSELTAMivir 30 mg PO BID
RX *oseltamivir 30 mg 1 capsule(s) by mouth twice a day Disp #*6
Capsule Refills:*0
2. ALPRAZolam 1 mg PO BID:PRN anxiety
3. ARIPiprazole 5 mg PO DAILY
4. BuPROPion 100 mg PO BID
5. Calcitriol 0.25 mcg PO 1X/WEEK (FR)
6. ClonazePAM 3 mg PO QHS
7. Gabapentin 600 mg PO QHS
8. Levothyroxine Sodium 125 mcg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Nystatin Cream 1 Appl TP TID
11. Promethazine ___ID:PRN migraine
12. QUEtiapine Fumarate 200 mg PO QHS
13. Simvastatin 40 mg PO QPM
14. Sodium Bicarbonate 650 mg PO BID
15. Tamsulosin 0.4 mg PO QHS
16. Topiramate (Topamax) 100 mg PO QHS
17. ZOLMitriptan 5 mg oral DAILY:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Influenza
SECONDARY:
-Acute on chronic kidney injury
-Migraine disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
-You were diagnosed with the flu.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You received an antiviral medication called Tamiflu to shorten
the duration of your symptoms.
-We monitored your breathing and oxygen levels, which remained
normal.
-You received fluids because you were not drinking well.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
-Please take Tamiflu until ___ (3 more days).
-Follow-up with Dr. ___ within one week.
-Get plenty of rest and remain well hydrated.
We wish you all the best!
Sincerely,
Your ___ care team
Followup Instructions:
___
|
[
"J111",
"N179",
"G43909",
"N189",
"E038",
"E785",
"E213",
"K219",
"K2270",
"F329",
"G35",
"F419",
"Z87891"
] |
Allergies: Penicillins / Erythromycin Base / Clindamycin / Bactrim DS / Sulfa(Sulfonamide Antibiotics) / Nitrofurantoin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / aspirin / Levaquin Chief Complaint: Fever, fatigue Major Surgical or Invasive Procedure: None History of Present Illness: FROM ADMISSION NOTE Ms. [MASKED] is a [MASKED] with history of migraines (w/ pain protocol), MS, CKD, hyperparathyroidism, depression, presenting with 1 day of fever and generalized malaise and fatigue. She states that she was feeling well up to the day prior to admission. Fairly quickly she started to feel generally unwell, with chills in the afternoon. She had sore throat, nasal congestion, cough. No emesis, diarrhea, abdominal pain. In the ED, initial VS were: 103.3 120 101/70 20 96% 4L NC Exam notable for: Fatigued, sleeping. Easily arousable and conversant, interacting per baseline. Lungs: Clear to auscultation bilaterally. Abd: Soft, nontender. Back: No cva tenderness. Ext: No swelling, no pitting edema. Labs showed: WBC 8.9, 88.9% PMNs, creatinine 1.8 (baseline 1.5), lactate 1.6 Imaging showed: CXR IMPRESSION: Chronic bibasilar atelectasis without definite focal consolidation. Consults: None Patient received: [MASKED] 01:06 PO/NG OSELTAMivir 75 mg [MASKED] 01:06 IV CefTRIAXone Started [MASKED] 01:11 IV CefTRIAXone Stopped ([MASKED]) [MASKED] 03:45 IV Promethazine 12.5 mg [MASKED] 03:45 IV DiphenhydrAMINE 12.5 mg [MASKED] 04:02 IV HYDROmorphone (Dilaudid) .5 mg [MASKED] 06:28 IV HYDROmorphone (Dilaudid) .5 mg [MASKED] 06:37 IV Ondansetron 4 mg [MASKED] 12:09 PO/NG OSELTAMivir 75 mg [MASKED] 12:09 IV Ondansetron 4 mg [MASKED] 14:16 IM Promethazine 12.5 mg [MASKED] 14:16 PO/NG DiphenhydrAMINE 25 mg [MASKED] 14:16 IV HYDROmorphone (Dilaudid) .5 mg [MASKED] 16:14 IV Ondansetron 4 mg [MASKED] 16:30 IM Promethazine 25 mg [MASKED] 16:30 IV HYDROmorphone (Dilaudid) .5 mg [MASKED] 22:13 PO/NG OSELTAMivir 75 mg [MASKED] 22:13 IV HYDROmorphone (Dilaudid) .5 mg [MASKED] 22:13 IV Ondansetron 4 mg Transfer VS were: 98.9 77 115/75 15 98% RA Flu A came back positive in the ED and the patient was given OSELTAMivir. There was initially some question of super imposed bacterial pneumonia and ceftriaxone was started, but given equivocal CXR this was stopped. The patient also developed a migraine in the ED. This was managed w/ existing pain protocol (IV dilaudid) + additional Zofran. On arrival to the floor, patient reports the pain has improved somewhat, now [MASKED] down from [MASKED]. Significant nausea. Moderate cough. No visual symptoms. No chest pain, dyspnea, dizziness. Past Medical History: FROM ADMISSION NOTE Multiple Sclerosis - in remission, not on treatment Hyperparathyroid Migraine Headache Chronic Renal Insufficency [MASKED] to hx lithium use (baseline Cr 1.5) Hypercholesterolemia Hypothyroid [MASKED] lithium [MASKED] Depression S/p TAH/BSO Social History: [MASKED] Family History: FROM ADMISSION NOTE Heart Disease: Father died age [MASKED], paternal grandfather [MASKED] Heart [MASKED]: Mother at age [MASKED] died. CVA: Mother [MASKED] brother [MASKED]: Father since age [MASKED] [MASKED]: Paternal Aunt, paternal grandmother. Suicide: Two distant paternal family members and paternal aunt. Lung [MASKED] Grandfather Physical [MASKED]: ADMISSION PHYSICAL EXAM: ====================== VS: 98.5 BP: 110/77 HR: 75 RR: 18 O2 sat: 93% on RA GENERAL: NAD HEENT: AT/NC, EOMI HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB ABDOMEN: Nondistended, nontender in all quadrants EXTREMITIES: No cyanosis, clubbing, or edema NEURO: A&Ox3, moving all 4 extremities with purpose, quite sleepy but not somnolent SKIN: Warm and well perfused, no excoriations or lesions, no rashes DISCHARE PHYSICAL EXAM: ===================== T 97.7 BP 130/70 HR 75 RR 18 O2 92% RA GENERAL: NAD, lying in bed HEENT: anicteric, oropharynx clear NECK: supple, no LAD HEART: RRR, S1/S2, no m/r/g LUNGS: unlabored, rare late inspiratory crackle ABDOMEN: soft, nondistended, nontender EXT: WWP without edema NEURO: non-focal Pertinent Results: ADMSSION LABS ============= [MASKED] 08:47PM BLOOD WBC-8.9# RBC-3.40* Hgb-10.5* Hct-33.2* MCV-98 MCH-30.9 MCHC-31.6* RDW-13.6 RDWSD-48.9* Plt [MASKED] [MASKED] 08:47PM BLOOD Neuts-88.9* Lymphs-5.3* Monos-5.2 Eos-0.0* Baso-0.1 Im [MASKED] AbsNeut-7.58*# AbsLymp-0.45* AbsMono-0.44 AbsEos-0.00* AbsBaso-0.01 [MASKED] 08:47PM BLOOD Glucose-143* UreaN-24* Creat-1.8* Na-138 K-4.3 Cl-106 HCO3-17* AnGap-15 [MASKED] 08:54PM BLOOD Lactate-1.6 [MASKED] 10:12PM OTHER BODY FLUID FluAPCR-POSITIVE* FluBPCR-NEGATIVE DISCHARGE LABS ============= [MASKED] 06:05AM BLOOD WBC-5.0 RBC-3.07* Hgb-9.5* Hct-30.3* MCV-99* MCH-30.9 MCHC-31.4* RDW-13.6 RDWSD-49.4* Plt [MASKED] [MASKED] 06:05AM BLOOD Glucose-74 UreaN-19 Creat-1.2* Na-143 K-4.2 Cl-112* HCO3-17* AnGap-14 [MASKED] 06:05AM BLOOD Calcium-7.3* Phos-2.7 Mg-2.1 IMAGING ======= CXR ([MASKED]) IMPRESSION: Chronic bibasilar atelectasis without definite focal consolidation. Brief Hospital Course: [MASKED] female with history of CKD, stage IIIB and migraine disorder presenting with fever 103 Fahrenheit and generalized malaise of one-day duration found to be influenza A positive. #) Influenza: fever on background constitutional symptoms, as above, of less than 48-hour duration. Oseltamivir 75 mg BID thus initiated on [MASKED] in the emergency department. Empiric ceftriaxone likewise initiated for possible bacterial superinfection, which was then discontinued at admission, in the absence of fever, leukocytosis, or hemodynamic instability. No respiratory distress or hypoxemia noted. CXR also reassuring. Patient quickly tolerated oral intake and was overall well enough for discharge by end of hospital day 1. Discharged on oseltamivir 30 mg BID, given GFR <60, for completion of five-day course (end date = [MASKED]. #) Migraine disorder: intermittent, typical migraine symptoms on the order of days, prompting initiation of established pain protocol in the emergency department. This was discontinued at admission for excessive sedation. Many of her sedating home medications were also held. #) Acute on chronic kidney disease: secondary to lithium toxicity. Creatinine 1.8 at presentation (from baseline creatinine 1.5), which rapidly declined with intravenous hydration and improved oral intake. TRANSITIONAL ISSUES [ ]Confirm completion of five-day course of oseltamivir (end date = [MASKED] [ ]Consider de-escalation of psychoactive medications, and amending emergency migraine pain protocol (from [MASKED], given excessive sedation Greater than 30 minutes spent in care coordination and counseling on the day of discharge. #CONTACT: [MASKED], husband ([MASKED]) #CODE: Full, presumed Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Sodium Bicarbonate 650 mg PO BID 2. Gabapentin 600 mg PO QHS 3. Topiramate (Topamax) 100 mg PO QHS 4. BuPROPion 100 mg PO BID 5. ARIPiprazole 5 mg PO DAILY 6. QUEtiapine Fumarate 200 mg PO QHS 7. ClonazePAM 3 mg PO QHS 8. ALPRAZolam 1 mg PO BID:PRN anxiety 9. Simvastatin 40 mg PO QPM 10. Multivitamins 1 TAB PO DAILY 11. Promethazine ID:PRN migraine 12. Nystatin Cream 1 Appl TP TID 13. Calcitriol 0.25 mcg PO 1X/WEEK (FR) 14. Tamsulosin 0.4 mg PO QHS 15. ZOLMitriptan 5 mg oral DAILY:PRN 16. Levothyroxine Sodium 125 mcg PO DAILY Discharge Medications: 1. OSELTAMivir 30 mg PO BID RX *oseltamivir 30 mg 1 capsule(s) by mouth twice a day Disp #*6 Capsule Refills:*0 2. ALPRAZolam 1 mg PO BID:PRN anxiety 3. ARIPiprazole 5 mg PO DAILY 4. BuPROPion 100 mg PO BID 5. Calcitriol 0.25 mcg PO 1X/WEEK (FR) 6. ClonazePAM 3 mg PO QHS 7. Gabapentin 600 mg PO QHS 8. Levothyroxine Sodium 125 mcg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Nystatin Cream 1 Appl TP TID 11. Promethazine ID:PRN migraine 12. QUEtiapine Fumarate 200 mg PO QHS 13. Simvastatin 40 mg PO QPM 14. Sodium Bicarbonate 650 mg PO BID 15. Tamsulosin 0.4 mg PO QHS 16. Topiramate (Topamax) 100 mg PO QHS 17. ZOLMitriptan 5 mg oral DAILY:PRN Discharge Disposition: Home Discharge Diagnosis: PRIMARY: -Influenza SECONDARY: -Acute on chronic kidney injury -Migraine disorder 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 WAS I ADMITTED TO THE HOSPITAL? -You were diagnosed with the flu. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? -You received an antiviral medication called Tamiflu to shorten the duration of your symptoms. -We monitored your breathing and oxygen levels, which remained normal. -You received fluids because you were not drinking well. WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL? -Please take Tamiflu until [MASKED] (3 more days). -Follow-up with Dr. [MASKED] within one week. -Get plenty of rest and remain well hydrated. We wish you all the best! Sincerely, Your [MASKED] care team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"N189",
"E785",
"K219",
"F329",
"F419",
"Z87891"
] |
[
"J111: Influenza due to unidentified influenza virus with other respiratory manifestations",
"N179: Acute kidney failure, unspecified",
"G43909: Migraine, unspecified, not intractable, without status migrainosus",
"N189: Chronic kidney disease, unspecified",
"E038: Other specified hypothyroidism",
"E785: Hyperlipidemia, unspecified",
"E213: Hyperparathyroidism, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"K2270: Barrett's esophagus without dysplasia",
"F329: Major depressive disorder, single episode, unspecified",
"G35: Multiple sclerosis",
"F419: Anxiety disorder, unspecified",
"Z87891: Personal history of nicotine dependence"
] |
10,025,282
| 29,973,577
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Topamax
Attending: ___
Chief Complaint:
Vertigo
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
___ is a ___ yo man with history of relapsing remitting MS on
___, chronic central vertigo, obesity, and DMII (on Lantus
and metformin) referred to the ED for worsening vertigo/MS
flare.
He reports over the last 2 weeks has deteriorated to the point
that he is not able to drive and apparently now can hardly get
out of his chair to go to the bathroom. He saw his neurologist
Dr. ___ in clinic this week after the symptoms worsened. At
the
time she wanted to arrange an admission for steroids but he
declined as he was moving to another apartment with his wife.
___ has been having constant vertigo and nausea for
approximately ___ years. The symptoms improve somewhat, but never
go away completely. He describes his dizziness as a sensation of
the room is still but his head is spinning. Associated with
nausea without vomiting. Symptoms are not better with closing
eyes. He notices still has the head spinning while in bed, but
denies worsening with turning in bed. At baseline he walks with
a cane. Denies visual changes, denies ringing in his ears, and
loss of hearing. He reports on WED he was moving so refused
admission but today felt worse so finally agreed to come in. He
has been taking Zofran twice daily for the nausea. Also notes
chronic paresthesias over his hands and fingertips. Reports
baseline left leg weakness for which he walks with a cane.
He reports initial MS symptoms presented with optic neuritis at
age ___. He was diagnosed much later at ___ y/o. During that
episode he remembers was working in an office and developed word
finding difficulty, as well as numbness in his and bilateral
fingers. At the time a neurologist at ___
diagnosed him with MS. ___ then he has been followed by Dr.
___. He reports has not been admitted frequently to the
hospital for management of flares.
Past Medical History:
DM
MS
___ cancer s/p radiation
Migraines on propranolol for prophylaxis
Social History:
___
Family History:
Mother- DM, ___
Father- DM, CAD
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD well-appearing man
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
Mental status: Awake, alert, oriented x 3. Able to relate
history
without difficulty. Attentive, able to name ___ backward without
difficulty. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. No dysarthria. Normal prosody. Able to register 3
objects and recall ___ at 5 minutes. No apraxia. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline and appendicular commands.
Cranial Nerves - PERRL 3.5->2 brisk. VF full. EOMI, no nystagmus
does endorse dizziness with extraocular movement testing. V1-V3
without deficits to light touch bilaterally. No facial movement
asymmetry. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. SCM/Trapezius strength ___ bilaterally.
Tongue midline.
Motor - Normal bulk and tone. No drift. No tremor or asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4 4+ 5 5 5 5
R 5 ___ ___ 4+ 5 5 5 5 5
Sensory: paresthesias over bilateral palms to soft touch. No
exinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 2
R 2 2 2 1 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally.
- Gait -wide-based. Listing to the left. Assisted with a cane.
DISCHARGE PHYSICAL EXAM;
Endorses dizziness w/ EOM to R; otherwise, non-focal
Pertinent Results:
___ 07:20AM BLOOD WBC-11.1* RBC-4.67 Hgb-13.0* Hct-40.4
MCV-87 MCH-27.8 MCHC-32.2 RDW-14.7 RDWSD-46.2 Plt ___
___ 08:00PM BLOOD WBC-7.1 RBC-4.77 Hgb-13.4* Hct-41.0
MCV-86 MCH-28.1 MCHC-32.7 RDW-14.3 RDWSD-44.6 Plt ___
___ 08:00PM BLOOD ___ PTT-42.3* ___
___ 07:20AM BLOOD Glucose-68* UreaN-23* Creat-0.8 Na-138
K-4.2 Cl-98 HCO3-29 AnGap-15
___ 08:00PM BLOOD Glucose-282* UreaN-28* Creat-0.6 Na-135
K-4.0 Cl-99 HCO3-21* AnGap-19
___ 08:00PM BLOOD ALT-21 AST-12 AlkPhos-100 TotBili-0.3
___ 08:00PM BLOOD Lipase-116*
___ 07:25AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0
___ 07:05AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.8
___ 08:00PM BLOOD Albumin-4.3
___ 05:06PM BLOOD %HbA1c-9.7* eAG-232*
___ 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ Head w/ and w/o
1. Unchanged nonenhancing white matter lesions, as described, in
keeping with history of multiple sclerosis. No new lesion or
associated enhancement.
2. No acute intracranial abnormality including hemorrhage,
infarct, or
enhancing mass.
Brief Hospital Course:
Pt presented to ___ per outpt neurologist due to acute
worsening of chronic vertigo. He underwent MRI Brain with no new
MS lesions noted although due to concern for new flare was
started on steroid therapy initially w/ Solumedrol 1g for 4
days. Despite no significant improvement, pt was continued at
lower dose of 500 and then 250mg for 4 more days, with total
administration of 8 days. During treatment with high dose
steroid therapy, patient was noted to have markedly elevated
blood sugars with diabetes regimen adjusted by ___ Consult
Service. With changes to his long acting and short acting
insulin regimen, patient's sugars improved. Following treatment
with steroid therapy, pt was also noted to have improvement in
his vertiginous symptoms except for continued dizziness with
certain eye movements. Due to his improvement and completion of
steroid therapy, patient was deemed stable for discharge from
the hospital.
Transition issues:
-Pt will need to continue monthly ___ infusion and follow up
with Dr. ___ in near future
-Pt will need to continue ___ as outpt
-Pt will need to adjust Diabetes regimen as noted in discharge
instructions with Metformin 1000mg BID, Lantus 40 units in
morning, and adjusted Humalog sliding scale at mealtimes; pt
will need to follow up with ___ for continued management of
his diabetes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO QHS
2. Amphetamine-Dextroamphetamine 10 mg PO DAILY PRN ADHD
3. Glargine 48 Units Breakfast
4. ___ (natalizumab) 300 mg/15 mL injection Monthly
5. MetFORMIN (Glucophage) 1000 mg PO DAILY
6. Propranolol 40 mg PO BID
7. Lovastatin 40 mg oral QHS
8. Aspirin 81 mg PO DAILY
9. Ondansetron 4 mg PO BID
Discharge Medications:
1. Glargine 40 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 40 Units before
BKFT; Disp #*10 Vial Refills:*0
RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR Up to 30
Units QID per sliding scale Disp #*15 Syringe Refills:*0
2. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin [Glucophage] 1,000 mg 1 tablet(s) by mouth Twice
daily Disp #*60 Tablet Refills:*0
3. Amphetamine-Dextroamphetamine 10 mg PO DAILY PRN ADHD
4. Aspirin 81 mg PO DAILY
5. Lovastatin 40 mg oral QHS
6. Propranolol 40 mg PO BID
7. Tamsulosin 0.4 mg PO QHS
8. ___ (natalizumab) 300 mg/15 mL injection Monthly
9.Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on Chronic Vertigo
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 ___ for symptoms of chronic
vertigo, which had worsened recently. Initially, there was
concern that your worsening vertigo may have been due to a
Multiple Sclerosis Flare. In this case, the vertigo would be
responsive to steroids.
You underwent Brain MRI which did not show evidence of new or
"active" MS lesions since your last image. You were treated
with 4 days of high dose steroids without significant
improvement. This makes it much less likely that a MS flare was
the cause of your symptoms.
There are many causes of vertigo. Your doctors suspect your
___ is playing a significant role in yours. We recommend
that you continue to follow with ___ to better control your
sugars. Please continue diabetes regimen as discussed with
___ (40 units Glargine in AM, Metformin 1000mg BID,
and sliding scale as provided). Please follow up with Dr. ___
as noted below.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
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Allergies: Penicillins / Topamax Chief Complaint: Vertigo Major Surgical or Invasive Procedure: n/a History of Present Illness: [MASKED] is a [MASKED] yo man with history of relapsing remitting MS on [MASKED], chronic central vertigo, obesity, and DMII (on Lantus and metformin) referred to the ED for worsening vertigo/MS flare. He reports over the last 2 weeks has deteriorated to the point that he is not able to drive and apparently now can hardly get out of his chair to go to the bathroom. He saw his neurologist Dr. [MASKED] in clinic this week after the symptoms worsened. At the time she wanted to arrange an admission for steroids but he declined as he was moving to another apartment with his wife. [MASKED] has been having constant vertigo and nausea for approximately [MASKED] years. The symptoms improve somewhat, but never go away completely. He describes his dizziness as a sensation of the room is still but his head is spinning. Associated with nausea without vomiting. Symptoms are not better with closing eyes. He notices still has the head spinning while in bed, but denies worsening with turning in bed. At baseline he walks with a cane. Denies visual changes, denies ringing in his ears, and loss of hearing. He reports on WED he was moving so refused admission but today felt worse so finally agreed to come in. He has been taking Zofran twice daily for the nausea. Also notes chronic paresthesias over his hands and fingertips. Reports baseline left leg weakness for which he walks with a cane. He reports initial MS symptoms presented with optic neuritis at age [MASKED]. He was diagnosed much later at [MASKED] y/o. During that episode he remembers was working in an office and developed word finding difficulty, as well as numbness in his and bilateral fingers. At the time a neurologist at [MASKED] diagnosed him with MS. [MASKED] then he has been followed by Dr. [MASKED]. He reports has not been admitted frequently to the hospital for management of flares. Past Medical History: DM MS [MASKED] cancer s/p radiation Migraines on propranolol for prophylaxis Social History: [MASKED] Family History: Mother- DM, [MASKED] Father- DM, CAD Physical Exam: ADMISSION PHYSICAL EXAM: General: NAD well-appearing man HEENT: NCAT, no oropharyngeal lesions, neck supple [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: Mental status: Awake, alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming intact. No paraphasias. No dysarthria. Normal prosody. Able to register 3 objects and recall [MASKED] at 5 minutes. No apraxia. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. Cranial Nerves - PERRL 3.5->2 brisk. VF full. EOMI, no nystagmus does endorse dizziness with extraocular movement testing. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength [MASKED] bilaterally. Tongue midline. Motor - Normal bulk and tone. No drift. No tremor or asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [MASKED] L 5 [MASKED] [MASKED] 4 4+ 5 5 5 5 R 5 [MASKED] [MASKED] 4+ 5 5 5 5 5 Sensory: paresthesias over bilateral palms to soft touch. No exinction to DSS. -DTRs: Bi Tri [MASKED] Pat Ach L 2 2 2 1 2 R 2 2 2 1 2 Plantar response flexor bilaterally. - Coordination - No dysmetria with finger to nose testing bilaterally. - Gait -wide-based. Listing to the left. Assisted with a cane. DISCHARGE PHYSICAL EXAM; Endorses dizziness w/ EOM to R; otherwise, non-focal Pertinent Results: [MASKED] 07:20AM BLOOD WBC-11.1* RBC-4.67 Hgb-13.0* Hct-40.4 MCV-87 MCH-27.8 MCHC-32.2 RDW-14.7 RDWSD-46.2 Plt [MASKED] [MASKED] 08:00PM BLOOD WBC-7.1 RBC-4.77 Hgb-13.4* Hct-41.0 MCV-86 MCH-28.1 MCHC-32.7 RDW-14.3 RDWSD-44.6 Plt [MASKED] [MASKED] 08:00PM BLOOD [MASKED] PTT-42.3* [MASKED] [MASKED] 07:20AM BLOOD Glucose-68* UreaN-23* Creat-0.8 Na-138 K-4.2 Cl-98 HCO3-29 AnGap-15 [MASKED] 08:00PM BLOOD Glucose-282* UreaN-28* Creat-0.6 Na-135 K-4.0 Cl-99 HCO3-21* AnGap-19 [MASKED] 08:00PM BLOOD ALT-21 AST-12 AlkPhos-100 TotBili-0.3 [MASKED] 08:00PM BLOOD Lipase-116* [MASKED] 07:25AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0 [MASKED] 07:05AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.8 [MASKED] 08:00PM BLOOD Albumin-4.3 [MASKED] 05:06PM BLOOD %HbA1c-9.7* eAG-232* [MASKED] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] Head w/ and w/o 1. Unchanged nonenhancing white matter lesions, as described, in keeping with history of multiple sclerosis. No new lesion or associated enhancement. 2. No acute intracranial abnormality including hemorrhage, infarct, or enhancing mass. Brief Hospital Course: Pt presented to [MASKED] per outpt neurologist due to acute worsening of chronic vertigo. He underwent MRI Brain with no new MS lesions noted although due to concern for new flare was started on steroid therapy initially w/ Solumedrol 1g for 4 days. Despite no significant improvement, pt was continued at lower dose of 500 and then 250mg for 4 more days, with total administration of 8 days. During treatment with high dose steroid therapy, patient was noted to have markedly elevated blood sugars with diabetes regimen adjusted by [MASKED] Consult Service. With changes to his long acting and short acting insulin regimen, patient's sugars improved. Following treatment with steroid therapy, pt was also noted to have improvement in his vertiginous symptoms except for continued dizziness with certain eye movements. Due to his improvement and completion of steroid therapy, patient was deemed stable for discharge from the hospital. Transition issues: -Pt will need to continue monthly [MASKED] infusion and follow up with Dr. [MASKED] in near future -Pt will need to continue [MASKED] as outpt -Pt will need to adjust Diabetes regimen as noted in discharge instructions with Metformin 1000mg BID, Lantus 40 units in morning, and adjusted Humalog sliding scale at mealtimes; pt will need to follow up with [MASKED] for continued management of his diabetes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tamsulosin 0.4 mg PO QHS 2. Amphetamine-Dextroamphetamine 10 mg PO DAILY PRN ADHD 3. Glargine 48 Units Breakfast 4. [MASKED] (natalizumab) 300 mg/15 mL injection Monthly 5. MetFORMIN (Glucophage) 1000 mg PO DAILY 6. Propranolol 40 mg PO BID 7. Lovastatin 40 mg oral QHS 8. Aspirin 81 mg PO DAILY 9. Ondansetron 4 mg PO BID Discharge Medications: 1. Glargine 40 Units Breakfast Insulin SC Sliding Scale using HUM Insulin RX *insulin glargine [Lantus] 100 unit/mL AS DIR 40 Units before BKFT; Disp #*10 Vial Refills:*0 RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR Up to 30 Units QID per sliding scale Disp #*15 Syringe Refills:*0 2. MetFORMIN (Glucophage) 1000 mg PO BID RX *metformin [Glucophage] 1,000 mg 1 tablet(s) by mouth Twice daily Disp #*60 Tablet Refills:*0 3. Amphetamine-Dextroamphetamine 10 mg PO DAILY PRN ADHD 4. Aspirin 81 mg PO DAILY 5. Lovastatin 40 mg oral QHS 6. Propranolol 40 mg PO BID 7. Tamsulosin 0.4 mg PO QHS 8. [MASKED] (natalizumab) 300 mg/15 mL injection Monthly 9.Outpatient Physical Therapy Discharge Disposition: Home Discharge Diagnosis: Acute on Chronic Vertigo 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] for symptoms of chronic vertigo, which had worsened recently. Initially, there was concern that your worsening vertigo may have been due to a Multiple Sclerosis Flare. In this case, the vertigo would be responsive to steroids. You underwent Brain MRI which did not show evidence of new or "active" MS lesions since your last image. You were treated with 4 days of high dose steroids without significant improvement. This makes it much less likely that a MS flare was the cause of your symptoms. There are many causes of vertigo. Your doctors suspect your [MASKED] is playing a significant role in yours. We recommend that you continue to follow with [MASKED] to better control your sugars. Please continue diabetes regimen as discussed with [MASKED] (40 units Glargine in AM, Metformin 1000mg BID, and sliding scale as provided). Please follow up with Dr. [MASKED] as noted below. It was a pleasure taking care of you, Your [MASKED] Care Team Followup Instructions: [MASKED]
|
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[
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"E1165: Type 2 diabetes mellitus with hyperglycemia",
"I10: Essential (primary) hypertension",
"R42: Dizziness and giddiness",
"E785: Hyperlipidemia, unspecified",
"Z794: Long term (current) use of insulin",
"Z87891: Personal history of nicotine dependence",
"Z8546: Personal history of malignant neoplasm of prostate",
"Z923: Personal history of irradiation",
"E669: Obesity, unspecified"
] |
10,025,630
| 21,983,726
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Right knee pain
Major Surgical or Invasive Procedure:
Right total knee replacement RG ___, MD ___
History of Present Illness:
___ w/ R knee OA who presents for right total knee replacement
Past Medical History:
Hypertension, obesity
Social History:
___
Family History:
Noncontributory
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:
X-rays of the right knee obtained post-op showed a right total
knee replacement in good alignment without fracture
___ 06:14AM BLOOD WBC-10.7* RBC-3.48* Hgb-9.7* Hct-29.7*
MCV-85 MCH-27.9 MCHC-32.7 RDW-15.1 RDWSD-45.9 Plt ___
___ 05:55AM BLOOD WBC-9.0 RBC-3.55*# Hgb-10.1*# Hct-30.2*#
MCV-85 MCH-28.5 MCHC-33.4 RDW-14.6 RDWSD-45.3 Plt ___
___ 05:56AM BLOOD Ret Aut-1.8 Abs Ret-0.05
___ 06:14AM BLOOD Glucose-91 UreaN-8 Creat-0.7 Na-141 K-4.3
Cl-102 HCO3-30 AnGap-13
___ 05:56AM BLOOD LD(LDH)-188 TotBili-0.3
___ 06:14AM BLOOD Calcium-9.0 Phos-2.7 Mg-2.0
___ 05:56AM BLOOD calTIBC-213* Ferritn-280* TRF-164*
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#0 overnight, the patient was given 500 mL of fluids for
low urine output. On POD#1, the patient's temperature spiked to
102.4. Urines were sent. She was suspected to have a urinary
tract infection and started on Cipofloxacin.
On POD#2, the patient was intermittently febrile and requiring
Oxygen, ___ NC. A chest xray was performed and marginal for RLL
pneumonia.
On POD#3, Ms. ___ continued to have a fever to 101.6. Her
urine culture was found to be negative. A CBC/diff and sputum
culture were sent, and her antibiotic course was changed to
cover PNA Levaquin 750mg PO QD x 5 days. A 500cc fluid bolus was
given for mild hypotension.
POD #6, remained afebrile with stable vitals, continued levaquin
per med recs.
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 and the Silverlon dressing was
removed on POD#2. The surgical incision was found to be clean
and intact without erythema or abnormal drainage. The patient
was seen daily by physical therapy. Labs were checked throughout
the hospital course and repleted accordingly. Drain was removed
once output slowed down. 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 rehab in stable condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Pregabalin 50 mg PO TID
3. TraMADol 50 mg PO Q6H:PRN severe LBP
4. Ibuprofen 800 mg PO Q8H:PRN pain
5. oxybutynin chloride 10 mg oral DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Pregabalin 50 mg PO TID
3. Acetaminophen 1000 mg PO Q8H
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
5. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin 40 mg/0.4 mL 40 mg sc daily Disp #*28 Syringe
Refills:*0
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*80 Tablet Refills:*0
7. oxybutynin chloride 10 mg oral DAILY
8. Levofloxacin 750 mg PO DAILY Duration: 5 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right knee osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment in three (3) weeks.
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 by your doctor at
follow-up appointment approximately 3 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. Mobilize with assistive devices (___) if
needed. Range of motion at the knee as tolerated. No strenuous
exercise or heavy lifting until follow up appointment.
Followup Instructions:
___
|
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Allergies: No Known Allergies / Adverse Drug Reactions [MASKED] Complaint: Right knee pain Major Surgical or Invasive Procedure: Right total knee replacement RG [MASKED], MD [MASKED] History of Present Illness: [MASKED] w/ R knee OA who presents for right total knee replacement Past Medical History: Hypertension, obesity Social History: [MASKED] Family History: Noncontributory 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: X-rays of the right knee obtained post-op showed a right total knee replacement in good alignment without fracture [MASKED] 06:14AM BLOOD WBC-10.7* RBC-3.48* Hgb-9.7* Hct-29.7* MCV-85 MCH-27.9 MCHC-32.7 RDW-15.1 RDWSD-45.9 Plt [MASKED] [MASKED] 05:55AM BLOOD WBC-9.0 RBC-3.55*# Hgb-10.1*# Hct-30.2*# MCV-85 MCH-28.5 MCHC-33.4 RDW-14.6 RDWSD-45.3 Plt [MASKED] [MASKED] 05:56AM BLOOD Ret Aut-1.8 Abs Ret-0.05 [MASKED] 06:14AM BLOOD Glucose-91 UreaN-8 Creat-0.7 Na-141 K-4.3 Cl-102 HCO3-30 AnGap-13 [MASKED] 05:56AM BLOOD LD(LDH)-188 TotBili-0.3 [MASKED] 06:14AM BLOOD Calcium-9.0 Phos-2.7 Mg-2.0 [MASKED] 05:56AM BLOOD calTIBC-213* Ferritn-280* TRF-164* 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#0 overnight, the patient was given 500 mL of fluids for low urine output. On POD#1, the patient's temperature spiked to 102.4. Urines were sent. She was suspected to have a urinary tract infection and started on Cipofloxacin. On POD#2, the patient was intermittently febrile and requiring Oxygen, [MASKED] NC. A chest xray was performed and marginal for RLL pneumonia. On POD#3, Ms. [MASKED] continued to have a fever to 101.6. Her urine culture was found to be negative. A CBC/diff and sputum culture were sent, and her antibiotic course was changed to cover PNA Levaquin 750mg PO QD x 5 days. A 500cc fluid bolus was given for mild hypotension. POD #6, remained afebrile with stable vitals, continued levaquin per med recs. 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 and the Silverlon dressing was removed on POD#2. The surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. Drain was removed once output slowed down. 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 rehab in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Pregabalin 50 mg PO TID 3. TraMADol 50 mg PO Q6H:PRN severe LBP 4. Ibuprofen 800 mg PO Q8H:PRN pain 5. oxybutynin chloride 10 mg oral DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Pregabalin 50 mg PO TID 3. Acetaminophen 1000 mg PO Q8H 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 5. Enoxaparin Sodium 40 mg SC DAILY RX *enoxaparin 40 mg/0.4 mL 40 mg sc daily Disp #*28 Syringe Refills:*0 6. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every 4 hours Disp #*80 Tablet Refills:*0 7. oxybutynin chloride 10 mg oral DAILY 8. Levofloxacin 750 mg PO DAILY Duration: 5 Days Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Right knee osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment in three (3) weeks. 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 by your doctor at follow-up appointment approximately 3 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. Mobilize with assistive devices ([MASKED]) if needed. Range of motion at the knee as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Followup Instructions: [MASKED]
|
[] |
[
"D62",
"N390",
"I10",
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] |
[
"M179: Osteoarthritis of knee, unspecified",
"J189: Pneumonia, unspecified organism",
"I959: Hypotension, unspecified",
"M87851: Other osteonecrosis, right femur",
"D62: Acute posthemorrhagic anemia",
"N390: Urinary tract infection, site not specified",
"J9811: Atelectasis",
"I10: Essential (primary) hypertension",
"E669: Obesity, unspecified",
"K5900: Constipation, unspecified",
"Z6832: Body mass index [BMI] 32.0-32.9, adult",
"D509: Iron deficiency anemia, unspecified",
"R0902: Hypoxemia"
] |
10,025,747
| 28,292,012
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Fentanyl / Zantac / Flagyl / Entocort EC / Sulfa (Sulfonamide
Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Flex sigmoidoscopy
History of Present Illness:
HISTORY OF PRESENT ILLNESS: ___ female patient with a
history of ___ disease (restarted on Humira ___ for new
flare) who came to the ED for abdominal pain since the morning
of
___ concerning for acute-on-chronic ___ flare, found to have
colitis on CT and leukocytosis to 27, and admitted for workup
and
IV antibiotics.
Per her report, she was diagnosed with "hemorrhagic ___ in
her ___ and nothing initially could control the bleeding; she
required a partial resection. She eventually went into a
___ admission, developing abdominal pain and cramping in
___. She was initially diagnosed with diverticulitis but
on CT scan was found to have colitis. She had a 5 day admission
to ___ at this time, for abdominal pain and symptomatic
hypotension. At the end of ___ she underwent a colonoscopy which
showed chronic severely active colitis with ulceration, which
was
negative for CMV. She was started on Humira the beginning of
___.
The morning of admission, she woke up feeling lightheaded and
was
dizzy on standing and "knew that her blood pressure was low.
"She also had cramping abdominal pain. Her last bowel movement
was 2 days prior to admission and was a formed stool. She has
been unable to tolerate p.o. for the past several days. She has
had some nausea and reflux as well, these are more chronic
symptoms for. She feels fatigued and weak.
In the ED, initial VS were 96.0 110 51/37 1893% nasal cannula.
She triggered for hypotension and was given first 1L NS with
improvement to 112/70.
She received:
-1 L normal saline at ___
-1 g vancomycin at 1500
-4.5g pip-tazo at 1500
-1g APAP PO at 1640
Subsequent pressures were ___ prompting the
additional NS mentioned above.
Past Medical History:
- ___ on Humira
- reflux with dysphagia
- hiatal hernia
- diverticulitis
- bronchiectasis
- positive hepatitis C antibody with a negative HCV RNA
- history of a sleep disorder
- pruritus
- fibroid uterus
- Sjogren's syndrome (clinical; negative autoantibody testing)
- interstitial cystitis
- fibromyalgia and chronic ___
Social History:
___
Family History:
Grandmother and several great aunts had ___ disease. Father
with type 2 diabetes. Brother passed away from AML in his ___.
Physical Exam:
Admission Physical Exam
================
VS: 97.8 | 153/72 | 97 | 20 | 91%Ra
GENERAL: NAD, thin but not cachectic, appears elderly and mildly
diaphoretic but nontoxic.
HEENT: PERRL, dry mucous membranes
NECK: full rom, no LAD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: well-healed RLQ scar. Minimally distended. Tender to
palpation throughout, worse in LLQ. No rebound/guarding.
Hyperactive bowel sounds. Typmpanic to percussion.
EXTREMITIES: WWP, no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, face grossly symmetric, no dysarthria. Moving all
4
extremities with purpose
SKIN: no excoriations or lesions, no rashes
Discharge Physical Exam
================
PHYSICAL EXAM:
VS: 98.0 PO 137 / 81 nL Lying 76 RR 16 O292 Ra
GENERAL: NAD, awake, alert
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, cracked lips, MMM
HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs
LUNGS: clear to auscultation, no increased work of breathing, no
crackles
ABDOMEN: soft, ND NT, no rebound/guarding, midline scar from
remote surgery, normoactive/hypoactive bowel sounds, improved
EXTREMITIES: no edema
NEURO: A&Ox3, ambulating normal
SKIN: warm and well perfused
Pertinent Results:
Admission Labs
===========
___ 02:30PM BLOOD WBC-27.9*# RBC-4.12 Hgb-12.3 Hct-38.8
MCV-94 MCH-29.9 MCHC-31.7* RDW-13.4 RDWSD-46.4* Plt ___
___ 02:30PM BLOOD Neuts-85.5* Lymphs-8.1* Monos-5.0
Eos-0.3* Baso-0.5 Im ___ AbsNeut-23.82* AbsLymp-2.26
AbsMono-1.39* AbsEos-0.07 AbsBaso-0.14*
___ 02:30PM BLOOD Plt ___
___ 02:30PM BLOOD Glucose-163* UreaN-15 Creat-1.2* Na-139
K-3.7 Cl-103 HCO3-16* AnGap-24*
___ 02:30PM BLOOD ALT-15 AST-23 AlkPhos-97 TotBili-0.5
___ 02:30PM BLOOD Albumin-3.8
___ 02:30PM BLOOD CRP-0.7
___ 03:10PM BLOOD ___ pO2-27* pCO2-43 pH-7.26*
calTCO2-20* Base XS--8
___ 03:10PM BLOOD Lactate-4.1*
___ 06:45AM BLOOD CRP-46.1*
___ 02:30PM BLOOD CRP-0.7
Discharge Labs
===========
___ 07:40AM BLOOD WBC-22.7* RBC-4.05 Hgb-11.9 Hct-37.1
MCV-92 MCH-29.4 MCHC-32.1 RDW-14.4 RDWSD-48.2* Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-98 UreaN-17 Creat-0.5 Na-141
K-4.1 Cl-99 HCO3-28 AnGap-14
___ 07:20AM BLOOD ALT-19 AST-14 AlkPhos-77 TotBili-0.3
___ 07:40AM BLOOD Calcium-9.7 Phos-3.5 Mg-2.0
___ 07:25AM BLOOD VitB12-224* Folate-6
___ 07:25AM BLOOD CRP-3.3
Microbiology
=========
___ STOOLC. difficile DNA amplification
assay- negative
___ URINE URINE CULTURE negative
___ BLOOD CULTUREBlood Culture negative
___ BLOOD CULTUREBlood Culture negative
___ STOOLFECAL CULTURE- Negative
___ CULTURE negative
___ CULTURE Negative
___ CULTURE Negative
Imaging
=========
___- Lung CTA
1. No pulmonary embolism or acute aortic abnormality.
2. Acute on chronic ___ flare with thickened hyperemic
transverse and
descending colon. No definite bowel obstruction.
3. Large left upper pole renal cyst with septations may be
further assessed
with non-emergent renal ultrasound.
4. Fibroid uterus.
5. Two lung nodules measuring up to 5 mm along the left fissure.
___- CXR
Cardiac silhouette size is normal. Mediastinal and hilar
contours are
unremarkable. The pulmonary vasculature is not engorged.
Elevation of the
right hemidiaphragm is of indeterminate chronicity. Patchy
opacities within
the lung bases likely reflect areas of atelectasis. No pleural
effusion or
focal consolidation is noted. There are no acute osseous
abnormalities. No
subdiaphragmatic free air is present.
___
Colonic and small bowel dilatation likely ileus, consider
cross-sectional
imaging if there is concern for obstruction.
___ Chest Xray
Left basal peribronchial opacification is improved slightly.
Right
hemidiaphragm remains severely elevated and is responsible for
new right
middle lobe atelectasis. Upper lungs are clear. Heart size is
normal.
Pleural effusions small if any. No pneumothorax.
___ Abd Xray
No significant change in bowel distention from the exam done two
days ago. No
free air demonstrated.
___- Echo
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF =
75%). Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). The right ventricular free wall
thickness is normal. Right ventricular chamber size is normal
with normal free wall contractility. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The left ventricular
inflow pattern suggests impaired relaxation. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
___ CXR
No significant interval change since the prior chest radiograph.
No evidence
of pulmonary edema.
___- CT abd/pelvis
1. No evidence of intra-abdominal abscess.
2. Interval increased conspicuity of right hepatic lobe
wedge-shaped perfusion
abnormality likely representing evolving infarct.
3. Moderate colonic stool, consider constipation.
4. Mildly increased size of left renal cyst with thin enhancing
septations
measuring 8.5 cm, previously measured 5.1 cm.
5. Additional findings as above.
___- Liver MRI
Previously seen abnormality at dome of the liver is not
visualized on MRI.
The liver enhances homogeneously and there is no evidence of
focal mass or
infarction
Brief Hospital Course:
Brief Hospital Course:
___ female patient with a history of ___ disease
(restarted on ___ ___ for new flare) who came to the ED
for abdominal pain since the morning of ___ concerning for
acute-on-chronic ___ flare, found to have colitis on CT and
leukocytosis to 27, and admitted for workup and IV antibiotics.
GI was consulted and followed the patient throughout the
hospitalization. It was believed the abdominal pain came about
secondary to constipation and abdominal distention. The patient
was given an aggressive bowel regimen, which helped the symptoms
which we believe were secondary to a previous botox injection
for pelvic floor disfunction. The patient also received her
second loading dose of Humira while in the hospital and was
started on a course of steroids (initially IV to PO prednisone).
Her abdominal pain and distension continued to improve and was
at baseline at discharge.
Throughout the hospitalization, the patient also had continued
hypoxia, which was something she had experienced at a recent
hospitalization at ___, but without any clear reason.
The patient required ___ of oxygen for the first half of her
stay to remain in the low ___ on her O2 stat and would desat
into the high ___ and low ___ during ambulation. Outside records
could not be gathered regarding any hypoxia. It was believe this
was caused by a raised right hemidiaphragm causing low lung
volumes, atlectosis from laying in bed, and blunting secondary
to abdominal pain. The patient was also found to have a
pneumonia (CAP) which was treated for 5 days with levaquin.
Ultimately, once the patient began ambulating and her abdominal
pain improved she was able to come of all O2 without difficulty
and did not require home oxygen.
The patient was also found to have leukocytosis on admission
which reached a nadir of 10 during the middle of the
hospitalization when the patient felt well, however began to
rise without a clear cause. The WBC went up to 23.9 and
stabilized around this value, and although the patient had been
started on steroids, was a suspicious rise in the context of her
clinical picture. A blood smear was obtained which showed
inflammation, B12 deficiency, and some questionable MDS type
cells. The patients B12 was found to be low at 224, but an MMA
was not obtained as it an outpatient lab. To evaluate for other
potential causes of leukocytosis, a CT abdomin/pelvis was done
to evaluate for potential abscess/occult infection, and revealed
a wedge-shaped infarct in a peripheral region of her liver. To
further classify this and to look for any local process which
could have contributed, a MRI liver was done which did not
demonstrate the lesion and heme/onc did not recommend
anticoagulation. The patient was discharged home in stable
condition.
=======================
TRANSITIONAL ISSUES:
=======================
[]Check CBC in 1 week to evaluate improving leukocytosis. If
continues to be elevated, consider heme/onc referral for
possible bone marrow biopsy for MDS ___
[]Vitamin B12 was deficient. Will replete B12 and folate.
Consider follow-up with methylmalonic acid and/or homocysteine
levels
[]Patient had severe constipation and on numerous
anticholinergeric medications. Can consider modifying her
regimen.
[]Cholestyramine was held due to constipation. Can consider
restarting if diarrhea reoccurs.
[]Patient's blood pressure had dizziness when taking lisinopril.
This was held during hospitalization and not restarted on d/c.
Can consider restarting as outpatient.
MEDICATIONS:
- New Meds: Prednisone 50mg daily, tapering 10mg weekly (on
___ until 30mg daily
- Stopped Meds: Sodium Chloride tablets, lisinopril
- Changed Meds: None
Incidental findings:
#RENAL CYST: Large left upper pole renal cyst on CT ___,
again on CT abd/ pelvis with septations. Will need follow up in
___ year with renal ultrasound
#PULM NODULES: 5 mm left fissural nodule and 4 mm RML nodule on
CT ___. For incidentally detected multiple solid pulmonary
nodules <6mm, no CT follow-up is recommended in a low-risk
patient. Optional CT follow-up in 12 months is recommended in a
high-risk patient. Can consider f/u CT in 12 months
# CONTACT: ___ ___
# CODE: Full Code
ACTIVE:
#COLITIS
#CROHNS: Abdominal pain was consistent with acute-on-chronic
Crohns flare. Ruled out infectious colitis w/ neg C.diff and
stool cultures. KUB demonstrated dilated colon with potential
ileus. Was given a strong bowel regimen, started on steroids,
and patient had Humira ___ loading dose on (___). A flex sig
___ unremarkable to sigmoid, though unable to visualize much
due to poor prep. GI followed closely and recommended tapering
steroids weekly by 10mg starting on ___, eventually
continuing at 30mg PO daily until follow-up with ___
___ in outpatient.
#LEUKOCYTOSIS:
Wedge-shaped low attentuation found on CT A/P ___ which was
suspicious for a liver infarct. Was originally thought to be
cause of leukocytosis, however was not redemonstrated on MRI. At
discharge, the ___ is 22.3. Will follow-up with PCP ___ 1 week
and consider heme/onc referral for further evaluation, possible
bone marrow biopsy, and consideration of MDS.
#CONSTIPATION: Improving bowel function on bowel regimen (daily
suppositories, Colace, senna). Constipation ___ rectal sphincter
dysfunction from hx of Botox injections for pelvic floor
dysfunction. Also precipitated by inflammation from active
Crohns flare. On numerous medications which can contribute, but
did not want to change regimen at this time. Her cholestyramine
was held during hospitalization.
#HYPOXIA: Resolving, O2sat in low ___ on RA throughout
hospitalization. Hypoxia likely secondary to splinting,
atelectasis, and poor lung expansion, precipitated by PNA and
completed a 5-day levo. Unclear hx of preload failure but TTE
___ without shunt or evidence of right heart strain. VBG
appropriate on ___. CT negative for PE on admission. Pulm
consult ___ suggesting atelectasis as cause, appreciate recs.
Patient was recommended to follow-up outpatient with
pulmonologist Dr. ___ at ___ and sleep doctor at ___.
#B12 DEFICIENCY:
B12 low at 224. No hyper segmentation seen on smear. Currently
asymptomatic with no GI or neuro sxs. Heme/onc recommended to
get an MMA and start B12 injections. These were not done in
house as it is a send out lab.
CHRONIC:
#HYPERTENSION:
- Home lisinopril was held.
#POTS: Has episodes of dizziness a/w abdominal pain.
- Holding home salt tablets, can continue outpatient
#SJOGREN'S,
#VAGINAL DRYNESS,
#PELVIC FLOOR DYSFUNCTION,
#MISC
- Home eye drops
- Home vaginal diazepam BID
- Home doxepin HS
- Hold home fluconazole unless having symptomatic yeast
infection
- Home pregabalin TID
- Home prevalite
- Home carisoprodol
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron ___ mg PO Q8H:PRN nausea
2. Humira (adalimumab) unknown subcutaneous unknown
3. Pantoprazole 40 mg PO Q24H
4. carisoprodol 350 mg oral TID:PRN
5. Doxepin HCl 50 mg PO HS
6. Lisinopril 5 mg PO DAILY
7. Prevalite (cholestyramine-aspartame) 4 gram oral BID
8. Diazepam 20 mg PO Q12H pelvic floor dysfunction
9. Dronabinol 2.5 mg PO BID-TID:PRN nausea
10. Sodium Chloride Dose is Unknown PO TID
11. Pregabalin 200 mg PO TID
12. Fluconazole 200 mg PO Q24H
Discharge Medications:
1. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
2. Bisacodyl ___AILY
3. Cyanocobalamin 100 mcg IM/SC DAILY Duration: 7 Days
RX *cyanocobalamin (vitamin B-12) [Vitamin B-12] 1,000 mcg/mL
1000 mcg IM weekly Disp #*3 Vial Refills:*0
4. Docusate Sodium 100 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. PredniSONE 50 mg PO DAILY
RX *prednisone 10 mg 5 tablet(s) by mouth daily Disp #*75 Tablet
Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
8. Sucralfate 1 gm PO QID:PRN stomach pain
9. Humira (adalimumab) 40 mg subcutaneous 1X/WEEK (___)
10. carisoprodol 350 mg oral TID:PRN
11. Diazepam 20 mg PO Q12H pelvic floor dysfunction
12. Doxepin HCl 50 mg PO HS
13. Dronabinol 2.5 mg PO BID-TID:PRN nausea
14. Fluconazole 200 mg PO Q24H
15. Ondansetron ___ mg PO Q8H:PRN nausea
16. Pantoprazole 40 mg PO Q24H
17. Pregabalin 200 mg PO TID
18. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until you see your PCP.
19. HELD- Prevalite (cholestyramine-aspartame) 4 gram oral BID
This medication was held. Do not restart Prevalite until you
talk to your PCP or GI doctor because you were constipated in
the hospital.
20. HELD- Sodium Chloride Dose is Unknown PO TID This
medication was held. Do not restart Sodium Chloride until you
talk to your PCP .
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
___ Flare
Secondary
Pneumonia
Vitamin B12 deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to ___ because you were having abdominal pain and
bloating in your stomach. You were found to have a flare of your
___ Disease and a pneumonia. You were given antibiotics for
your infections and started on steroids. The gastrointestinal
(GI) team came to see you and you got your second loading dose
of Humira. You were having low oxygen numbers and were found to
have a pneumonia and were treated with antibiotics. You were
seen by a hematologist, a doctor who is an expert in blood
problems, who found you had low vitamin B12. You also had a CT
scan, which showed a possible area of low blood flow in your
liver, but another imaging test, an MRI, was done to help us
look at this and did not find anything abnormal.
Please see the instructions for what to do after leaving the
hospital.
-You should continue your prednisone 50 mg until ___ and then
decrease your dose by 10mg every ___ until you are taking
30mg a day and follow-up with Dr. ___.
- You should follow-up with you PCP ___ on ___
- You should start weekly Humira administration on ___, with
the next dose ___
- You should take your B12 shot once a week
- You should talk to your GI doctor about your cholestyramine
- You should talk to your PCP about your sodium chloride pills
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
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Allergies: Fentanyl / Zantac / Flagyl / Entocort EC / Sulfa (Sulfonamide Antibiotics) Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Flex sigmoidoscopy History of Present Illness: HISTORY OF PRESENT ILLNESS: [MASKED] female patient with a history of [MASKED] disease (restarted on Humira [MASKED] for new flare) who came to the ED for abdominal pain since the morning of [MASKED] concerning for acute-on-chronic [MASKED] flare, found to have colitis on CT and leukocytosis to 27, and admitted for workup and IV antibiotics. Per her report, she was diagnosed with "hemorrhagic [MASKED] in her [MASKED] and nothing initially could control the bleeding; she required a partial resection. She eventually went into a [MASKED] admission, developing abdominal pain and cramping in [MASKED]. She was initially diagnosed with diverticulitis but on CT scan was found to have colitis. She had a 5 day admission to [MASKED] at this time, for abdominal pain and symptomatic hypotension. At the end of [MASKED] she underwent a colonoscopy which showed chronic severely active colitis with ulceration, which was negative for CMV. She was started on Humira the beginning of [MASKED]. The morning of admission, she woke up feeling lightheaded and was dizzy on standing and "knew that her blood pressure was low. "She also had cramping abdominal pain. Her last bowel movement was 2 days prior to admission and was a formed stool. She has been unable to tolerate p.o. for the past several days. She has had some nausea and reflux as well, these are more chronic symptoms for. She feels fatigued and weak. In the ED, initial VS were 96.0 110 51/37 1893% nasal cannula. She triggered for hypotension and was given first 1L NS with improvement to 112/70. She received: -1 L normal saline at [MASKED] -1 g vancomycin at 1500 -4.5g pip-tazo at 1500 -1g APAP PO at 1640 Subsequent pressures were [MASKED] prompting the additional NS mentioned above. Past Medical History: - [MASKED] on Humira - reflux with dysphagia - hiatal hernia - diverticulitis - bronchiectasis - positive hepatitis C antibody with a negative HCV RNA - history of a sleep disorder - pruritus - fibroid uterus - Sjogren's syndrome (clinical; negative autoantibody testing) - interstitial cystitis - fibromyalgia and chronic [MASKED] Social History: [MASKED] Family History: Grandmother and several great aunts had [MASKED] disease. Father with type 2 diabetes. Brother passed away from AML in his [MASKED]. Physical Exam: Admission Physical Exam ================ VS: 97.8 | 153/72 | 97 | 20 | 91%Ra GENERAL: NAD, thin but not cachectic, appears elderly and mildly diaphoretic but nontoxic. HEENT: PERRL, dry mucous membranes NECK: full rom, no LAD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: well-healed RLQ scar. Minimally distended. Tender to palpation throughout, worse in LLQ. No rebound/guarding. Hyperactive bowel sounds. Typmpanic to percussion. EXTREMITIES: WWP, no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, face grossly symmetric, no dysarthria. Moving all 4 extremities with purpose SKIN: no excoriations or lesions, no rashes Discharge Physical Exam ================ PHYSICAL EXAM: VS: 98.0 PO 137 / 81 nL Lying 76 RR 16 O292 Ra GENERAL: NAD, awake, alert HEENT: AT/NC, EOMI, PERRL, anicteric sclera, cracked lips, MMM HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs LUNGS: clear to auscultation, no increased work of breathing, no crackles ABDOMEN: soft, ND NT, no rebound/guarding, midline scar from remote surgery, normoactive/hypoactive bowel sounds, improved EXTREMITIES: no edema NEURO: A&Ox3, ambulating normal SKIN: warm and well perfused Pertinent Results: Admission Labs =========== [MASKED] 02:30PM BLOOD WBC-27.9*# RBC-4.12 Hgb-12.3 Hct-38.8 MCV-94 MCH-29.9 MCHC-31.7* RDW-13.4 RDWSD-46.4* Plt [MASKED] [MASKED] 02:30PM BLOOD Neuts-85.5* Lymphs-8.1* Monos-5.0 Eos-0.3* Baso-0.5 Im [MASKED] AbsNeut-23.82* AbsLymp-2.26 AbsMono-1.39* AbsEos-0.07 AbsBaso-0.14* [MASKED] 02:30PM BLOOD Plt [MASKED] [MASKED] 02:30PM BLOOD Glucose-163* UreaN-15 Creat-1.2* Na-139 K-3.7 Cl-103 HCO3-16* AnGap-24* [MASKED] 02:30PM BLOOD ALT-15 AST-23 AlkPhos-97 TotBili-0.5 [MASKED] 02:30PM BLOOD Albumin-3.8 [MASKED] 02:30PM BLOOD CRP-0.7 [MASKED] 03:10PM BLOOD [MASKED] pO2-27* pCO2-43 pH-7.26* calTCO2-20* Base XS--8 [MASKED] 03:10PM BLOOD Lactate-4.1* [MASKED] 06:45AM BLOOD CRP-46.1* [MASKED] 02:30PM BLOOD CRP-0.7 Discharge Labs =========== [MASKED] 07:40AM BLOOD WBC-22.7* RBC-4.05 Hgb-11.9 Hct-37.1 MCV-92 MCH-29.4 MCHC-32.1 RDW-14.4 RDWSD-48.2* Plt [MASKED] [MASKED] 07:40AM BLOOD Plt [MASKED] [MASKED] 07:40AM BLOOD Glucose-98 UreaN-17 Creat-0.5 Na-141 K-4.1 Cl-99 HCO3-28 AnGap-14 [MASKED] 07:20AM BLOOD ALT-19 AST-14 AlkPhos-77 TotBili-0.3 [MASKED] 07:40AM BLOOD Calcium-9.7 Phos-3.5 Mg-2.0 [MASKED] 07:25AM BLOOD VitB12-224* Folate-6 [MASKED] 07:25AM BLOOD CRP-3.3 Microbiology ========= [MASKED] STOOLC. difficile DNA amplification assay- negative [MASKED] URINE URINE CULTURE negative [MASKED] BLOOD CULTUREBlood Culture negative [MASKED] BLOOD CULTUREBlood Culture negative [MASKED] STOOLFECAL CULTURE- Negative [MASKED] CULTURE negative [MASKED] CULTURE Negative [MASKED] CULTURE Negative Imaging ========= [MASKED]- Lung CTA 1. No pulmonary embolism or acute aortic abnormality. 2. Acute on chronic [MASKED] flare with thickened hyperemic transverse and descending colon. No definite bowel obstruction. 3. Large left upper pole renal cyst with septations may be further assessed with non-emergent renal ultrasound. 4. Fibroid uterus. 5. Two lung nodules measuring up to 5 mm along the left fissure. [MASKED]- CXR Cardiac silhouette size is normal. Mediastinal and hilar contours are unremarkable. The pulmonary vasculature is not engorged. Elevation of the right hemidiaphragm is of indeterminate chronicity. Patchy opacities within the lung bases likely reflect areas of atelectasis. No pleural effusion or focal consolidation is noted. There are no acute osseous abnormalities. No subdiaphragmatic free air is present. [MASKED] Colonic and small bowel dilatation likely ileus, consider cross-sectional imaging if there is concern for obstruction. [MASKED] Chest Xray Left basal peribronchial opacification is improved slightly. Right hemidiaphragm remains severely elevated and is responsible for new right middle lobe atelectasis. Upper lungs are clear. Heart size is normal. Pleural effusions small if any. No pneumothorax. [MASKED] Abd Xray No significant change in bowel distention from the exam done two days ago. No free air demonstrated. [MASKED]- Echo The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF = 75%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular free wall thickness is normal. Right ventricular chamber size is normal with normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. [MASKED] CXR No significant interval change since the prior chest radiograph. No evidence of pulmonary edema. [MASKED]- CT abd/pelvis 1. No evidence of intra-abdominal abscess. 2. Interval increased conspicuity of right hepatic lobe wedge-shaped perfusion abnormality likely representing evolving infarct. 3. Moderate colonic stool, consider constipation. 4. Mildly increased size of left renal cyst with thin enhancing septations measuring 8.5 cm, previously measured 5.1 cm. 5. Additional findings as above. [MASKED]- Liver MRI Previously seen abnormality at dome of the liver is not visualized on MRI. The liver enhances homogeneously and there is no evidence of focal mass or infarction Brief Hospital Course: Brief Hospital Course: [MASKED] female patient with a history of [MASKED] disease (restarted on [MASKED] [MASKED] for new flare) who came to the ED for abdominal pain since the morning of [MASKED] concerning for acute-on-chronic [MASKED] flare, found to have colitis on CT and leukocytosis to 27, and admitted for workup and IV antibiotics. GI was consulted and followed the patient throughout the hospitalization. It was believed the abdominal pain came about secondary to constipation and abdominal distention. The patient was given an aggressive bowel regimen, which helped the symptoms which we believe were secondary to a previous botox injection for pelvic floor disfunction. The patient also received her second loading dose of Humira while in the hospital and was started on a course of steroids (initially IV to PO prednisone). Her abdominal pain and distension continued to improve and was at baseline at discharge. Throughout the hospitalization, the patient also had continued hypoxia, which was something she had experienced at a recent hospitalization at [MASKED], but without any clear reason. The patient required [MASKED] of oxygen for the first half of her stay to remain in the low [MASKED] on her O2 stat and would desat into the high [MASKED] and low [MASKED] during ambulation. Outside records could not be gathered regarding any hypoxia. It was believe this was caused by a raised right hemidiaphragm causing low lung volumes, atlectosis from laying in bed, and blunting secondary to abdominal pain. The patient was also found to have a pneumonia (CAP) which was treated for 5 days with levaquin. Ultimately, once the patient began ambulating and her abdominal pain improved she was able to come of all O2 without difficulty and did not require home oxygen. The patient was also found to have leukocytosis on admission which reached a nadir of 10 during the middle of the hospitalization when the patient felt well, however began to rise without a clear cause. The WBC went up to 23.9 and stabilized around this value, and although the patient had been started on steroids, was a suspicious rise in the context of her clinical picture. A blood smear was obtained which showed inflammation, B12 deficiency, and some questionable MDS type cells. The patients B12 was found to be low at 224, but an MMA was not obtained as it an outpatient lab. To evaluate for other potential causes of leukocytosis, a CT abdomin/pelvis was done to evaluate for potential abscess/occult infection, and revealed a wedge-shaped infarct in a peripheral region of her liver. To further classify this and to look for any local process which could have contributed, a MRI liver was done which did not demonstrate the lesion and heme/onc did not recommend anticoagulation. The patient was discharged home in stable condition. ======================= TRANSITIONAL ISSUES: ======================= []Check CBC in 1 week to evaluate improving leukocytosis. If continues to be elevated, consider heme/onc referral for possible bone marrow biopsy for MDS [MASKED] []Vitamin B12 was deficient. Will replete B12 and folate. Consider follow-up with methylmalonic acid and/or homocysteine levels []Patient had severe constipation and on numerous anticholinergeric medications. Can consider modifying her regimen. []Cholestyramine was held due to constipation. Can consider restarting if diarrhea reoccurs. []Patient's blood pressure had dizziness when taking lisinopril. This was held during hospitalization and not restarted on d/c. Can consider restarting as outpatient. MEDICATIONS: - New Meds: Prednisone 50mg daily, tapering 10mg weekly (on [MASKED] until 30mg daily - Stopped Meds: Sodium Chloride tablets, lisinopril - Changed Meds: None Incidental findings: #RENAL CYST: Large left upper pole renal cyst on CT [MASKED], again on CT abd/ pelvis with septations. Will need follow up in [MASKED] year with renal ultrasound #PULM NODULES: 5 mm left fissural nodule and 4 mm RML nodule on CT [MASKED]. For incidentally detected multiple solid pulmonary nodules <6mm, no CT follow-up is recommended in a low-risk patient. Optional CT follow-up in 12 months is recommended in a high-risk patient. Can consider f/u CT in 12 months # CONTACT: [MASKED] [MASKED] # CODE: Full Code ACTIVE: #COLITIS #CROHNS: Abdominal pain was consistent with acute-on-chronic Crohns flare. Ruled out infectious colitis w/ neg C.diff and stool cultures. KUB demonstrated dilated colon with potential ileus. Was given a strong bowel regimen, started on steroids, and patient had Humira [MASKED] loading dose on ([MASKED]). A flex sig [MASKED] unremarkable to sigmoid, though unable to visualize much due to poor prep. GI followed closely and recommended tapering steroids weekly by 10mg starting on [MASKED], eventually continuing at 30mg PO daily until follow-up with [MASKED] [MASKED] in outpatient. #LEUKOCYTOSIS: Wedge-shaped low attentuation found on CT A/P [MASKED] which was suspicious for a liver infarct. Was originally thought to be cause of leukocytosis, however was not redemonstrated on MRI. At discharge, the [MASKED] is 22.3. Will follow-up with PCP [MASKED] 1 week and consider heme/onc referral for further evaluation, possible bone marrow biopsy, and consideration of MDS. #CONSTIPATION: Improving bowel function on bowel regimen (daily suppositories, Colace, senna). Constipation [MASKED] rectal sphincter dysfunction from hx of Botox injections for pelvic floor dysfunction. Also precipitated by inflammation from active Crohns flare. On numerous medications which can contribute, but did not want to change regimen at this time. Her cholestyramine was held during hospitalization. #HYPOXIA: Resolving, O2sat in low [MASKED] on RA throughout hospitalization. Hypoxia likely secondary to splinting, atelectasis, and poor lung expansion, precipitated by PNA and completed a 5-day levo. Unclear hx of preload failure but TTE [MASKED] without shunt or evidence of right heart strain. VBG appropriate on [MASKED]. CT negative for PE on admission. Pulm consult [MASKED] suggesting atelectasis as cause, appreciate recs. Patient was recommended to follow-up outpatient with pulmonologist Dr. [MASKED] at [MASKED] and sleep doctor at [MASKED]. #B12 DEFICIENCY: B12 low at 224. No hyper segmentation seen on smear. Currently asymptomatic with no GI or neuro sxs. Heme/onc recommended to get an MMA and start B12 injections. These were not done in house as it is a send out lab. CHRONIC: #HYPERTENSION: - Home lisinopril was held. #POTS: Has episodes of dizziness a/w abdominal pain. - Holding home salt tablets, can continue outpatient #SJOGREN'S, #VAGINAL DRYNESS, #PELVIC FLOOR DYSFUNCTION, #MISC - Home eye drops - Home vaginal diazepam BID - Home doxepin HS - Hold home fluconazole unless having symptomatic yeast infection - Home pregabalin TID - Home prevalite - Home carisoprodol Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron [MASKED] mg PO Q8H:PRN nausea 2. Humira (adalimumab) unknown subcutaneous unknown 3. Pantoprazole 40 mg PO Q24H 4. carisoprodol 350 mg oral TID:PRN 5. Doxepin HCl 50 mg PO HS 6. Lisinopril 5 mg PO DAILY 7. Prevalite (cholestyramine-aspartame) 4 gram oral BID 8. Diazepam 20 mg PO Q12H pelvic floor dysfunction 9. Dronabinol 2.5 mg PO BID-TID:PRN nausea 10. Sodium Chloride Dose is Unknown PO TID 11. Pregabalin 200 mg PO TID 12. Fluconazole 200 mg PO Q24H Discharge Medications: 1. Artificial Tears Preserv. Free [MASKED] DROP BOTH EYES PRN dry eyes 2. Bisacodyl AILY 3. Cyanocobalamin 100 mcg IM/SC DAILY Duration: 7 Days RX *cyanocobalamin (vitamin B-12) [Vitamin B-12] 1,000 mcg/mL 1000 mcg IM weekly Disp #*3 Vial Refills:*0 4. Docusate Sodium 100 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. PredniSONE 50 mg PO DAILY RX *prednisone 10 mg 5 tablet(s) by mouth daily Disp #*75 Tablet Refills:*0 7. Senna 8.6 mg PO BID:PRN constipation 8. Sucralfate 1 gm PO QID:PRN stomach pain 9. Humira (adalimumab) 40 mg subcutaneous 1X/WEEK ([MASKED]) 10. carisoprodol 350 mg oral TID:PRN 11. Diazepam 20 mg PO Q12H pelvic floor dysfunction 12. Doxepin HCl 50 mg PO HS 13. Dronabinol 2.5 mg PO BID-TID:PRN nausea 14. Fluconazole 200 mg PO Q24H 15. Ondansetron [MASKED] mg PO Q8H:PRN nausea 16. Pantoprazole 40 mg PO Q24H 17. Pregabalin 200 mg PO TID 18. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do not restart Lisinopril until you see your PCP. 19. HELD- Prevalite (cholestyramine-aspartame) 4 gram oral BID This medication was held. Do not restart Prevalite until you talk to your PCP or GI doctor because you were constipated in the hospital. 20. HELD- Sodium Chloride Dose is Unknown PO TID This medication was held. Do not restart Sodium Chloride until you talk to your PCP . Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary [MASKED] Flare Secondary Pneumonia Vitamin B12 deficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You came to [MASKED] because you were having abdominal pain and bloating in your stomach. You were found to have a flare of your [MASKED] Disease and a pneumonia. You were given antibiotics for your infections and started on steroids. The gastrointestinal (GI) team came to see you and you got your second loading dose of Humira. You were having low oxygen numbers and were found to have a pneumonia and were treated with antibiotics. You were seen by a hematologist, a doctor who is an expert in blood problems, who found you had low vitamin B12. You also had a CT scan, which showed a possible area of low blood flow in your liver, but another imaging test, an MRI, was done to help us look at this and did not find anything abnormal. Please see the instructions for what to do after leaving the hospital. -You should continue your prednisone 50 mg until [MASKED] and then decrease your dose by 10mg every [MASKED] until you are taking 30mg a day and follow-up with Dr. [MASKED]. - You should follow-up with you PCP [MASKED] on [MASKED] - You should start weekly Humira administration on [MASKED], with the next dose [MASKED] - You should take your B12 shot once a week - You should talk to your GI doctor about your cholestyramine - You should talk to your PCP about your sodium chloride pills It was a pleasure participating in your care. We wish you the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"Y929",
"I10",
"K219"
] |
[
"K5010: Crohn's disease of large intestine without complications",
"J189: Pneumonia, unspecified organism",
"G9340: Encephalopathy, unspecified",
"N179: Acute kidney failure, unspecified",
"K567: Ileus, unspecified",
"J9811: Atelectasis",
"R0902: Hypoxemia",
"D72829: Elevated white blood cell count, unspecified",
"E538: Deficiency of other specified B group vitamins",
"K5909: Other constipation",
"T48295A: Adverse effect of other drugs acting on muscles, initial encounter",
"Y929: Unspecified place or not applicable",
"N281: Cyst of kidney, acquired",
"R918: Other nonspecific abnormal finding of lung field",
"I10: Essential (primary) hypertension",
"I498: Other specified cardiac arrhythmias",
"I951: Orthostatic hypotension",
"M3500: Sicca syndrome, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"M797: Fibromyalgia",
"Z006: Encounter for examination for normal comparison and control in clinical research program",
"E876: Hypokalemia",
"R102: Pelvic and perineal pain"
] |
10,025,862
| 20,695,044
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tetracycline
Attending: ___.
Chief Complaint:
Monitoring post ERCP/EUS for pancreatic mass
Major Surgical or Invasive Procedure:
EGD/EUS ___
History of Present Illness:
___ with hx of depression, hypothyroidism, nephrolithiasis,
admitted to ___ ___ for workup of elevated LFTs and
MRI with "CBD stricture vs malignancy or stone," s/p
nondiagnostic ERCP and bx on ___, readmitted for monitoring
after ERCP and EUS with FNA in setting of 1.4 cm pancreatic head
mass. Please see HPI from discharge summary dated ___ for
detailed history of events leading up that hospitalization.
Since leaving the hospital in ___, she notes that she has
actually felt better, with improvement in morning fogginess,
arthralgias, and more energetic. She notes that she has stopped
her simvastatin at the suggestion of her PCP, and wonders if her
improved symptoms are related to this medication change, or
perhaps to a chance in her thyroid medication. She notes limited
appetite, as well as ongoing early satiety. She has an
epigastric heaviness that comes and goes with no clear
precipitating factors. On the floor, abdominal discomfort is
present, wraps around to bilateral flanks, ___ at present.
Denies fevers, chills, nausea, vomiting, diarrhea. She has not
had a BM since her colonoscopy on ___ (reportedly
"negative"), which was done at ___.
Per ERCP team, EUS done today with FNA/FNB of pancreas mass and
ERCP with removal of plastic stent, brushings of distal CBD
stricture and placement of 10 mm x 60 mm fully covered metal
stent. Postprocedure pt was noted to have "severe pain,"
received dilaudid 0.5 mg IV and stat KUB which did not reveal
free air. Per ERCP request, CT abd/pelvis to rule out
perforation if KUB negative.
ROS: all else negative
Past Medical History:
Hypothyroidism - ___'s
Depression
Hyperlipidema (although not on statin currently)
Nephrolithiasis (long time ago, passed a kidney stone)
Past Surgical History:
-prior eye surgery many years ago to correct a strabismus when
she was a child
Social History:
___
Family History:
She notes that her mother had an episode of "jaundice" at ___ or
___ years, was diagnosed with colon cancer at age ___, and died 6
months later. Grandmother died from "septicemia," abdominal
causes. She is ___ of five children, all in good health. Sister
with ___ disease.
Physical Exam:
ADMISSION
VS: 97.7, 153/72, 59, 18, 98% RA
GEN: Alert, lying in bed, no acute distress, interactive
HEENT: MMM, anicteric sclera, no conjunctival pallor, clear
oropharynx
NECK: Supple, no cervical or supraclavicular LAD
PULM: Clear, no wheeze, rales, or rhonchi
CV: RRR, normal S1/S2, no murmurs
ABD: Soft, ND, tender to palpation at epigastrium without
rebound or guarding, +BS, no hepatomegaly
EXTREM: Warm, no edema
GU: No foley
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE
VS - 98.6 107/52 71 16 94%RA
Gen - sitting up in bed, comfortable-appearing
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft, very mild tenderness to epigastric palpation, much
improved from prior; no rebound/guarding; no CVA tenderness;
hypoactive bowel sounds
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 11:40AM BLOOD WBC-6.3 RBC-4.33 Hgb-12.8 Hct-37.8 MCV-87
MCH-29.6 MCHC-33.9 RDW-13.3 RDWSD-42.6 Plt ___
___ 11:40AM BLOOD UreaN-15 Creat-0.8 Na-139 K-4.1 Cl-101
HCO3-26 AnGap-16
___ 11:40AM BLOOD ALT-30 AST-35 AlkPhos-94 Amylase-126*
TotBili-0.4 DirBili-0.1 IndBili-0.3
DISCHARGE
___ 06:20AM BLOOD WBC-6.7 RBC-3.38* Hgb-10.1* Hct-28.9*
MCV-86 MCH-29.9 MCHC-34.9 RDW-12.9 RDWSD-40.2 Plt ___
___ 06:20AM BLOOD Glucose-77 UreaN-8 Creat-0.7 Na-138 K-3.9
Cl-102 HCO3-24 AnGap-16
___ 06:20AM BLOOD ALT-20 AST-21 AlkPhos-65 TotBili-0.5
EUS ___:
Impression: A 1.4 ill-defined mass was noted in the head of the
pancreas.
FNA and FNB were performed. A total of four needle passes were
made into the mass. The specimens were sent for cytology and
pathology.
The mass appeared to abut the portal vein. The right hepatic
artery could not be well visualized.
A previously placed plastic biliary stent was noted. The
pancreas mass appeared to impinge upon the bile duct at the
level of the head of the pancreas.
ERCP ___:
Impression: The scout film showed evidence of a previously
placed plastic biliary stent.
The previously placed plastic biliary stent was found in the
major papilla. The stent was removed with a snare and sent for
cytology.
Evidence of a previous sphincterotomy was noted in the major
papilla.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
Contrast medium was injected resulting in complete
opacification.
A single stricture that was 5 mm long was seen at the middle
third of the common bile duct just below the cystic duct takeoff
with moderate post-obstructive dilation.
Brushings were obtained of the stricture with a cytology brush.
A 10 mm x 60 mm Wallflex Biliary Fully Covered metal stent (REF
___, LOT ___ was placed successfully into the common bile
duct.
Excellent drainage of bile and contrast was noted
endoscopically and fluoroscopically.
Otherwise normal ercp to third part of the duodenum
CT Abd/Pelvis ___
1. No evidence of free air or leakage of contrast within the
abdomen to indicate bowel perforation. Pneumobilia consistent
with recent ERCP and stent placement.
2. Area fullness at the head of the pancreas may be region that
was recently biopsied. The pancreatic duct upstream of the area
of fullness is dilated.
3. Significant peripancreatic stranding may be due to
pancreatitis.
FNA Pancreas Mass ___
FINE NEEDLE ASPIRATION, PANCREAS MASS:
SUSPICIOUS FOR MALIGNANT CELLS.
Hypocellular degenerated specimen with scattered small clusters
of very atypical epithelioid cells;
Cytology ___
COMMON BILE DUCT STENT:
POSITIVE FOR MALIGNANT CELLS.
Consistent with adenocarcinoma.
Cytology ___
COMMON BILE DUCT BRUSHING:
POSITIVE FOR MALIGNANT CELLS.
Consistent with adenocarcinoma (see note).
Brief Hospital Course:
This is a ___ year old female with past medical history of recent
admission for biliary stricture, admitted ___ following EUS
and ERCP, post-procedure course complicated by
post-ERCP pancreatitis, now improved with conservative
management and ready for discharge home with scheduled follow-up
in multidisciplinary pancreas clinic.
# Biliary Obstruction / Malignancy of Head of Pancreas - patient
with recent ERCP and stenting for pancreas mass, who was
admitted after repeat ERCP with metal stent placement and EUS
with FNA/FNB of mass suspected to be malignancy. Preliminary
cytology returned consistent with malignancy, specifically
adenocarcinoma. These results were discussed with patient, and
patient was scheduled for multi-disciplinary pancreas clinic
follow-up Patient was treated with post-ERCP antibiotic
prophylaxis (Ciprofloxacin 500mg BID x 5 days). At time of
discharge IgG subclasses were pending.
# Post-ERCP Acute ___ - hospital course was complicated
by persistant pain and and nausea following ERCP. CT Abd/Pelvis
was performed to rule out perforaction, but instead showed
stranding at pancreas consistent with pancreatitis. Patient
managed conservatively with IV fluids, NPO and prn
anti-pain/nausea meds. Patient subsequently able to advance
diet and tolerate regular food. Discharged home with above
follow-up.
# Constipation - Patient reported that she had not moved her
bowels for several days leading up to admission. No signs
obstruction. Patient started on bowel regimen, and after
pancreatitis began to resolve, was able to have a bowel
movement.
# Hypothyroidism - continued levothyroxine
# Depression - continued venlafaxine
Transitional Issues
- Contact: Husband, ___ ___
- Code status: FULL
- IGG SUBCLASSES pending at discharge
- GI Mucosal biopsy pending at discharge
- Patient scheduled for follow-up with multidisciplinary
pancreas clinic
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Venlafaxine XR 75 mg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Venlafaxine XR 75 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 2 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*5 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# Post-ERCP Acute Pancreatitis
# Constipation
# Biliary Obstruction / Head of Pancreas Mass
# Anemia
# Hypothyroidism
# Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___:
It was a pleasure caring for you at ___. You were admitted
after an ERCP (endoscopic retrograde cholangiopancreatography)
and EUS (endoscopic ultrasound) with biopsy of your pancreas.
After your procedure you had pain and nausea that was likely due
to inflammation near the site of your procedure--this is called
pancreatitis. You were treated and improved. You are now ready
for discharge.
As we discussed, your biopsy was concerning for a malignancy.
We have made an appointment for you in the multi-disciplinary
pancreas clinic to further evaluate your imaging and biopsy
results.
It will be important for you to finish a 5-day course of
antibiotics to prevent infection after your ERCP.
Followup Instructions:
___
|
[
"C240",
"K9189",
"K859",
"Y838",
"E039",
"F329",
"K5900",
"D649",
"Z87891"
] |
Allergies: tetracycline Chief Complaint: Monitoring post ERCP/EUS for pancreatic mass Major Surgical or Invasive Procedure: EGD/EUS [MASKED] History of Present Illness: [MASKED] with hx of depression, hypothyroidism, nephrolithiasis, admitted to [MASKED] [MASKED] for workup of elevated LFTs and MRI with "CBD stricture vs malignancy or stone," s/p nondiagnostic ERCP and bx on [MASKED], readmitted for monitoring after ERCP and EUS with FNA in setting of 1.4 cm pancreatic head mass. Please see HPI from discharge summary dated [MASKED] for detailed history of events leading up that hospitalization. Since leaving the hospital in [MASKED], she notes that she has actually felt better, with improvement in morning fogginess, arthralgias, and more energetic. She notes that she has stopped her simvastatin at the suggestion of her PCP, and wonders if her improved symptoms are related to this medication change, or perhaps to a chance in her thyroid medication. She notes limited appetite, as well as ongoing early satiety. She has an epigastric heaviness that comes and goes with no clear precipitating factors. On the floor, abdominal discomfort is present, wraps around to bilateral flanks, [MASKED] at present. Denies fevers, chills, nausea, vomiting, diarrhea. She has not had a BM since her colonoscopy on [MASKED] (reportedly "negative"), which was done at [MASKED]. Per ERCP team, EUS done today with FNA/FNB of pancreas mass and ERCP with removal of plastic stent, brushings of distal CBD stricture and placement of 10 mm x 60 mm fully covered metal stent. Postprocedure pt was noted to have "severe pain," received dilaudid 0.5 mg IV and stat KUB which did not reveal free air. Per ERCP request, CT abd/pelvis to rule out perforation if KUB negative. ROS: all else negative Past Medical History: Hypothyroidism - [MASKED]'s Depression Hyperlipidema (although not on statin currently) Nephrolithiasis (long time ago, passed a kidney stone) Past Surgical History: -prior eye surgery many years ago to correct a strabismus when she was a child Social History: [MASKED] Family History: She notes that her mother had an episode of "jaundice" at [MASKED] or [MASKED] years, was diagnosed with colon cancer at age [MASKED], and died 6 months later. Grandmother died from "septicemia," abdominal causes. She is [MASKED] of five children, all in good health. Sister with [MASKED] disease. Physical Exam: ADMISSION VS: 97.7, 153/72, 59, 18, 98% RA GEN: Alert, lying in bed, no acute distress, interactive HEENT: MMM, anicteric sclera, no conjunctival pallor, clear oropharynx NECK: Supple, no cervical or supraclavicular LAD PULM: Clear, no wheeze, rales, or rhonchi CV: RRR, normal S1/S2, no murmurs ABD: Soft, ND, tender to palpation at epigastrium without rebound or guarding, +BS, no hepatomegaly EXTREM: Warm, no edema GU: No foley NEURO: CN II-XII grossly intact, motor function grossly normal DISCHARGE VS - 98.6 107/52 71 16 94%RA Gen - sitting up in bed, comfortable-appearing Eyes - EOMI ENT - OP clear, MMM Heart - RRR no mrg Lungs - CTA bilaterally Abd - soft, very mild tenderness to epigastric palpation, much improved from prior; no rebound/guarding; no CVA tenderness; hypoactive bowel sounds Ext - no edema Skin - no rashes Vasc - 2+ DP/radial pulses Neuro - AOx3, moving all extremities Psych - appropriate Pertinent Results: ADMISSION [MASKED] 11:40AM BLOOD WBC-6.3 RBC-4.33 Hgb-12.8 Hct-37.8 MCV-87 MCH-29.6 MCHC-33.9 RDW-13.3 RDWSD-42.6 Plt [MASKED] [MASKED] 11:40AM BLOOD UreaN-15 Creat-0.8 Na-139 K-4.1 Cl-101 HCO3-26 AnGap-16 [MASKED] 11:40AM BLOOD ALT-30 AST-35 AlkPhos-94 Amylase-126* TotBili-0.4 DirBili-0.1 IndBili-0.3 DISCHARGE [MASKED] 06:20AM BLOOD WBC-6.7 RBC-3.38* Hgb-10.1* Hct-28.9* MCV-86 MCH-29.9 MCHC-34.9 RDW-12.9 RDWSD-40.2 Plt [MASKED] [MASKED] 06:20AM BLOOD Glucose-77 UreaN-8 Creat-0.7 Na-138 K-3.9 Cl-102 HCO3-24 AnGap-16 [MASKED] 06:20AM BLOOD ALT-20 AST-21 AlkPhos-65 TotBili-0.5 EUS [MASKED]: Impression: A 1.4 ill-defined mass was noted in the head of the pancreas. FNA and FNB were performed. A total of four needle passes were made into the mass. The specimens were sent for cytology and pathology. The mass appeared to abut the portal vein. The right hepatic artery could not be well visualized. A previously placed plastic biliary stent was noted. The pancreas mass appeared to impinge upon the bile duct at the level of the head of the pancreas. ERCP [MASKED]: Impression: The scout film showed evidence of a previously placed plastic biliary stent. The previously placed plastic biliary stent was found in the major papilla. The stent was removed with a snare and sent for cytology. Evidence of a previous sphincterotomy was noted in the major papilla. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. A single stricture that was 5 mm long was seen at the middle third of the common bile duct just below the cystic duct takeoff with moderate post-obstructive dilation. Brushings were obtained of the stricture with a cytology brush. A 10 mm x 60 mm Wallflex Biliary Fully Covered metal stent (REF [MASKED], LOT [MASKED] was placed successfully into the common bile duct. Excellent drainage of bile and contrast was noted endoscopically and fluoroscopically. Otherwise normal ercp to third part of the duodenum CT Abd/Pelvis [MASKED] 1. No evidence of free air or leakage of contrast within the abdomen to indicate bowel perforation. Pneumobilia consistent with recent ERCP and stent placement. 2. Area fullness at the head of the pancreas may be region that was recently biopsied. The pancreatic duct upstream of the area of fullness is dilated. 3. Significant peripancreatic stranding may be due to pancreatitis. FNA Pancreas Mass [MASKED] FINE NEEDLE ASPIRATION, PANCREAS MASS: SUSPICIOUS FOR MALIGNANT CELLS. Hypocellular degenerated specimen with scattered small clusters of very atypical epithelioid cells; Cytology [MASKED] COMMON BILE DUCT STENT: POSITIVE FOR MALIGNANT CELLS. Consistent with adenocarcinoma. Cytology [MASKED] COMMON BILE DUCT BRUSHING: POSITIVE FOR MALIGNANT CELLS. Consistent with adenocarcinoma (see note). Brief Hospital Course: This is a [MASKED] year old female with past medical history of recent admission for biliary stricture, admitted [MASKED] following EUS and ERCP, post-procedure course complicated by post-ERCP pancreatitis, now improved with conservative management and ready for discharge home with scheduled follow-up in multidisciplinary pancreas clinic. # Biliary Obstruction / Malignancy of Head of Pancreas - patient with recent ERCP and stenting for pancreas mass, who was admitted after repeat ERCP with metal stent placement and EUS with FNA/FNB of mass suspected to be malignancy. Preliminary cytology returned consistent with malignancy, specifically adenocarcinoma. These results were discussed with patient, and patient was scheduled for multi-disciplinary pancreas clinic follow-up Patient was treated with post-ERCP antibiotic prophylaxis (Ciprofloxacin 500mg BID x 5 days). At time of discharge IgG subclasses were pending. # Post-ERCP Acute [MASKED] - hospital course was complicated by persistant pain and and nausea following ERCP. CT Abd/Pelvis was performed to rule out perforaction, but instead showed stranding at pancreas consistent with pancreatitis. Patient managed conservatively with IV fluids, NPO and prn anti-pain/nausea meds. Patient subsequently able to advance diet and tolerate regular food. Discharged home with above follow-up. # Constipation - Patient reported that she had not moved her bowels for several days leading up to admission. No signs obstruction. Patient started on bowel regimen, and after pancreatitis began to resolve, was able to have a bowel movement. # Hypothyroidism - continued levothyroxine # Depression - continued venlafaxine Transitional Issues - Contact: Husband, [MASKED] [MASKED] - Code status: FULL - IGG SUBCLASSES pending at discharge - GI Mucosal biopsy pending at discharge - Patient scheduled for follow-up with multidisciplinary pancreas clinic Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Venlafaxine XR 75 mg PO DAILY Discharge Medications: 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Venlafaxine XR 75 mg PO DAILY 3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 2 Days RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*5 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: # Post-ERCP Acute Pancreatitis # Constipation # Biliary Obstruction / Head of Pancreas Mass # Anemia # Hypothyroidism # Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [MASKED]: It was a pleasure caring for you at [MASKED]. You were admitted after an ERCP (endoscopic retrograde cholangiopancreatography) and EUS (endoscopic ultrasound) with biopsy of your pancreas. After your procedure you had pain and nausea that was likely due to inflammation near the site of your procedure--this is called pancreatitis. You were treated and improved. You are now ready for discharge. As we discussed, your biopsy was concerning for a malignancy. We have made an appointment for you in the multi-disciplinary pancreas clinic to further evaluate your imaging and biopsy results. It will be important for you to finish a 5-day course of antibiotics to prevent infection after your ERCP. Followup Instructions: [MASKED]
|
[] |
[
"E039",
"F329",
"K5900",
"D649",
"Z87891"
] |
[
"C240: Malignant neoplasm of extrahepatic bile duct",
"K9189: Other postprocedural complications and disorders of digestive system",
"K859: Acute pancreatitis, 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",
"E039: Hypothyroidism, unspecified",
"F329: Major depressive disorder, single episode, unspecified",
"K5900: Constipation, unspecified",
"D649: Anemia, unspecified",
"Z87891: Personal history of nicotine dependence"
] |
10,025,862
| 21,206,487
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
tetracycline
Attending: ___.
Chief Complaint:
Pancreatic cancer
Major Surgical or Invasive Procedure:
___:
1. Exploratory laparoscopy.
2. Radical pancreaticoduodenectomy with distal gastrectomy.
3. En bloc resection of main portal vein and replace right
hepatic artery.
4. Cholecystectomy.
5. End-to-end primary repair of portal vein.
6. Placement of gold fiducials.
7. End-to-side duct to mucosa pancreaticojejunostomy.
8. End-to-side hepaticojejunostomy.
9. Antecolic ___ gastrojejunostomy.
10.Transgastric feeding jejunostomy.
History of Present Illness:
Mrs. ___ is a ___ woman who has completed
preoperative chemotherapy and radiation for borderline
resectable pancreatic ductal carcinoma characterized by main
portal vein involvement and encasement of the very large
replaced right hepatic artery. She has completed chemoradiation
as well as preoperative plugged occlusion of the replaced right
hepatic artery with
development of adequate arterial collaterals to the right liver.
She is now taken to the operating room for definitive surgical
resection and vascular reconstruction. The risks and benefits
of surgery have been discussed with the patient in great detail
and are documented in a separate note.
Past Medical History:
Hypothyroidism - ___'s
Depression
Hyperlipidema (although not on statin currently)
Nephrolithiasis (long time ago, passed a kidney stone)
Past Surgical History:
-prior eye surgery many years ago to correct a strabismus when
she was a child
Social History:
___
Family History:
She notes that her mother had an episode of "jaundice" at ___ or
___ years, was diagnosed with colon cancer at age ___, and died 6
months later. Grandmother died from "septicemia," abdominal
causes. She is ___ of five children, all in good health. Sister
with ___ disease.
Physical Exam:
Prior to Discharge:
VS: 98.5, 80, 161/87, 18, 96% RA
GEN: NAD
CV: RRR, no m/r/g
PULM: CTAB
ABD: Trapdoor incision open to air with steri strips and c/d/I.
RLQ 2 old JP sites with dsd and c/d/i
EXTR: Warm, no c/c/e
Pertinent Results:
___ 07:00AM BLOOD WBC-6.2# RBC-2.36* Hgb-8.0* Hct-24.3*
MCV-103*# MCH-33.9* MCHC-32.9 RDW-13.7 RDWSD-51.2* Plt ___
___ 07:00AM BLOOD Glucose-90 UreaN-8 Creat-0.5 Na-134 K-3.4
Cl-100 HCO3-23 AnGap-14
___ 04:11AM BLOOD ALT-56* AST-76* AlkPhos-55 TotBili-0.3
___ 07:00AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.6
___ 06:44PM ASCITES Amylase-11
___ 06:45PM ASCITES Amylase-8
PATHOLOGY: Pancreatic adenocarcinoma
Brief Hospital Course:
The patient with pancreatic ca s/p neoadjuvant therapy was
admitted to the HPB Surgical Service for elective Whipple. On
___, the patient underwent pancreaticoduodenectomy
(Whipple), open cholecystectomy and portal vein reconstruction,
which went well without complication (reader referred to the
Operative Note for details). After a brief, uneventful stay in
the PACU, the patient arrived on the floor NPO with an NG tube,
on IV fluids, with a foley catheter and a JP drain in place, and
epidural catheter for pain control. The patient was
hemodynamically stable.
The ___ hospital course was uneventful and followed the
___ Clinical Pathway without deviation. Post-operative pain
was initially well controlled with epidural and PCA, which was
converted to oral pain medication when tolerating clear liquids.
The NG tube was discontinued on POD#3, and the foley catheter
discontinued at midnight of POD#4. The patient subsequently
voided without problem. The patient was started on sips of
clears on POD#4, which was progressively advanced as tolerated
to a regular diet by POD#7. JP amylase was sent in the evening
of POD#6; the JP was discontinued on POD#7 as the output and
amylase level were low.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated.
At the time of discharge on ___, 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. Staples were removed, and steri-strips
placed. 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. Venlafaxine 75 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Creon ___ CAP PO TID W/MEALS
4. LORazepam 0.5-1 mg PO Q6H:PRN anxiety
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. Docusate Sodium 100 mg PO BID
7. Loratadine 10 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Fish Oil (Omega 3) 90 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Levothyroxine Sodium 75 mcg PO DAILY
3. LORazepam 0.5-1 mg PO Q6H:PRN anxiety
4. Venlafaxine XR 150 mg PO DAILY
5. Acetaminophen 1000 mg PO Q8H
do not exceed more then 3000 mg/day
6. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*5
7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*80 Tablet Refills:*0
8. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tab by mouth QIDACHS Disp #*56
Tablet Refills:*0
9. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
10. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*5
11. Senna 8.6 mg PO BID
12. Fish Oil (Omega 3) 90 mg PO DAILY
13. Loratadine 10 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Polyethylene Glycol 17 g PO DAILY
16. Prochlorperazine 10 mg PO Q6H:PRN nausea
17. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*30 Tablet Refills:*0
18. Creon ___ CAP PO TID W/MEALS
19. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pancreatic adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service at ___ for surgical
resection of your pancreatic mass. You have done well in the
post operative period and are now safe to return home to
complete your recovery with the following instructions:
.
Please call Dr. ___ office at ___ or ___
___, RN at ___ if you have any questions or
concerns.
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
.
G/J-tube: Capped.
Followup Instructions:
___
|
[
"C253",
"C7989",
"K7581",
"Z9221",
"T451X5A",
"Y92019",
"E063",
"E039",
"F329",
"E785",
"Z87442",
"Z87891"
] |
Allergies: tetracycline Chief Complaint: Pancreatic cancer Major Surgical or Invasive Procedure: [MASKED]: 1. Exploratory laparoscopy. 2. Radical pancreaticoduodenectomy with distal gastrectomy. 3. En bloc resection of main portal vein and replace right hepatic artery. 4. Cholecystectomy. 5. End-to-end primary repair of portal vein. 6. Placement of gold fiducials. 7. End-to-side duct to mucosa pancreaticojejunostomy. 8. End-to-side hepaticojejunostomy. 9. Antecolic [MASKED] gastrojejunostomy. 10.Transgastric feeding jejunostomy. History of Present Illness: Mrs. [MASKED] is a [MASKED] woman who has completed preoperative chemotherapy and radiation for borderline resectable pancreatic ductal carcinoma characterized by main portal vein involvement and encasement of the very large replaced right hepatic artery. She has completed chemoradiation as well as preoperative plugged occlusion of the replaced right hepatic artery with development of adequate arterial collaterals to the right liver. She is now taken to the operating room for definitive surgical resection and vascular reconstruction. The risks and benefits of surgery have been discussed with the patient in great detail and are documented in a separate note. Past Medical History: Hypothyroidism - [MASKED]'s Depression Hyperlipidema (although not on statin currently) Nephrolithiasis (long time ago, passed a kidney stone) Past Surgical History: -prior eye surgery many years ago to correct a strabismus when she was a child Social History: [MASKED] Family History: She notes that her mother had an episode of "jaundice" at [MASKED] or [MASKED] years, was diagnosed with colon cancer at age [MASKED], and died 6 months later. Grandmother died from "septicemia," abdominal causes. She is [MASKED] of five children, all in good health. Sister with [MASKED] disease. Physical Exam: Prior to Discharge: VS: 98.5, 80, 161/87, 18, 96% RA GEN: NAD CV: RRR, no m/r/g PULM: CTAB ABD: Trapdoor incision open to air with steri strips and c/d/I. RLQ 2 old JP sites with dsd and c/d/i EXTR: Warm, no c/c/e Pertinent Results: [MASKED] 07:00AM BLOOD WBC-6.2# RBC-2.36* Hgb-8.0* Hct-24.3* MCV-103*# MCH-33.9* MCHC-32.9 RDW-13.7 RDWSD-51.2* Plt [MASKED] [MASKED] 07:00AM BLOOD Glucose-90 UreaN-8 Creat-0.5 Na-134 K-3.4 Cl-100 HCO3-23 AnGap-14 [MASKED] 04:11AM BLOOD ALT-56* AST-76* AlkPhos-55 TotBili-0.3 [MASKED] 07:00AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.6 [MASKED] 06:44PM ASCITES Amylase-11 [MASKED] 06:45PM ASCITES Amylase-8 PATHOLOGY: Pancreatic adenocarcinoma Brief Hospital Course: The patient with pancreatic ca s/p neoadjuvant therapy was admitted to the HPB Surgical Service for elective Whipple. On [MASKED], the patient underwent pancreaticoduodenectomy (Whipple), open cholecystectomy and portal vein reconstruction, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO with an NG tube, on IV fluids, with a foley catheter and a JP drain in place, and epidural catheter for pain control. The patient was hemodynamically stable. The [MASKED] hospital course was uneventful and followed the [MASKED] Clinical Pathway without deviation. Post-operative pain was initially well controlled with epidural and PCA, which was converted to oral pain medication when tolerating clear liquids. The NG tube was discontinued on POD#3, and the foley catheter discontinued at midnight of POD#4. The patient subsequently voided without problem. The patient was started on sips of clears on POD#4, which was progressively advanced as tolerated to a regular diet by POD#7. JP amylase was sent in the evening of POD#6; the JP was discontinued on POD#7 as the output and amylase level were low. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated. At the time of discharge on [MASKED], 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. Staples were removed, and steri-strips placed. 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. Venlafaxine 75 mg PO DAILY 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Creon [MASKED] CAP PO TID W/MEALS 4. LORazepam 0.5-1 mg PO Q6H:PRN anxiety 5. Prochlorperazine 10 mg PO Q6H:PRN nausea 6. Docusate Sodium 100 mg PO BID 7. Loratadine 10 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Fish Oil (Omega 3) 90 mg PO DAILY 10. Polyethylene Glycol 17 g PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Levothyroxine Sodium 75 mcg PO DAILY 3. LORazepam 0.5-1 mg PO Q6H:PRN anxiety 4. Venlafaxine XR 150 mg PO DAILY 5. Acetaminophen 1000 mg PO Q8H do not exceed more then 3000 mg/day 6. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*5 7. HYDROmorphone (Dilaudid) [MASKED] mg PO Q4H:PRN pain RX *hydromorphone 2 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*80 Tablet Refills:*0 8. Metoclopramide 10 mg PO QIDACHS RX *metoclopramide HCl 10 mg 1 tab by mouth QIDACHS Disp #*56 Tablet Refills:*0 9. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 10. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*5 11. Senna 8.6 mg PO BID 12. Fish Oil (Omega 3) 90 mg PO DAILY 13. Loratadine 10 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. Polyethylene Glycol 17 g PO DAILY 16. Prochlorperazine 10 mg PO Q6H:PRN nausea 17. Ondansetron ODT 4 mg PO Q8H:PRN nausea RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 18. Creon [MASKED] CAP PO TID W/MEALS 19. Enoxaparin Sodium 40 mg SC DAILY Start: Today - [MASKED], First Dose: Next Routine Administration Time Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Pancreatic adenocarcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the surgery service at [MASKED] for surgical resection of your pancreatic mass. You have done well in the post operative period and are now safe to return home to complete your recovery with the following instructions: . Please call Dr. [MASKED] office at [MASKED] or [MASKED] [MASKED], RN at [MASKED] if you have any questions or concerns. . Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Incision Care: *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. . G/J-tube: Capped. Followup Instructions: [MASKED]
|
[] |
[
"E039",
"F329",
"E785",
"Z87891"
] |
[
"C253: Malignant neoplasm of pancreatic duct",
"C7989: Secondary malignant neoplasm of other specified sites",
"K7581: Nonalcoholic steatohepatitis (NASH)",
"Z9221: Personal history of antineoplastic chemotherapy",
"T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter",
"Y92019: Unspecified place in single-family (private) house as the place of occurrence of the external cause",
"E063: Autoimmune thyroiditis",
"E039: Hypothyroidism, unspecified",
"F329: Major depressive disorder, single episode, unspecified",
"E785: Hyperlipidemia, unspecified",
"Z87442: Personal history of urinary calculi",
"Z87891: Personal history of nicotine dependence"
] |
10,025,862
| 22,828,313
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
tetracycline
Attending: ___.
Chief Complaint:
Inability to take PO, dehydration
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ hx pancreatic adenoca s/p radical whipple
with PV
reconstruction (___) admitted for dehydration, diarrhea, and
vomiting. Patient was discharged from the hospital on ___ and
did well for several days, until ___ days ago when she started
experiencing nausea, NBNB vomiting, and inability to tolerate po
intake with orthostatic dizziness. Reports associated crampy
abdominal pain in the lower quadrants and frequent non-watery
small bowel movements ___, mucus-like in quality), as
well as chills but no fevers. Has noted a 10-lb weight loss
since discharge, though has recently increased her synthroid
dose from 75 to 100 and also reports occasional palpitations.
Patient reports that she has stopped taking her po medications
over since onset of symptomts.
Patient was seen in clinic last week for drainage at the
proximal
aspect of her midline incision. Reports improvement in drainage,
though still persistent. Has not noted increased drainage or
change in quality of drainage, pain, or redness at the site.
Past Medical History:
Hypothyroidism - ___'s
Depression
Hyperlipidema (although not on statin currently)
Nephrolithiasis (long time ago, passed a kidney stone)
Past Surgical History:
-prior eye surgery many years ago to correct a strabismus when
she was a child
Social History:
___
Family History:
She notes that her mother had an episode of "jaundice" at 45 or
___ years, was diagnosed with colon cancer at age ___, and died 6
months later. Grandmother died from "septicemia," abdominal
causes. She is ___ of five children, all in good health. Sister
with ___ disease.
Physical Exam:
T 97.8, BP 100/73, HR95, 98% RA, RR 16
General- pale-appearing female, NAD
HEENT- NCAT, sclera anicteric
Cardiac- RRR, no murmurs
Chest- CTAB, normal work of breathing
Abd- soft, tender in lower abdomen, non-distended. Proximal
aspect of midline incision open with minimal purulent drainage,
covered with bandage. Remainder of incision c/d/I. G/J-tube site
c/d/I.
Ext- WWP, no edema
Skin- no jaundice, rashes
Pertinent Results:
___ 05:20AM BLOOD WBC-5.0 RBC-2.53* Hgb-8.3* Hct-25.7*
MCV-102* MCH-32.8* MCHC-32.3 RDW-14.3 RDWSD-53.2* Plt ___
___ 05:20AM BLOOD Glucose-119* UreaN-14 Creat-0.5 Na-137
K-4.2 Cl-98 HCO3-32 AnGap-11
___ 05:20AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9
___ 10:30AM BLOOD Albumin-3.8 Calcium-9.5 Phos-4.3 Mg-2.0
___ 10:30AM BLOOD TSH-22*
___ 10:30AM BLOOD Free T4-0.8*
___ KUB:
IMPRESSION:
1. Nonobstructive bowel-gas pattern with large amount of stool
in the
descending and sigmoid colon and rectum.
2. Mesenteric calcification as seen on prior exam still
present.
MICRO:
___ 7:36 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.
Brief Hospital Course:
The patient s/p classic Whipple procedure with PV reconstruction
on ___ was admitted to the HPB Surgical Service from clinic
for initiation of supplemental nutrition secondary to poor PO
intake at home and weight loss. Patient was started on IV fluid
and tube feeds (Vital 1.5) and Nutritional service was
consulted. RD recommended continue tubefeed @ 50 cc/hr x 24 hrs
and cycle with rate 75 cc/hr x 16 hrs when patient able. On
admission labs was noticed that patient has elevated TSH.
Endocrinology service was consulted and patient's home dose
Synthroid was increased to 125 mcg/day from 100 mcg/day.
Patient's tubefeed was slowly advanced to goal within next 4
days secondary to poor tubefeed tolerance. Patient home dose
Creon was increased to ___ with meals, diet was advanced to
fulls with supplements and was well tolerated. On HD 5,
patient's TF was at goal an attempt to cycle TF over 16 hours
was taken. Patient only was able to tolerate TF at 65 cc/hr. She
was discharged home next day on regular diet, and with order to
continue TF at home with close to goal rate and advance to goal
as tolerated. Patient's stool was negative for infection or
parasites. Patient was started on Hyoscyamine secondary to
abdominal spasms.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet and tubefeed with close to goal rate, 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:
1. Docusate Sodium 100 mg PO BID
2. Levothyroxine Sodium 100 mcg PO DAILY
3. LORazepam 0.5-1 mg PO Q6H:PRN anxiety
4. Venlafaxine XR 150 mg PO DAILY
5. Acetaminophen 1000 mg PO Q8H
do not exceed more then 3000 mg/day
6. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*5
7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*80 Tablet Refills:*0
8. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tab by mouth QIDACHS Disp #*56
Tablet Refills:*0
9. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
10. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*5
11. Senna 8.6 mg PO BID
12. Fish Oil (Omega 3) 90 mg PO DAILY
13. Loratadine 10 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Polyethylene Glycol 17 g PO DAILY
16. Prochlorperazine 10 mg PO Q6H:PRN nausea
17. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*30 Tablet Refills:*0
18. Creon ___ CAP PO TID W/MEALS
19. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
Discharge Medications:
1. Creon (lipase-protease-amylase) ___ unit
oral Other
take 2 caps with meals and one cap with snacks.
RX *lipase-protease-amylase [Creon] 36,000 unit-114,000
unit-180,000 unit ___ capsule(s) by mouth QIDACHS Disp #*240
Capsule Refills:*3
2. Hyoscyamine 0.125 mg PO QID
RX *hyoscyamine sulfate 0.125 mg 1 tablet(s) by mouth four times
a day Disp #*30 Tablet Refills:*0
3. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide 2 mg 1 capsule(s) by mouth four times a day Disp
#*30 Capsule Refills:*0
4. Psyllium Wafer 1 WAF PO DAILY for diarrhea
5. Vital 1.5 Cal (nut.tx.impaired dige fxn-fiber) 0.07-1.5
gram-kcal/mL oral DAILY
Tubefeed rate 75 cc/hr
Cycle for 16 hours, flush J-tube with 30 cc of H2O q8h
RX *nut.tx.impaired dige fxn-fiber [Vital 1.5 Cal] 0.07 gram-1.5
kcal/mL 1200 mLs J-tube once a day Refills:*0
6. Levothyroxine Sodium 125 mcg PO DAILY
RX *levothyroxine 125 mcg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
7. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
8. Aspirin 81 mg PO DAILY
9. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
10. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Severe
RX *hydromorphone 2 mg ___ tablet(s) by mouth every six (6)
hours Disp #*80 Tablet Refills:*0
11. Ondansetron ___ mg PO Q8H:PRN nausea
12. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
13. Venlafaxine XR 150 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Pancreatic ductal adenocarcinoma s/p ___ on ___.
2. Dehydration
3. Severe malnutrition
4. Hyperthyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service at ___ from clinic
secondary to dehydration and poor PO intake. You were started on
tubefeed, pancreatic enzymes and continued on regular diet with
supplements. You and are now safe to return home to complete
your recovery with the following instructions:
.
Please call Dr. ___ office at ___ if you have any
questions or concerns.
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Incision Care:
___ nurses ___ continue to change your wound dressing daily.
*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.
.
G/J-tube: Keep G-tube capped. J-tube - flush with 30 cc of tap
water Q8H, before and after every use. Change dressing daily and
prn. Monitor for signs and symptoms of infection. Prevent
dislocation.
Followup Instructions:
___
|
[
"E860",
"E43",
"C253",
"R627",
"T814XXA",
"Z931",
"R197",
"F329",
"R252",
"Z9889",
"E0580",
"Z87891",
"E871",
"Z934",
"Z6824",
"Y838"
] |
Allergies: tetracycline Chief Complaint: Inability to take PO, dehydration Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a [MASKED] hx pancreatic adenoca s/p radical whipple with PV reconstruction ([MASKED]) admitted for dehydration, diarrhea, and vomiting. Patient was discharged from the hospital on [MASKED] and did well for several days, until [MASKED] days ago when she started experiencing nausea, NBNB vomiting, and inability to tolerate po intake with orthostatic dizziness. Reports associated crampy abdominal pain in the lower quadrants and frequent non-watery small bowel movements [MASKED], mucus-like in quality), as well as chills but no fevers. Has noted a 10-lb weight loss since discharge, though has recently increased her synthroid dose from 75 to 100 and also reports occasional palpitations. Patient reports that she has stopped taking her po medications over since onset of symptomts. Patient was seen in clinic last week for drainage at the proximal aspect of her midline incision. Reports improvement in drainage, though still persistent. Has not noted increased drainage or change in quality of drainage, pain, or redness at the site. Past Medical History: Hypothyroidism - [MASKED]'s Depression Hyperlipidema (although not on statin currently) Nephrolithiasis (long time ago, passed a kidney stone) Past Surgical History: -prior eye surgery many years ago to correct a strabismus when she was a child Social History: [MASKED] Family History: She notes that her mother had an episode of "jaundice" at 45 or [MASKED] years, was diagnosed with colon cancer at age [MASKED], and died 6 months later. Grandmother died from "septicemia," abdominal causes. She is [MASKED] of five children, all in good health. Sister with [MASKED] disease. Physical Exam: T 97.8, BP 100/73, HR95, 98% RA, RR 16 General- pale-appearing female, NAD HEENT- NCAT, sclera anicteric Cardiac- RRR, no murmurs Chest- CTAB, normal work of breathing Abd- soft, tender in lower abdomen, non-distended. Proximal aspect of midline incision open with minimal purulent drainage, covered with bandage. Remainder of incision c/d/I. G/J-tube site c/d/I. Ext- WWP, no edema Skin- no jaundice, rashes Pertinent Results: [MASKED] 05:20AM BLOOD WBC-5.0 RBC-2.53* Hgb-8.3* Hct-25.7* MCV-102* MCH-32.8* MCHC-32.3 RDW-14.3 RDWSD-53.2* Plt [MASKED] [MASKED] 05:20AM BLOOD Glucose-119* UreaN-14 Creat-0.5 Na-137 K-4.2 Cl-98 HCO3-32 AnGap-11 [MASKED] 05:20AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9 [MASKED] 10:30AM BLOOD Albumin-3.8 Calcium-9.5 Phos-4.3 Mg-2.0 [MASKED] 10:30AM BLOOD TSH-22* [MASKED] 10:30AM BLOOD Free T4-0.8* [MASKED] KUB: IMPRESSION: 1. Nonobstructive bowel-gas pattern with large amount of stool in the descending and sigmoid colon and rectum. 2. Mesenteric calcification as seen on prior exam still present. MICRO: [MASKED] 7:36 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. Brief Hospital Course: The patient s/p classic Whipple procedure with PV reconstruction on [MASKED] was admitted to the HPB Surgical Service from clinic for initiation of supplemental nutrition secondary to poor PO intake at home and weight loss. Patient was started on IV fluid and tube feeds (Vital 1.5) and Nutritional service was consulted. RD recommended continue tubefeed @ 50 cc/hr x 24 hrs and cycle with rate 75 cc/hr x 16 hrs when patient able. On admission labs was noticed that patient has elevated TSH. Endocrinology service was consulted and patient's home dose Synthroid was increased to 125 mcg/day from 100 mcg/day. Patient's tubefeed was slowly advanced to goal within next 4 days secondary to poor tubefeed tolerance. Patient home dose Creon was increased to [MASKED] with meals, diet was advanced to fulls with supplements and was well tolerated. On HD 5, patient's TF was at goal an attempt to cycle TF over 16 hours was taken. Patient only was able to tolerate TF at 65 cc/hr. She was discharged home next day on regular diet, and with order to continue TF at home with close to goal rate and advance to goal as tolerated. Patient's stool was negative for infection or parasites. Patient was started on Hyoscyamine secondary to abdominal spasms. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet and tubefeed with close to goal rate, 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: 1. Docusate Sodium 100 mg PO BID 2. Levothyroxine Sodium 100 mcg PO DAILY 3. LORazepam 0.5-1 mg PO Q6H:PRN anxiety 4. Venlafaxine XR 150 mg PO DAILY 5. Acetaminophen 1000 mg PO Q8H do not exceed more then 3000 mg/day 6. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*5 7. HYDROmorphone (Dilaudid) [MASKED] mg PO Q4H:PRN pain RX *hydromorphone 2 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*80 Tablet Refills:*0 8. Metoclopramide 10 mg PO QIDACHS RX *metoclopramide HCl 10 mg 1 tab by mouth QIDACHS Disp #*56 Tablet Refills:*0 9. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 10. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*5 11. Senna 8.6 mg PO BID 12. Fish Oil (Omega 3) 90 mg PO DAILY 13. Loratadine 10 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. Polyethylene Glycol 17 g PO DAILY 16. Prochlorperazine 10 mg PO Q6H:PRN nausea 17. Ondansetron ODT 4 mg PO Q8H:PRN nausea RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 18. Creon [MASKED] CAP PO TID W/MEALS 19. Enoxaparin Sodium 40 mg SC DAILY Start: Today - [MASKED], First Dose: Next Routine Administration Time Discharge Medications: 1. Creon (lipase-protease-amylase) [MASKED] unit oral Other take 2 caps with meals and one cap with snacks. RX *lipase-protease-amylase [Creon] 36,000 unit-114,000 unit-180,000 unit [MASKED] capsule(s) by mouth QIDACHS Disp #*240 Capsule Refills:*3 2. Hyoscyamine 0.125 mg PO QID RX *hyoscyamine sulfate 0.125 mg 1 tablet(s) by mouth four times a day Disp #*30 Tablet Refills:*0 3. LOPERamide 2 mg PO QID:PRN diarrhea RX *loperamide 2 mg 1 capsule(s) by mouth four times a day Disp #*30 Capsule Refills:*0 4. Psyllium Wafer 1 WAF PO DAILY for diarrhea 5. Vital 1.5 Cal (nut.tx.impaired dige fxn-fiber) 0.07-1.5 gram-kcal/mL oral DAILY Tubefeed rate 75 cc/hr Cycle for 16 hours, flush J-tube with 30 cc of H2O q8h RX *nut.tx.impaired dige fxn-fiber [Vital 1.5 Cal] 0.07 gram-1.5 kcal/mL 1200 mLs J-tube once a day Refills:*0 6. Levothyroxine Sodium 125 mcg PO DAILY RX *levothyroxine 125 mcg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 7. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 8. Aspirin 81 mg PO DAILY 9. Enoxaparin Sodium 40 mg SC DAILY Start: Today - [MASKED], First Dose: Next Routine Administration Time 10. HYDROmorphone (Dilaudid) [MASKED] mg PO Q4H:PRN Pain - Severe RX *hydromorphone 2 mg [MASKED] tablet(s) by mouth every six (6) hours Disp #*80 Tablet Refills:*0 11. Ondansetron [MASKED] mg PO Q8H:PRN nausea 12. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 13. Venlafaxine XR 150 mg PO QHS Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: 1. Pancreatic ductal adenocarcinoma s/p [MASKED] on [MASKED]. 2. Dehydration 3. Severe malnutrition 4. Hyperthyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the surgery service at [MASKED] from clinic secondary to dehydration and poor PO intake. You were started on tubefeed, pancreatic enzymes and continued on regular diet with supplements. You and are now safe to return home to complete your recovery with the following instructions: . Please call Dr. [MASKED] office at [MASKED] if you have any questions or concerns. . Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Incision Care: [MASKED] nurses [MASKED] continue to change your wound dressing daily. *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. . G/J-tube: Keep G-tube capped. J-tube - flush with 30 cc of tap water Q8H, before and after every use. Change dressing daily and prn. Monitor for signs and symptoms of infection. Prevent dislocation. Followup Instructions: [MASKED]
|
[] |
[
"F329",
"Z87891",
"E871"
] |
[
"E860: Dehydration",
"E43: Unspecified severe protein-calorie malnutrition",
"C253: Malignant neoplasm of pancreatic duct",
"R627: Adult failure to thrive",
"T814XXA: Infection following a procedure",
"Z931: Gastrostomy status",
"R197: Diarrhea, unspecified",
"F329: Major depressive disorder, single episode, unspecified",
"R252: Cramp and spasm",
"Z9889: Other specified postprocedural states",
"E0580: Other thyrotoxicosis without thyrotoxic crisis or storm",
"Z87891: Personal history of nicotine dependence",
"E871: Hypo-osmolality and hyponatremia",
"Z934: Other artificial openings of gastrointestinal tract status",
"Z6824: Body mass index [BMI] 24.0-24.9, adult",
"Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure"
] |
10,025,862
| 23,264,000
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tetracycline
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of
Stage IA (ypT1N0M0) PDAC s/p neoadjuvant FOLFIRINOX, SBRT,
Whipple (___), adjuvant FOLFOX, now with metastatic disease
to the lung on Rexahn trial (DF/___ trial ___ who presents
with fever.
The patient was admitted 5 months ago with high grade fevers due
to pan-sensitive klebsiella bacteremia of unclear source. Since
discharge, the patient had been doing well, but had continued to
have low grade fevers 99-100 which was attributed to her
chemotherapy which improved with taking dexamethasone. over the
last week or so, the patient had noticed increased fatigue and
dizziness, with persistently low grade fevers ~100. She
contacted
her outpatient oncologist who recommended she keep a close eye
on
her temperature. The day prior to admission it spiked to 103.
In addition, over the last few days, she has had increased
rhinorrhea and sinus congestion, but states she has had milder
versions of these symptoms throughout the winter. In addition
she
has had a mild headache without vision changes. Furthermore,
over
the last ___ days, she has had positional, substernal chest pain
which she described as throbbing. It is constant, without
radiation and exacerbated with deep breaths and lying flat. It
is
relieved with leaning forward. It is not associated with dyspnea
and is without radiation.
Lastly, over the last 3 weeks, she has had intermittent loose,
non-bloody stool up to 3 times per day. 2 days ago she took
Imodium which stopped her BMs. She has not have a BM since.
Given her fever, she presented to ___ ED for further
evaluation.
She initially presented to ___ where vitals were Temp
103.1, BP 103/74, HR 110, RR 18, and O2 sat 94% RA. Labs were
notable for WBC 6.5, H/H 9.0/27.6, Plt 414, Na 131, K 4.4,
BUN/Cr
___, phos 2.2, Mg 1.7, LFTs/lipase wnl, lactate 2.1, and UA
negative. Blood cultures were sent. CXR was negative. CTA chest
was negative for pneumonia but remonstrated metastatic disease.
She was given zosyn, Tylenol, ibuprofen, and NS. She was
transferred to the ___ ED.
On arrival to the ED, initial vitals were 98.6 79 100/62 18 94%
RA. Exam was notable for stenal tenderness to palpation. Labs
were notable for WBC 4.0, H/H 8.5/26.3, Plt 326, Na 139, K 4.1,
and BUN/Cr ___. Influenza A/B PCR was negative. ECG showed
NSR
with inferior Q waves.
Of note, the patient was admitted with sepsis in ___ due to
pan-sensitive klebseilla bacteremia without obvious source.
On arrival to the floor, patient reports the above history and
feels slightly more energized. She has no fevers or chills.
Chest
pain as noted above. No dyspnea or abd pain. No dysuria.
Past Medical History:
- Pancreatic CA
- Hyperlipidemia
- Hypothyroidism
- GERD
- Depression
- Nephrolithiasis
- Right Breast ALH in ___ s/p excision
- s/p remote eye surgery to correct strabismus she had when she
was a child
Social History:
___
Family History:
She notes that her mother had an episode of "jaundice" at ___ or
___ years, was diagnosed with colon cancer at age ___, and died 6
months later. Grandmother died from "septicemia," abdominal
causes. She is ___ of five children, all in good health. Sister
with ___ disease.
Physical Exam:
GEN: Well appearing pleasant Caucasian woman sitting up in bed
HEENT: Oropharynx clear, MMM, sclerae anicteric
___: RRR no murmurs
RESP: CTAB
ABD: Soft, nontender, nondistended
EXT: warm, no peripheral edema
SKIN: Dry, no rashes
NEURO: alert, fluent speech, answers questions appropriately,
PERRL, palate elevates symmetrically
ACCESS: POC c/d/i
Pertinent Results:
PERTINENT LABS:
Blood culture x 2 (___) ___ NGTD
Blood culture x 3 (___) ___ NGTD
Rapid Flu PCR (___): Negative
Respiratory Viral Screen (___): inadequate sample
PERTINENT IMAGING
CXR ___ at ___
1. Linear opacity in the left lower lobe likely due to linear
atelectasis noted.
2. Slightly enlarged heart. Right venous catheter in place.
CTA Chest ___ at ___
1. Large irregular right lower lobe lesion with numerous nodules
bilaterally.
2. no acute thoracic abnormality seen otherwise.
Brief Hospital Course:
___ with metastatic pancreatic cancer and history of klebsiella
bacteremia, who presented from home with fevers to 103,
rhinorrhea, congestion, and substernal chest pain.
#Fevers
Presented with fever to ___ with URI symptoms and suspected
pericarditis (substernal chest pain that was worse with lying
flat and better with sitting forward). Given her previous
history of klebsiella bacteremia and immunosuppression in the
setting of chemotherapy, she was started on broad spectrum
antibiotics. Blood cultures were unrevealing and she had no
further episodes of fever while hospitalized. Her antibiotics
were peeled off and ultimately stopped on the morning of
discharge.
EKG was unchanged from prior. A TTE was considered, but her
pericarditis symptoms self-resolved with supportive care and was
deferred.
# Metastatic Pancreatic Adenocarcinoma:
# Secondary Neoplasm of Lung:
Currently on Phase ___ trial ___ of RX-3117 (oral cytidine
analogue) + abraxane. She will follow up tomorrow in clinic for
continuation of therapy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Creon (lipase-protease-amylase) ___ unit
oral TID W/MEALS
2. Levothyroxine Sodium 125 mcg PO DAILY
3. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea
4. Omeprazole 40 mg PO DAILY
5. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
6. Venlafaxine XR 150 mg PO DINNER
7. Vitamin D ___ UNIT PO DAILY
8. coenzyme Q10 200 mg oral DAILY
9. colesevelam 625 mg oral BID
10. turmeric 1 capsule oral DAILY
11. Pyridoxine 50 mg PO DAILY
Discharge Medications:
1. coenzyme Q10 200 mg oral DAILY
2. colesevelam 625 mg oral BID
3. Creon (lipase-protease-amylase) ___ unit
oral TID W/MEALS
4. Levothyroxine Sodium 125 mcg PO DAILY
5. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea
6. Omeprazole 40 mg PO DAILY
7. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
8. Pyridoxine 50 mg PO DAILY
9. Pyridoxine 50 mg PO DAILY
10. turmeric 1 capsule oral DAILY
11. Venlafaxine XR 150 mg PO DINNER
12. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
Pericarditis
Metastatic pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
___ MD ___
Completed by: ___
|
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"E785",
"E039",
"K219",
"F329",
"Z87891",
"D6489",
"R197",
"G4700",
"Z515"
] |
Allergies: tetracycline Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] female with history of Stage IA (ypT1N0M0) PDAC s/p neoadjuvant FOLFIRINOX, SBRT, Whipple ([MASKED]), adjuvant FOLFOX, now with metastatic disease to the lung on Rexahn trial (DF/[MASKED] trial [MASKED] who presents with fever. The patient was admitted 5 months ago with high grade fevers due to pan-sensitive klebsiella bacteremia of unclear source. Since discharge, the patient had been doing well, but had continued to have low grade fevers 99-100 which was attributed to her chemotherapy which improved with taking dexamethasone. over the last week or so, the patient had noticed increased fatigue and dizziness, with persistently low grade fevers ~100. She contacted her outpatient oncologist who recommended she keep a close eye on her temperature. The day prior to admission it spiked to 103. In addition, over the last few days, she has had increased rhinorrhea and sinus congestion, but states she has had milder versions of these symptoms throughout the winter. In addition she has had a mild headache without vision changes. Furthermore, over the last [MASKED] days, she has had positional, substernal chest pain which she described as throbbing. It is constant, without radiation and exacerbated with deep breaths and lying flat. It is relieved with leaning forward. It is not associated with dyspnea and is without radiation. Lastly, over the last 3 weeks, she has had intermittent loose, non-bloody stool up to 3 times per day. 2 days ago she took Imodium which stopped her BMs. She has not have a BM since. Given her fever, she presented to [MASKED] ED for further evaluation. She initially presented to [MASKED] where vitals were Temp 103.1, BP 103/74, HR 110, RR 18, and O2 sat 94% RA. Labs were notable for WBC 6.5, H/H 9.0/27.6, Plt 414, Na 131, K 4.4, BUN/Cr [MASKED], phos 2.2, Mg 1.7, LFTs/lipase wnl, lactate 2.1, and UA negative. Blood cultures were sent. CXR was negative. CTA chest was negative for pneumonia but remonstrated metastatic disease. She was given zosyn, Tylenol, ibuprofen, and NS. She was transferred to the [MASKED] ED. On arrival to the ED, initial vitals were 98.6 79 100/62 18 94% RA. Exam was notable for stenal tenderness to palpation. Labs were notable for WBC 4.0, H/H 8.5/26.3, Plt 326, Na 139, K 4.1, and BUN/Cr [MASKED]. Influenza A/B PCR was negative. ECG showed NSR with inferior Q waves. Of note, the patient was admitted with sepsis in [MASKED] due to pan-sensitive klebseilla bacteremia without obvious source. On arrival to the floor, patient reports the above history and feels slightly more energized. She has no fevers or chills. Chest pain as noted above. No dyspnea or abd pain. No dysuria. Past Medical History: - Pancreatic CA - Hyperlipidemia - Hypothyroidism - GERD - Depression - Nephrolithiasis - Right Breast ALH in [MASKED] s/p excision - s/p remote eye surgery to correct strabismus she had when she was a child Social History: [MASKED] Family History: She notes that her mother had an episode of "jaundice" at [MASKED] or [MASKED] years, was diagnosed with colon cancer at age [MASKED], and died 6 months later. Grandmother died from "septicemia," abdominal causes. She is [MASKED] of five children, all in good health. Sister with [MASKED] disease. Physical Exam: GEN: Well appearing pleasant Caucasian woman sitting up in bed HEENT: Oropharynx clear, MMM, sclerae anicteric [MASKED]: RRR no murmurs RESP: CTAB ABD: Soft, nontender, nondistended EXT: warm, no peripheral edema SKIN: Dry, no rashes NEURO: alert, fluent speech, answers questions appropriately, PERRL, palate elevates symmetrically ACCESS: POC c/d/i Pertinent Results: PERTINENT LABS: Blood culture x 2 ([MASKED]) [MASKED] NGTD Blood culture x 3 ([MASKED]) [MASKED] NGTD Rapid Flu PCR ([MASKED]): Negative Respiratory Viral Screen ([MASKED]): inadequate sample PERTINENT IMAGING CXR [MASKED] at [MASKED] 1. Linear opacity in the left lower lobe likely due to linear atelectasis noted. 2. Slightly enlarged heart. Right venous catheter in place. CTA Chest [MASKED] at [MASKED] 1. Large irregular right lower lobe lesion with numerous nodules bilaterally. 2. no acute thoracic abnormality seen otherwise. Brief Hospital Course: [MASKED] with metastatic pancreatic cancer and history of klebsiella bacteremia, who presented from home with fevers to 103, rhinorrhea, congestion, and substernal chest pain. #Fevers Presented with fever to [MASKED] with URI symptoms and suspected pericarditis (substernal chest pain that was worse with lying flat and better with sitting forward). Given her previous history of klebsiella bacteremia and immunosuppression in the setting of chemotherapy, she was started on broad spectrum antibiotics. Blood cultures were unrevealing and she had no further episodes of fever while hospitalized. Her antibiotics were peeled off and ultimately stopped on the morning of discharge. EKG was unchanged from prior. A TTE was considered, but her pericarditis symptoms self-resolved with supportive care and was deferred. # Metastatic Pancreatic Adenocarcinoma: # Secondary Neoplasm of Lung: Currently on Phase [MASKED] trial [MASKED] of RX-3117 (oral cytidine analogue) + abraxane. She will follow up tomorrow in clinic for continuation of therapy Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon (lipase-protease-amylase) [MASKED] unit oral TID W/MEALS 2. Levothyroxine Sodium 125 mcg PO DAILY 3. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea 4. Omeprazole 40 mg PO DAILY 5. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 6. Venlafaxine XR 150 mg PO DINNER 7. Vitamin D [MASKED] UNIT PO DAILY 8. coenzyme Q10 200 mg oral DAILY 9. colesevelam 625 mg oral BID 10. turmeric 1 capsule oral DAILY 11. Pyridoxine 50 mg PO DAILY Discharge Medications: 1. coenzyme Q10 200 mg oral DAILY 2. colesevelam 625 mg oral BID 3. Creon (lipase-protease-amylase) [MASKED] unit oral TID W/MEALS 4. Levothyroxine Sodium 125 mcg PO DAILY 5. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea 6. Omeprazole 40 mg PO DAILY 7. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 8. Pyridoxine 50 mg PO DAILY 9. Pyridoxine 50 mg PO DAILY 10. turmeric 1 capsule oral DAILY 11. Venlafaxine XR 150 mg PO DINNER 12. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Fever Pericarditis Metastatic pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [MASKED] MD [MASKED] Completed by: [MASKED]
|
[] |
[
"E785",
"E039",
"K219",
"F329",
"Z87891",
"G4700",
"Z515"
] |
[
"I319: Disease of pericardium, unspecified",
"J069: Acute upper respiratory infection, unspecified",
"C7800: Secondary malignant neoplasm of unspecified lung",
"Z8507: Personal history of malignant neoplasm of pancreas",
"E785: Hyperlipidemia, unspecified",
"E039: Hypothyroidism, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"F329: Major depressive disorder, single episode, unspecified",
"Z87891: Personal history of nicotine dependence",
"D6489: Other specified anemias",
"R197: Diarrhea, unspecified",
"G4700: Insomnia, unspecified",
"Z515: Encounter for palliative care"
] |
10,025,862
| 26,197,726
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tetracycline
Attending: ___.
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
None this hospitalization.
History of Present Illness:
___ is a ___ yo woman with metastatic (lung)
recurrence of Stage IA (ypT1N0M0) PDAC (pancreatic CA) s/p
neoadjuvant FOLFIRINOX, SBRT, Whipple (___), adjuvant
FOLFOX, on Phase ___ DF/___ ___ trial, who presents with
fever and found to have GNR bacteremia and e coli UTI.
She was feeling well until ___ (2 days PTA) when she felt
feverish and spiked a temperature to Tmax 101.3F. She presented
to ___ the next morning (___) and received infectious
workup including BCx, UCx, flu, strep, CXR, which were
preliminarily negative. She was discharged home, but called back
in late in the evening when ___ BCx turned positive for GNRs.
At ___-P, she received a CT A/P which did not show any
intraabdominal source of infection. UCx at that time was no
growth, but later it turned positive for >100,000 cfu e coli.
She was started on zosyn and transferred to ___ for further
management.
In the ___ ED: T ___ F | 95 | 126/82 | 97% RA. She received IV
zosyn prior to admission.
When seen at bedside, Mrs. ___ reports a ___ frontal and
posterior headache, which she attributes to fatigue and says has
been intermittent since the initiation of chemotherapy. She also
has some mild back and chest pain, which she gets routinely
after G-CSF (received neulasta yesterday). She also reports she
has some abdominal discomfort and had 1 loose bowel movement per
day over the last 2 days. She otherwise denies n/v, recurrent
fever, chills, sweats, dysuria, cloudy urine, cough, cold
symptoms (has chronic congestion for months, but no sore throat,
rhinorrhea). No sick contacts, no suspicious food intake.
All other review of systems are negative unless stated
otherwise.
Past Medical History:
Metastatic recurrence of pancreatic cancer: Presented with
transaminitis and malignant CBD stricture ___. CTA showed 1.4
cm pancreatic head mass. She received 3 cycles of neoadjuvant
FOLFIRINOX (___), followed by SBRT (___),
and then Whipple ___. Her final pathologic staging was T1N0
(1.3 cm PDAC in head of pancreas; ___ nodes, negative margins,
+ PNI and grade II large vessel angiolymphatic invasion). She
received 3 cycles of adjuvant FOLFOX (___). In ___, CT
torso showed multiple subcm pulmonary nodules, which were noted
to increase on follow up CTs ___ and ___. A lung biopsy
confirmed metastatic disease ___ and she was consented and
started on Phase ___ open label trial of RX-___ in combination
with abraxane at ___. C1D1 ___.
Hyperlipidemia
Hypothyroidism
GERD
depression
nephrolithiasis
Remote eye surgery to correct strabismus she had when she was
a child
hx right breast ALH ___ s/p excision at OSH
dry eyes
dry mouth since chemotherapy
Social History:
___
Family History:
She notes that her mother had an episode of "jaundice" at ___ or
___ years, was diagnosed with colon cancer at age ___, and died 6
months later. Grandmother died from "septicemia," abdominal
causes. She is ___ of five children, all in good health. Sister
with ___ disease.
Physical Exam:
========================
Admission Physical Exam:
========================
VITALS: T 98.6 F | 139/76 | 73 | 95% RA
General: Well appearing pleasant Caucasian woman, sitting up in
bed.
Neuro: Alert, oriented to person, place and time, provides clear
and cogent history.
HEENT: Oropharynx clear, MMM, no palpable cervical or
supraclavicular adenopathy, no sinus tenderness to palpation.
Cardiovascular: RRR, soft ___ systolic murmur.
Chest/Pulmonary: Clear to auscultation bilaterally.
Abdomen: Soft, nontender, nondistended, bowel sounds present.
Back: No CVA tenderness.
Extr/MSK: No peripheral edema.
Skin: No rashes on torso, arms, legs.
Access: R POC is c/d/I and nontender to palpation.
========================
Discharge Physical Exam:
========================
VS: Temp 98.1, BP 119/70, HR 70, RR 20, O2 sat 96% RA.
Exam otherwise unchanged.
Pertinent Results:
===============
Admission Labs:
===============
___ 02:00PM BLOOD WBC-7.0 RBC-2.59* Hgb-8.1* Hct-24.2*
MCV-93 MCH-31.3 MCHC-33.5 RDW-16.7* RDWSD-55.6* Plt ___
___ 02:00PM BLOOD Neuts-82.1* Lymphs-11.0* Monos-4.9*
Eos-1.6 Baso-0.1 Im ___ AbsNeut-5.72 AbsLymp-0.77*
AbsMono-0.34 AbsEos-0.11 AbsBaso-0.01
___ 12:56PM BLOOD Glucose-85 UreaN-13 Creat-0.7 Na-140
K-4.0 Cl-105 HCO3-23 AnGap-12
___ 05:31AM BLOOD ALT-21 AST-23 AlkPhos-57 TotBili-0.4
===============
Discharge Labs:
===============
___ 05:31AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9
___ 06:00AM BLOOD WBC-22.9* RBC-2.66* Hgb-8.3* Hct-25.5*
MCV-96 MCH-31.2 MCHC-32.5 RDW-17.9* RDWSD-59.7* Plt ___
___ 06:00AM BLOOD Glucose-85 UreaN-13 Creat-0.8 Na-142
K-4.0 Cl-103 HCO3-25 AnGap-14
=============
Microbiology:
=============
___ Group A Strep Throat at ___: Rapid Antigen -
Negative; Culture - Pending
___ Influenza A/B PCR at ___ - Negative
___ Blood Culture x 2 at ___ - Klebsiella
Pneumoniae
___ Urine Culture at ___ - E. Coli
___ Blood Culture x 2 at ___ - Pending
___ Influenza A/B PCR - Negative
___ Urine Culture - Pending
___ Blood Culture x 2 - Pending
========
Imaging:
========
CXR ___ at ___
Impression: Unchanged and no evidence of active disease.
CT Abdomen/Pelvis w/ Contrast ___ at ___
Impression: Bilateral pulmonary nodules are noted for which
follow-up chest CT is recommended to evaluate for stability. No
acute abdominal pelvic process is identified.
Brief Hospital Course:
Ms. ___ is a ___ woman with metastatic
pancreatic cancer s/p neoadjuvant FOLFIRINOX, SBRT, Whipple
(___), adjuvant FOLFOX, and currently on Phase ___ DF/___
___ trial who presents with fever and found to have GNR
bacteremia and E. coli UTI.
# Sepsis Secondary to Klebsiella Bacteremia: Culture data from
___. 1 of 4 blood cultures growing Klebsiella. Potentially
transient bacteremia from biliary
source. Received CT A/P at ___ which did not show
intraabdominal abscess. Her cultures cleared and she was feeling
well. She had some mild diarrhea that was negative for C. diff.
She was discharged to complete a 14-day course of ciprofloxacin
(Day ___, to be completed ___.
# E. Coli UTI: Urine growing E. coli but patient asymptomatic
and UA unimpressive. Likely asymptomatic bacteriuria but
regardless will be treated by cipro as above.
# Metastatic Pancreatic Adenocarcinoma:
# Secondary Neoplasm of Lung: Currently on Phase ___ trial
___ of RX-3117 (oral cytidine analogue) + abraxane; last
received C3D8 on ___. She received Neulasta at ___ on
___. Continued home creon, Ativan, and Zofran. Will follow-up
in clinic.
# Anemia: Secondary to malignancy and chemotherapy.
# Leukocytosis: Likely secondary to Neulasta which she receiving
at ___. No elevated WBC on initial presentation.
# HLP: Continued home colesevelam.
# Hypothyroidism: Continued home levothyroxine.
# GERD: Continued home omeprazole.
# Depression: Continued home venlafaxine.
# BILLING: 35 minutes were spent in preparation of discharge
summary and coordination with outpatient providers.
====================
Transitional Issues:
====================
- Patient discharged to complete a 14-day course of
ciprofloxacin (Day ___, to be completed ___.
- Please follow-up pending blood cultures from ___ on ___.
- Please follow-up multiple pending blood cultures from
___ on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. colesevelam 625 mg oral BID
2. Levothyroxine Sodium 125 mcg PO DAILY
3. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea
4. Omeprazole 40 mg PO DAILY
5. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
6. Venlafaxine XR 150 mg PO DINNER
7. Vitamin D ___ UNIT PO DAILY
8. coenzyme Q10 200 mg oral DAILY
9. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
10. Senna 8.6 mg PO BID:PRN Constipation - First Line
11. Multivitamins 1 TAB PO DAILY
12. Fish Oil (Omega 3) 1000 mg PO DAILY
13. turmeric 1 capsule oral DAILY
14. Creon (lipase-protease-amylase) ___ unit
oral TID W/MEALS
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
Plan for 14-day course (Day ___, to be completed ___.
RX *ciprofloxacin HCl 500 mg Take 1 tablet by mouth twice daily.
Disp #*22 Tablet Refills:*0
2. coenzyme Q10 200 mg oral DAILY
3. colesevelam 625 mg oral BID
4. Creon (lipase-protease-amylase) ___ unit
oral TID W/MEALS
5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Levothyroxine Sodium 125 mcg PO DAILY
8. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First
Line
12. Senna 8.6 mg PO BID:PRN Constipation - First Line
13. turmeric 1 capsule oral DAILY
14. Venlafaxine XR 150 mg PO DINNER
15. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Sepsis Secondary to Klebsiella Bacteremia
- E. Coli Urinary Tract Infection
- Metastatic Pancreatic Adenocarcinoma
- Secondary Neoplasm of Lung
- Anemia
- Leukocytosis
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 ___
___. You were admitted to the hospital with
a fever. You were found to have a bacteria in your blood called
Klebsiella. Fortunately this bacteria can be treated with
multiple antibiotics including oral antibiotics. Also only one
of the blood cultures grew bacteria and the rest have remained
negative. You were discharged on ciprofloxacin to complete a
2-week course. You can start taking the antibiotic on ___
morning.
You also had a CAT scan of your abdomen and a chest x-ray at
___ that did now show any cause of the infection.
Please continue your prior home medications.
Please follow-up with your outpatient team.
All the best,
Your ___ Team
Followup Instructions:
___
|
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Allergies: tetracycline Chief Complaint: Sepsis Major Surgical or Invasive Procedure: None this hospitalization. History of Present Illness: [MASKED] is a [MASKED] yo woman with metastatic (lung) recurrence of Stage IA (ypT1N0M0) PDAC (pancreatic CA) s/p neoadjuvant FOLFIRINOX, SBRT, Whipple ([MASKED]), adjuvant FOLFOX, on Phase [MASKED] DF/[MASKED] [MASKED] trial, who presents with fever and found to have GNR bacteremia and e coli UTI. She was feeling well until [MASKED] (2 days PTA) when she felt feverish and spiked a temperature to Tmax 101.3F. She presented to [MASKED] the next morning ([MASKED]) and received infectious workup including BCx, UCx, flu, strep, CXR, which were preliminarily negative. She was discharged home, but called back in late in the evening when [MASKED] BCx turned positive for GNRs. At [MASKED]-P, she received a CT A/P which did not show any intraabdominal source of infection. UCx at that time was no growth, but later it turned positive for >100,000 cfu e coli. She was started on zosyn and transferred to [MASKED] for further management. In the [MASKED] ED: T [MASKED] F | 95 | 126/82 | 97% RA. She received IV zosyn prior to admission. When seen at bedside, Mrs. [MASKED] reports a [MASKED] frontal and posterior headache, which she attributes to fatigue and says has been intermittent since the initiation of chemotherapy. She also has some mild back and chest pain, which she gets routinely after G-CSF (received neulasta yesterday). She also reports she has some abdominal discomfort and had 1 loose bowel movement per day over the last 2 days. She otherwise denies n/v, recurrent fever, chills, sweats, dysuria, cloudy urine, cough, cold symptoms (has chronic congestion for months, but no sore throat, rhinorrhea). No sick contacts, no suspicious food intake. All other review of systems are negative unless stated otherwise. Past Medical History: Metastatic recurrence of pancreatic cancer: Presented with transaminitis and malignant CBD stricture [MASKED]. CTA showed 1.4 cm pancreatic head mass. She received 3 cycles of neoadjuvant FOLFIRINOX ([MASKED]), followed by SBRT ([MASKED]), and then Whipple [MASKED]. Her final pathologic staging was T1N0 (1.3 cm PDAC in head of pancreas; [MASKED] nodes, negative margins, + PNI and grade II large vessel angiolymphatic invasion). She received 3 cycles of adjuvant FOLFOX ([MASKED]). In [MASKED], CT torso showed multiple subcm pulmonary nodules, which were noted to increase on follow up CTs [MASKED] and [MASKED]. A lung biopsy confirmed metastatic disease [MASKED] and she was consented and started on Phase [MASKED] open label trial of RX-[MASKED] in combination with abraxane at [MASKED]. C1D1 [MASKED]. Hyperlipidemia Hypothyroidism GERD depression nephrolithiasis Remote eye surgery to correct strabismus she had when she was a child hx right breast ALH [MASKED] s/p excision at OSH dry eyes dry mouth since chemotherapy Social History: [MASKED] Family History: She notes that her mother had an episode of "jaundice" at [MASKED] or [MASKED] years, was diagnosed with colon cancer at age [MASKED], and died 6 months later. Grandmother died from "septicemia," abdominal causes. She is [MASKED] of five children, all in good health. Sister with [MASKED] disease. Physical Exam: ======================== Admission Physical Exam: ======================== VITALS: T 98.6 F | 139/76 | 73 | 95% RA General: Well appearing pleasant Caucasian woman, sitting up in bed. Neuro: Alert, oriented to person, place and time, provides clear and cogent history. HEENT: Oropharynx clear, MMM, no palpable cervical or supraclavicular adenopathy, no sinus tenderness to palpation. Cardiovascular: RRR, soft [MASKED] systolic murmur. Chest/Pulmonary: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended, bowel sounds present. Back: No CVA tenderness. Extr/MSK: No peripheral edema. Skin: No rashes on torso, arms, legs. Access: R POC is c/d/I and nontender to palpation. ======================== Discharge Physical Exam: ======================== VS: Temp 98.1, BP 119/70, HR 70, RR 20, O2 sat 96% RA. Exam otherwise unchanged. Pertinent Results: =============== Admission Labs: =============== [MASKED] 02:00PM BLOOD WBC-7.0 RBC-2.59* Hgb-8.1* Hct-24.2* MCV-93 MCH-31.3 MCHC-33.5 RDW-16.7* RDWSD-55.6* Plt [MASKED] [MASKED] 02:00PM BLOOD Neuts-82.1* Lymphs-11.0* Monos-4.9* Eos-1.6 Baso-0.1 Im [MASKED] AbsNeut-5.72 AbsLymp-0.77* AbsMono-0.34 AbsEos-0.11 AbsBaso-0.01 [MASKED] 12:56PM BLOOD Glucose-85 UreaN-13 Creat-0.7 Na-140 K-4.0 Cl-105 HCO3-23 AnGap-12 [MASKED] 05:31AM BLOOD ALT-21 AST-23 AlkPhos-57 TotBili-0.4 =============== Discharge Labs: =============== [MASKED] 05:31AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9 [MASKED] 06:00AM BLOOD WBC-22.9* RBC-2.66* Hgb-8.3* Hct-25.5* MCV-96 MCH-31.2 MCHC-32.5 RDW-17.9* RDWSD-59.7* Plt [MASKED] [MASKED] 06:00AM BLOOD Glucose-85 UreaN-13 Creat-0.8 Na-142 K-4.0 Cl-103 HCO3-25 AnGap-14 ============= Microbiology: ============= [MASKED] Group A Strep Throat at [MASKED]: Rapid Antigen - Negative; Culture - Pending [MASKED] Influenza A/B PCR at [MASKED] - Negative [MASKED] Blood Culture x 2 at [MASKED] - Klebsiella Pneumoniae [MASKED] Urine Culture at [MASKED] - E. Coli [MASKED] Blood Culture x 2 at [MASKED] - Pending [MASKED] Influenza A/B PCR - Negative [MASKED] Urine Culture - Pending [MASKED] Blood Culture x 2 - Pending ======== Imaging: ======== CXR [MASKED] at [MASKED] Impression: Unchanged and no evidence of active disease. CT Abdomen/Pelvis w/ Contrast [MASKED] at [MASKED] Impression: Bilateral pulmonary nodules are noted for which follow-up chest CT is recommended to evaluate for stability. No acute abdominal pelvic process is identified. Brief Hospital Course: Ms. [MASKED] is a [MASKED] woman with metastatic pancreatic cancer s/p neoadjuvant FOLFIRINOX, SBRT, Whipple ([MASKED]), adjuvant FOLFOX, and currently on Phase [MASKED] DF/[MASKED] [MASKED] trial who presents with fever and found to have GNR bacteremia and E. coli UTI. # Sepsis Secondary to Klebsiella Bacteremia: Culture data from [MASKED]. 1 of 4 blood cultures growing Klebsiella. Potentially transient bacteremia from biliary source. Received CT A/P at [MASKED] which did not show intraabdominal abscess. Her cultures cleared and she was feeling well. She had some mild diarrhea that was negative for C. diff. She was discharged to complete a 14-day course of ciprofloxacin (Day [MASKED], to be completed [MASKED]. # E. Coli UTI: Urine growing E. coli but patient asymptomatic and UA unimpressive. Likely asymptomatic bacteriuria but regardless will be treated by cipro as above. # Metastatic Pancreatic Adenocarcinoma: # Secondary Neoplasm of Lung: Currently on Phase [MASKED] trial [MASKED] of RX-3117 (oral cytidine analogue) + abraxane; last received C3D8 on [MASKED]. She received Neulasta at [MASKED] on [MASKED]. Continued home creon, Ativan, and Zofran. Will follow-up in clinic. # Anemia: Secondary to malignancy and chemotherapy. # Leukocytosis: Likely secondary to Neulasta which she receiving at [MASKED]. No elevated WBC on initial presentation. # HLP: Continued home colesevelam. # Hypothyroidism: Continued home levothyroxine. # GERD: Continued home omeprazole. # Depression: Continued home venlafaxine. # BILLING: 35 minutes were spent in preparation of discharge summary and coordination with outpatient providers. ==================== Transitional Issues: ==================== - Patient discharged to complete a 14-day course of ciprofloxacin (Day [MASKED], to be completed [MASKED]. - Please follow-up pending blood cultures from [MASKED] on [MASKED]. - Please follow-up multiple pending blood cultures from [MASKED] on [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. colesevelam 625 mg oral BID 2. Levothyroxine Sodium 125 mcg PO DAILY 3. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea 4. Omeprazole 40 mg PO DAILY 5. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 6. Venlafaxine XR 150 mg PO DINNER 7. Vitamin D [MASKED] UNIT PO DAILY 8. coenzyme Q10 200 mg oral DAILY 9. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 10. Senna 8.6 mg PO BID:PRN Constipation - First Line 11. Multivitamins 1 TAB PO DAILY 12. Fish Oil (Omega 3) 1000 mg PO DAILY 13. turmeric 1 capsule oral DAILY 14. Creon (lipase-protease-amylase) [MASKED] unit oral TID W/MEALS Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H Plan for 14-day course (Day [MASKED], to be completed [MASKED]. RX *ciprofloxacin HCl 500 mg Take 1 tablet by mouth twice daily. Disp #*22 Tablet Refills:*0 2. coenzyme Q10 200 mg oral DAILY 3. colesevelam 625 mg oral BID 4. Creon (lipase-protease-amylase) [MASKED] unit oral TID W/MEALS 5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 6. Fish Oil (Omega 3) 1000 mg PO DAILY 7. Levothyroxine Sodium 125 mcg PO DAILY 8. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea 9. Multivitamins 1 TAB PO DAILY 10. Omeprazole 40 mg PO DAILY 11. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 12. Senna 8.6 mg PO BID:PRN Constipation - First Line 13. turmeric 1 capsule oral DAILY 14. Venlafaxine XR 150 mg PO DINNER 15. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Sepsis Secondary to Klebsiella Bacteremia - E. Coli Urinary Tract Infection - Metastatic Pancreatic Adenocarcinoma - Secondary Neoplasm of Lung - Anemia - Leukocytosis 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]. You were admitted to the hospital with a fever. You were found to have a bacteria in your blood called Klebsiella. Fortunately this bacteria can be treated with multiple antibiotics including oral antibiotics. Also only one of the blood cultures grew bacteria and the rest have remained negative. You were discharged on ciprofloxacin to complete a 2-week course. You can start taking the antibiotic on [MASKED] morning. You also had a CAT scan of your abdomen and a chest x-ray at [MASKED] that did now show any cause of the infection. Please continue your prior home medications. Please follow-up with your outpatient team. All the best, Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"N390",
"Y929",
"E785",
"E039",
"K219",
"F329",
"Z87891"
] |
[
"A4159: Other Gram-negative sepsis",
"C7801: Secondary malignant neoplasm of right lung",
"C7802: Secondary malignant neoplasm of left lung",
"N390: Urinary tract infection, site not specified",
"B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere",
"Z8507: Personal history of malignant neoplasm of pancreas",
"D630: Anemia in neoplastic disease",
"D6481: Anemia due to antineoplastic chemotherapy",
"T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter",
"Y929: Unspecified place or not applicable",
"R079: Chest pain, unspecified",
"M549: Dorsalgia, unspecified",
"D72829: Elevated white blood cell count, unspecified",
"T458X5A: Adverse effect of other primarily systemic and hematological agents, initial encounter",
"Y92238: Other place in hospital as the place of occurrence of the external cause",
"R51: Headache",
"R197: Diarrhea, unspecified",
"E785: Hyperlipidemia, unspecified",
"E039: Hypothyroidism, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"F329: Major depressive disorder, single episode, unspecified",
"Z87891: Personal history of nicotine dependence"
] |
10,025,862
| 26,276,305
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tetracycline
Attending: ___.
Chief Complaint:
Abnormal LFTs
Major Surgical or Invasive Procedure:
ERCP with stent
History of Present Illness:
Ms. ___ is a ___ woman with history of depression,
hypothyroidism, nephrolithiasis and several months of morning
"fogginess" transferred from ___ after her PCP
referred her to the ED for elevated LFTs and MRI reportedly
showed "CBD stricture vs malignancy or stone." RUQUS in our ED
confirmed CBD intrahepatic biliary ductal dilation and CBD up to
1.7cm. No evidence of cholangitis. Admitted for further workup
including MRCP.
Ms. ___ presented to her PCP about ___ month or two ago
complaining of feeling "foggy" in the morning, the sensation
that she could not concentrate. Initially, her TSH was rechecked
and her levothyroxine dose was adjusted upwards to her current
dose. This did not seem to help so her PCP did routing liver
function tests and discovered elevated AST/ALT and alkaline
phosphatase. Wokrup including HBV, HCV HAV were all negative and
per records, she had an RUQUS done on ___ which showed dilated
hepatic bile duct and possible fatty infiltrate. She had noted
ETOH use the weekend prior . She was referred to her local
hospital, ___, and reportedly an MRI was done
which showed, "CBD stricture vs malignancy or stone," and
referred her to ___ for potential ERCP. Upon arrival to
us, she was feeling well, no complaints currently.
She denies ab pain but does note that her urine has seemed more
dark lately and she did have one bowel movement about a week ago
that was tan colored instead of her usual brown.
ROS:
(+)also notes headaches occasionally, also notes feeling
slightly "bloated" in her abdomen
(-)comprehensive ROS was otherwise negative.
Past Medical History:
Hypothyroidism
Depression
Hyperlipidema (although not on statin currently)
Nephrolithiasis (long time ago, passed a kidney stone)
Past Surgical History:
-prior eye surgery many years ago to correct a strabismus when
she was a child
Social History:
___
Family History:
She notes that her mother had an episode of "jaundice" many
years ago and has since passed away from other causes. She
cannot recall the etiology (if any) to which this was attributed
to.
Physical Exam:
VS: 06.7 P82 138/91 R18 97% on RA
GEN: Alert, lying in bed, no acute distress, alert and talkative
with a ___ accent
HEENT: MMM, anicteric sclera, no conjunctival pallor
NECK: Supple without LAD
PULM: Clear, no wheeze, rales, or rhonchi
COR: RRR, normal S1/S2, no murmurs
ABD: Soft, NT ND, normal BS
EXTREM: Warm, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
___ 09:36PM LACTATE-1.1
___ 09:19PM GLUCOSE-83 UREA N-15 CREAT-0.7 SODIUM-138
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-20* ANION GAP-18
___ 09:19PM estGFR-Using this
___ 09:19PM ALT(SGPT)-674* AST(SGOT)-316* ALK PHOS-334*
TOT BILI-1.1 DIR BILI-0.6* INDIR BIL-0.5
___ 09:19PM LIPASE-136*
___ 09:19PM ALBUMIN-4.5
___ 09:19PM WBC-6.5 RBC-4.40 HGB-12.9 HCT-38.5 MCV-88
MCH-29.3 MCHC-33.5 RDW-14.3 RDWSD-45.9
___ 09:19PM NEUTS-52.2 ___ MONOS-6.5 EOS-2.2
BASOS-0.5 IM ___ AbsNeut-3.38 AbsLymp-2.48 AbsMono-0.42
AbsEos-0.14 AbsBaso-0.03
___ 09:19PM PLT COUNT-282
___ 09:19PM ___ PTT-32.4 ___
Impression: Normal major papilla.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
A single stricture that was 5 mm long was seen at the middle
third of the common bile duct just below the cystic duct
takeoff.
There was moder post-obstructive dilation with the upstream
bile duct measuring 15mm.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Spy cholangioscopy was performed. ___ stricture was
noted under direct visualization: it appeared as a tapered
lumenal narrowing without neovascularization/tumor vessels or
papillary mucosal projections noted.
___ the main bile duct appeared normal to the
bifurcation.
___ cystic duct also appeared normal.
___ forceps were taken of the stricture for
histopathology.
Cytology samples were obtained for histology using a brush in
the middle third of the common bile duct.
A 7cm by ___ ___ biliary stent was placed
successfully using a Oasis stent introducer kit.
Recommendations: Return to ward under ongoing care.
NPO overnight with aggressive IV hydration with LR at 200 cc/hr
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
CT pancreas protocol
Ciprofloxacin 500mg PO BID x 5 days.
Follow up path and cytology reports; further management will
depend on the results. Please call Dr ___ office at ___ in 7 days for the results.
Repeat ERCP in 6 weeks for stent pull and re-evaluation
Follow-up with Dr. ___ as previously scheduled.
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call ERCP
fellow on call ___
Brief Hospital Course:
A/P: ___ woman with history of depression, hypothyroidism,
nephrolithiasis and several months of morning "fogginess"
transferred from ___ after her PCP referred her to
the ED for elevated LFTs and ultrasound showing intrahepatic
ductal dilatation. RUQUS in our ED confirmed CBD intrahepatic
biliary ductal dilation and CBD up to 1.7cm. No evidence of
cholangitis. Admitted for further workup including MRCP.
#CBD stricture/bile obstruction: asymptomatic infiltrative
pattern with elevated AST/ALT into the 100s with moderately
elevated alk phos. Would expect a higher bilirubin with biliary
obstruction but seems like it may have been higher recently
given previous acholic stools and dark urine which were
reported. The biliary ductal dilatation is concerning for
obstruction, either due to stone or malignancy. There is no
evidence of cholangitis either on exam or by labs. MRCP at OSH
reviewed, consistent for CBD stricture near cystic duct, dilated
pancreatic duct, no clear mass/stone. She underwent ERCP
confirming CBD stricture, bx sent. stent placed. She did well
post procedure and her diet was advanced. SHe was given Cipro
500mg BID x5 days.
- Her plan will be for her to follow up with ERCP and have
repeat ERCP to address stent. She will also have CTA pancreas,
ordered by ERCP team. They will follow up with her and
regarding biopsy results.
# Leg swelling:
Minimal difference on L side. ___ negative for DVT
#Hypothyroidism/depression: continued home meds.
#Hypertension: SBP up to 160s since arrival. No prior dx of
essential HTN. Will continue to follow for now. PCP follow up
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine 75 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Venlafaxine XR 75 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
CBD stricture
Hypothyroidism
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for ERCP and were found to have a stricture in
your common bile duct. You will need to return for another
procedure to have your stent removed. You will also need to
schedule a CT scan of your liver and pancreas.
Please call the radiology dept to schedule this test ASAP: ___. You will be called with the results of your biopsy
and for follow up with the GI team.
Followup Instructions:
___
|
[
"K831",
"R7989",
"R1013",
"E039",
"F329",
"E785",
"Z87891",
"M7989",
"I10"
] |
Allergies: tetracycline Chief Complaint: Abnormal LFTs Major Surgical or Invasive Procedure: ERCP with stent History of Present Illness: Ms. [MASKED] is a [MASKED] woman with history of depression, hypothyroidism, nephrolithiasis and several months of morning "fogginess" transferred from [MASKED] after her PCP referred her to the ED for elevated LFTs and MRI reportedly showed "CBD stricture vs malignancy or stone." RUQUS in our ED confirmed CBD intrahepatic biliary ductal dilation and CBD up to 1.7cm. No evidence of cholangitis. Admitted for further workup including MRCP. Ms. [MASKED] presented to her PCP about [MASKED] month or two ago complaining of feeling "foggy" in the morning, the sensation that she could not concentrate. Initially, her TSH was rechecked and her levothyroxine dose was adjusted upwards to her current dose. This did not seem to help so her PCP did routing liver function tests and discovered elevated AST/ALT and alkaline phosphatase. Wokrup including HBV, HCV HAV were all negative and per records, she had an RUQUS done on [MASKED] which showed dilated hepatic bile duct and possible fatty infiltrate. She had noted ETOH use the weekend prior . She was referred to her local hospital, [MASKED], and reportedly an MRI was done which showed, "CBD stricture vs malignancy or stone," and referred her to [MASKED] for potential ERCP. Upon arrival to us, she was feeling well, no complaints currently. She denies ab pain but does note that her urine has seemed more dark lately and she did have one bowel movement about a week ago that was tan colored instead of her usual brown. ROS: (+)also notes headaches occasionally, also notes feeling slightly "bloated" in her abdomen (-)comprehensive ROS was otherwise negative. Past Medical History: Hypothyroidism Depression Hyperlipidema (although not on statin currently) Nephrolithiasis (long time ago, passed a kidney stone) Past Surgical History: -prior eye surgery many years ago to correct a strabismus when she was a child Social History: [MASKED] Family History: She notes that her mother had an episode of "jaundice" many years ago and has since passed away from other causes. She cannot recall the etiology (if any) to which this was attributed to. Physical Exam: VS: 06.7 P82 138/91 R18 97% on RA GEN: Alert, lying in bed, no acute distress, alert and talkative with a [MASKED] accent HEENT: MMM, anicteric sclera, no conjunctival pallor NECK: Supple without LAD PULM: Clear, no wheeze, rales, or rhonchi COR: RRR, normal S1/S2, no murmurs ABD: Soft, NT ND, normal BS EXTREM: Warm, no edema NEURO: CN II-XII grossly intact, motor function grossly normal Pertinent Results: [MASKED] 09:36PM LACTATE-1.1 [MASKED] 09:19PM GLUCOSE-83 UREA N-15 CREAT-0.7 SODIUM-138 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-20* ANION GAP-18 [MASKED] 09:19PM estGFR-Using this [MASKED] 09:19PM ALT(SGPT)-674* AST(SGOT)-316* ALK PHOS-334* TOT BILI-1.1 DIR BILI-0.6* INDIR BIL-0.5 [MASKED] 09:19PM LIPASE-136* [MASKED] 09:19PM ALBUMIN-4.5 [MASKED] 09:19PM WBC-6.5 RBC-4.40 HGB-12.9 HCT-38.5 MCV-88 MCH-29.3 MCHC-33.5 RDW-14.3 RDWSD-45.9 [MASKED] 09:19PM NEUTS-52.2 [MASKED] MONOS-6.5 EOS-2.2 BASOS-0.5 IM [MASKED] AbsNeut-3.38 AbsLymp-2.48 AbsMono-0.42 AbsEos-0.14 AbsBaso-0.03 [MASKED] 09:19PM PLT COUNT-282 [MASKED] 09:19PM [MASKED] PTT-32.4 [MASKED] Impression: Normal major papilla. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. A single stricture that was 5 mm long was seen at the middle third of the common bile duct just below the cystic duct takeoff. There was moder post-obstructive dilation with the upstream bile duct measuring 15mm. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Spy cholangioscopy was performed. [MASKED] stricture was noted under direct visualization: it appeared as a tapered lumenal narrowing without neovascularization/tumor vessels or papillary mucosal projections noted. [MASKED] the main bile duct appeared normal to the bifurcation. [MASKED] cystic duct also appeared normal. [MASKED] forceps were taken of the stricture for histopathology. Cytology samples were obtained for histology using a brush in the middle third of the common bile duct. A 7cm by [MASKED] [MASKED] biliary stent was placed successfully using a Oasis stent introducer kit. Recommendations: Return to ward under ongoing care. NPO overnight with aggressive IV hydration with LR at 200 cc/hr If no abdominal pain in the morning, advance diet to clear liquids and then advance as tolerated CT pancreas protocol Ciprofloxacin 500mg PO BID x 5 days. Follow up path and cytology reports; further management will depend on the results. Please call Dr [MASKED] office at [MASKED] in 7 days for the results. Repeat ERCP in 6 weeks for stent pull and re-evaluation Follow-up with Dr. [MASKED] as previously scheduled. Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call ERCP fellow on call [MASKED] Brief Hospital Course: A/P: [MASKED] woman with history of depression, hypothyroidism, nephrolithiasis and several months of morning "fogginess" transferred from [MASKED] after her PCP referred her to the ED for elevated LFTs and ultrasound showing intrahepatic ductal dilatation. RUQUS in our ED confirmed CBD intrahepatic biliary ductal dilation and CBD up to 1.7cm. No evidence of cholangitis. Admitted for further workup including MRCP. #CBD stricture/bile obstruction: asymptomatic infiltrative pattern with elevated AST/ALT into the 100s with moderately elevated alk phos. Would expect a higher bilirubin with biliary obstruction but seems like it may have been higher recently given previous acholic stools and dark urine which were reported. The biliary ductal dilatation is concerning for obstruction, either due to stone or malignancy. There is no evidence of cholangitis either on exam or by labs. MRCP at OSH reviewed, consistent for CBD stricture near cystic duct, dilated pancreatic duct, no clear mass/stone. She underwent ERCP confirming CBD stricture, bx sent. stent placed. She did well post procedure and her diet was advanced. SHe was given Cipro 500mg BID x5 days. - Her plan will be for her to follow up with ERCP and have repeat ERCP to address stent. She will also have CTA pancreas, ordered by ERCP team. They will follow up with her and regarding biopsy results. # Leg swelling: Minimal difference on L side. [MASKED] negative for DVT #Hypothyroidism/depression: continued home meds. #Hypertension: SBP up to 160s since arrival. No prior dx of essential HTN. Will continue to follow for now. PCP follow up [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Venlafaxine 75 mg PO DAILY 2. Levothyroxine Sodium 100 mcg PO DAILY Discharge Medications: 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Venlafaxine XR 75 mg PO DAILY 3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: CBD stricture Hypothyroidism Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for ERCP and were found to have a stricture in your common bile duct. You will need to return for another procedure to have your stent removed. You will also need to schedule a CT scan of your liver and pancreas. Please call the radiology dept to schedule this test ASAP: [MASKED]. You will be called with the results of your biopsy and for follow up with the GI team. Followup Instructions: [MASKED]
|
[] |
[
"E039",
"F329",
"E785",
"Z87891",
"I10"
] |
[
"K831: Obstruction of bile duct",
"R7989: Other specified abnormal findings of blood chemistry",
"R1013: Epigastric pain",
"E039: Hypothyroidism, unspecified",
"F329: Major depressive disorder, single episode, unspecified",
"E785: Hyperlipidemia, unspecified",
"Z87891: Personal history of nicotine dependence",
"M7989: Other specified soft tissue disorders",
"I10: Essential (primary) hypertension"
] |
10,025,862
| 28,183,306
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tetracycline
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
=============================================================
ONCOLOGY HOSPITALIST ADMISSION NOTE
=============================================================
DATE: ___
PRIMARY ONCOLOGIST: ___, MD
PRIMARY DIAGNOSIS: Metastatic recurrence of pancreatic cancer
TREATMENT REGIMEN: Rexahn trial (DF/___ trial ___- phase ___
open-label study of RX-___ (oral cytidine analogue) + abraxane
=== HPI ===
Chief Complaint: Fever
___ is a ___ yo woman with metastatic (lung)
recurrence of Stage IA (ypT1N0M0) PDAC (pancreatic CA) s/p
neoadjuvant FOLFIRINOX, SBRT, Whipple (___), adjuvant
FOLFOX,
on Phase ___ DF/___ ___ trial, discharged this afternoon for
klebsiella bacteremia and e coli uti, who returns to the
hospital
with fever to ___.
Mrs. ___ reports she felt a little clammy last night. She
did
not have any recorded fevers in the hospital. On the way home,
she began having shaking chills. She checked her temperature
when
she arrived home and found she had a temp to Tmax 103 (via
forehead probe) and ___ F (via oral thermometer). She called her
oncologist and was directly re-admitted.
She reports in retrospect she is having some more sinus
congestion and clear rhinorrhea. She didn't ambulate much in the
hospital, but on returning home she noticed she was dyspneic
after going up one flight of stairs which is unusual for her.
She
does not have cough, palpitations, fevers, ___ edema. She
reported
a few loose stools during the first day of admission and a C
diff
was negative. She has not had any more loose stool, but does
have
some vague and diffuse abdominal discomfort. She thinks her
urine
looks a little darker, but does not have dysuria or flank pain.
On arrival to the floor, T 100.3 F.
All other review of systems are negative unless stated otherwise
Past Medical History:
Metastatic recurrence of pancreatic cancer: Presented with
transaminitis and malignant CBD stricture ___. CTA showed 1.4
cm pancreatic head mass. She received 3 cycles of neoadjuvant
FOLFIRINOX (___), followed by SBRT (___),
and then Whipple ___. Her final pathologic staging was T1N0
(1.3 cm PDAC in head of pancreas; ___ nodes, negative margins,
+ PNI and grade II large vessel angiolymphatic invasion). She
received 3 cycles of adjuvant FOLFOX (___). In ___, CT
torso showed multiple subcm pulmonary nodules, which were noted
to increase on follow up CTs ___ and ___. A lung biopsy
confirmed metastatic disease ___ and she was consented and
started on Phase ___ open label trial of RX-3117 in combination
with abraxane at ___. C1D1 ___.
Hyperlipidemia
Hypothyroidism
GERD
depression
nephrolithiasis
Remote eye surgery to correct strabismus she had when she was
a child
hx right breast ALH ___ s/p excision at OSH
dry eyes
dry mouth since chemotherapy
Social History:
___
Family History:
She notes that her mother had an episode of "jaundice" at ___ or
___ years, was diagnosed with colon cancer at age ___, and died 6
months later. Grandmother died from "septicemia," abdominal
causes. She is ___ of five children, all in good health. Sister
with ___ disease.
Physical Exam:
PHYSICAL EXAM:
VITAL SIGNS: 98.0 PO 124 / 78 L Manual Sitting 61 18 98 RA
General: NAD
HEENT: MMM, no thrush, no OP lesions
CV: RR, NL S1S2 no S3S4, no MRG
PULM: CTAB, respirations unlabored
ABD: BS+ SNT/ND
LIMBS: No ___, WWP
SKIN: No rashes on extremities
NEURO: Speech fluent, strength grossly intact
PSYCH: thought process logical, linear, future oriented
ACCESS: R chest port site intact w/o erythema, accessed and
dressing C/D/I
Pertinent Results:
___ 05:40AM BLOOD WBC-18.1* RBC-2.60* Hgb-8.2* Hct-25.2*
MCV-97 MCH-31.5 MCHC-32.5 RDW-18.0* RDWSD-62.7* Plt ___
___ 05:40AM BLOOD Glucose-94 UreaN-12 Creat-0.7 Na-141
K-4.4 Cl-102 HCO3-26 AnGap-13
___ 05:40AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.1
Brief Hospital Course:
IMAGING:
CXR ___ at ___
Impression: Unchanged and no evidence of active disease.
CT Abdomen/Pelvis w/ Contrast ___ at ___
Impression: Bilateral pulmonary nodules are noted for which
follow-up chest CT is recommended to evaluate for stability. No
acute abdominal pelvic process is identified.
CXR ___
Impresion: Right-sided Port-A-Cath projects to the SVC.
Cardiomediastinal silhouette is stable. There is no pleural
effusion. No pneumothorax is seen.
ASSESSMENT AND PLAN: Ms. ___ is a ___ woman
with metastatic pancreatic cancer s/p neoadjuvant FOLFIRINOX,
SBRT, Whipple (___), adjuvant FOLFOX, and currently on Phase
___ DF/HCC ___ trial, with a recent admission for fever found
to have
Klebsiella bacteremia and E. coli UTI who represents with fever
to 103 found to have a URI.
# Sepsis secondary to Klebsiella Bacteremia:
# Fever:
# Dyspnea/Nasal Congestion/Rhinorrhea:
# Diarrhea:
Discharged on cipro for klebsiella bacteremia (1 of 4
positive blood cultures from ___. Potentially
transient
bacteremia from biliary source. CT A/P at BID-P
did not show intraabdominal abscess. Now with recurrent fever
with upper respiratory symptoms and diarrhea. dyspnea and/or
diarrhea may be related to viral process. C. diff negative.
Differential also includes tumor fever and fever secondary to
chemotherapy agents which patient has reported in the past.
Her symptoms spontaneously resolved with supportive therapy
without any adjustments to her antibiosis. Flu neg.
- Continue cipro to complete a 14-day course(Day ___, to be
completed ___
# Metastatic Pancreatic Adenocarcinoma:
# Secondary Neoplasm of Lung: Currently on Phase ___ trial
___
of RX-3117 (oral cytidine analogue) + abraxane; last received
C3D8 on ___. She received Neulasta at ___ on ___.
- Continue home creon, Ativan and zofran PRN
- f/u onc in clinic
# Anemia: Secondary to malignancy and chemotherapy
# Leukocytosis: Likely secondary to Neulasta
# HLP: cont home colesevelam
# Hypothyroidism: Continue home levothyroxine
# GERD: Continue home omeprazole
# Depression: Continue home venlafaxine
FEN: Regular
PPX: Heparin SC BID inpatient
ACCESS: POC
CODE: Full Code (presumed)
COMMUNICATION: Patient
EMERGENCY CONTACT HCP: ___ (husband) ___
DISPO: Home w/o services
BILLING: >30 min spent coordinating care for discharge
______________
___, D.O.
Heme/___ Hospitalist
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. colesevelam 625 mg oral BID
2. Levothyroxine Sodium 125 mcg PO DAILY
3. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
8. Venlafaxine XR 150 mg PO DINNER
9. Vitamin D ___ UNIT PO DAILY
10. coenzyme Q10 200 mg oral DAILY
11. Creon (lipase-protease-amylase) ___ unit
oral TID W/MEALS
12. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
13. Fish Oil (Omega 3) 1000 mg PO DAILY
14. turmeric 1 capsule oral DAILY
15. Ciprofloxacin HCl 500 mg PO Q12H
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
last day ___. coenzyme Q10 200 mg oral DAILY
3. colesevelam 625 mg oral BID
4. Creon (lipase-protease-amylase) ___ unit
oral TID W/MEALS
5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Levothyroxine Sodium 125 mcg PO DAILY
8. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First
Line
12. Senna 8.6 mg PO BID:PRN Constipation - First Line
13. turmeric 1 capsule oral DAILY
14. Venlafaxine XR 150 mg PO DINNER
15. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Viral Upper Respiratory Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure caring for you in the hospital. You were
admitted with a recurrent fever and found to have most likely a
viral respiratory infection. You had no evidence of pneumonia on
x-ray and your blood cultures and urine cultures from ___ have
not grown anything. You need to continue your 14-day course of
ciprofloxacin (Day ___, to be completed ___.
Followup Instructions:
___
|
[
"J069",
"C7800",
"D6481",
"D630",
"E785",
"E039",
"K219",
"F329",
"D72829",
"T458X5A",
"T451X5A",
"Y929",
"Z8507",
"Z87891"
] |
Allergies: tetracycline Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: ============================================================= ONCOLOGY HOSPITALIST ADMISSION NOTE ============================================================= DATE: [MASKED] PRIMARY ONCOLOGIST: [MASKED], MD PRIMARY DIAGNOSIS: Metastatic recurrence of pancreatic cancer TREATMENT REGIMEN: Rexahn trial (DF/[MASKED] trial [MASKED]- phase [MASKED] open-label study of RX-[MASKED] (oral cytidine analogue) + abraxane === HPI === Chief Complaint: Fever [MASKED] is a [MASKED] yo woman with metastatic (lung) recurrence of Stage IA (ypT1N0M0) PDAC (pancreatic CA) s/p neoadjuvant FOLFIRINOX, SBRT, Whipple ([MASKED]), adjuvant FOLFOX, on Phase [MASKED] DF/[MASKED] [MASKED] trial, discharged this afternoon for klebsiella bacteremia and e coli uti, who returns to the hospital with fever to [MASKED]. Mrs. [MASKED] reports she felt a little clammy last night. She did not have any recorded fevers in the hospital. On the way home, she began having shaking chills. She checked her temperature when she arrived home and found she had a temp to Tmax 103 (via forehead probe) and [MASKED] F (via oral thermometer). She called her oncologist and was directly re-admitted. She reports in retrospect she is having some more sinus congestion and clear rhinorrhea. She didn't ambulate much in the hospital, but on returning home she noticed she was dyspneic after going up one flight of stairs which is unusual for her. She does not have cough, palpitations, fevers, [MASKED] edema. She reported a few loose stools during the first day of admission and a C diff was negative. She has not had any more loose stool, but does have some vague and diffuse abdominal discomfort. She thinks her urine looks a little darker, but does not have dysuria or flank pain. On arrival to the floor, T 100.3 F. All other review of systems are negative unless stated otherwise Past Medical History: Metastatic recurrence of pancreatic cancer: Presented with transaminitis and malignant CBD stricture [MASKED]. CTA showed 1.4 cm pancreatic head mass. She received 3 cycles of neoadjuvant FOLFIRINOX ([MASKED]), followed by SBRT ([MASKED]), and then Whipple [MASKED]. Her final pathologic staging was T1N0 (1.3 cm PDAC in head of pancreas; [MASKED] nodes, negative margins, + PNI and grade II large vessel angiolymphatic invasion). She received 3 cycles of adjuvant FOLFOX ([MASKED]). In [MASKED], CT torso showed multiple subcm pulmonary nodules, which were noted to increase on follow up CTs [MASKED] and [MASKED]. A lung biopsy confirmed metastatic disease [MASKED] and she was consented and started on Phase [MASKED] open label trial of RX-3117 in combination with abraxane at [MASKED]. C1D1 [MASKED]. Hyperlipidemia Hypothyroidism GERD depression nephrolithiasis Remote eye surgery to correct strabismus she had when she was a child hx right breast ALH [MASKED] s/p excision at OSH dry eyes dry mouth since chemotherapy Social History: [MASKED] Family History: She notes that her mother had an episode of "jaundice" at [MASKED] or [MASKED] years, was diagnosed with colon cancer at age [MASKED], and died 6 months later. Grandmother died from "septicemia," abdominal causes. She is [MASKED] of five children, all in good health. Sister with [MASKED] disease. Physical Exam: PHYSICAL EXAM: VITAL SIGNS: 98.0 PO 124 / 78 L Manual Sitting 61 18 98 RA General: NAD HEENT: MMM, no thrush, no OP lesions CV: RR, NL S1S2 no S3S4, no MRG PULM: CTAB, respirations unlabored ABD: BS+ SNT/ND LIMBS: No [MASKED], WWP SKIN: No rashes on extremities NEURO: Speech fluent, strength grossly intact PSYCH: thought process logical, linear, future oriented ACCESS: R chest port site intact w/o erythema, accessed and dressing C/D/I Pertinent Results: [MASKED] 05:40AM BLOOD WBC-18.1* RBC-2.60* Hgb-8.2* Hct-25.2* MCV-97 MCH-31.5 MCHC-32.5 RDW-18.0* RDWSD-62.7* Plt [MASKED] [MASKED] 05:40AM BLOOD Glucose-94 UreaN-12 Creat-0.7 Na-141 K-4.4 Cl-102 HCO3-26 AnGap-13 [MASKED] 05:40AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.1 Brief Hospital Course: IMAGING: CXR [MASKED] at [MASKED] Impression: Unchanged and no evidence of active disease. CT Abdomen/Pelvis w/ Contrast [MASKED] at [MASKED] Impression: Bilateral pulmonary nodules are noted for which follow-up chest CT is recommended to evaluate for stability. No acute abdominal pelvic process is identified. CXR [MASKED] Impresion: Right-sided Port-A-Cath projects to the SVC. Cardiomediastinal silhouette is stable. There is no pleural effusion. No pneumothorax is seen. ASSESSMENT AND PLAN: Ms. [MASKED] is a [MASKED] woman with metastatic pancreatic cancer s/p neoadjuvant FOLFIRINOX, SBRT, Whipple ([MASKED]), adjuvant FOLFOX, and currently on Phase [MASKED] DF/HCC [MASKED] trial, with a recent admission for fever found to have Klebsiella bacteremia and E. coli UTI who represents with fever to 103 found to have a URI. # Sepsis secondary to Klebsiella Bacteremia: # Fever: # Dyspnea/Nasal Congestion/Rhinorrhea: # Diarrhea: Discharged on cipro for klebsiella bacteremia (1 of 4 positive blood cultures from [MASKED]. Potentially transient bacteremia from biliary source. CT A/P at BID-P did not show intraabdominal abscess. Now with recurrent fever with upper respiratory symptoms and diarrhea. dyspnea and/or diarrhea may be related to viral process. C. diff negative. Differential also includes tumor fever and fever secondary to chemotherapy agents which patient has reported in the past. Her symptoms spontaneously resolved with supportive therapy without any adjustments to her antibiosis. Flu neg. - Continue cipro to complete a 14-day course(Day [MASKED], to be completed [MASKED] # Metastatic Pancreatic Adenocarcinoma: # Secondary Neoplasm of Lung: Currently on Phase [MASKED] trial [MASKED] of RX-3117 (oral cytidine analogue) + abraxane; last received C3D8 on [MASKED]. She received Neulasta at [MASKED] on [MASKED]. - Continue home creon, Ativan and zofran PRN - f/u onc in clinic # Anemia: Secondary to malignancy and chemotherapy # Leukocytosis: Likely secondary to Neulasta # HLP: cont home colesevelam # Hypothyroidism: Continue home levothyroxine # GERD: Continue home omeprazole # Depression: Continue home venlafaxine FEN: Regular PPX: Heparin SC BID inpatient ACCESS: POC CODE: Full Code (presumed) COMMUNICATION: Patient EMERGENCY CONTACT HCP: [MASKED] (husband) [MASKED] DISPO: Home w/o services BILLING: >30 min spent coordinating care for discharge [MASKED] [MASKED], D.O. Heme/[MASKED] Hospitalist [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. colesevelam 625 mg oral BID 2. Levothyroxine Sodium 125 mcg PO DAILY 3. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 7. Senna 8.6 mg PO BID:PRN Constipation - First Line 8. Venlafaxine XR 150 mg PO DINNER 9. Vitamin D [MASKED] UNIT PO DAILY 10. coenzyme Q10 200 mg oral DAILY 11. Creon (lipase-protease-amylase) [MASKED] unit oral TID W/MEALS 12. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 13. Fish Oil (Omega 3) 1000 mg PO DAILY 14. turmeric 1 capsule oral DAILY 15. Ciprofloxacin HCl 500 mg PO Q12H Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H last day [MASKED]. coenzyme Q10 200 mg oral DAILY 3. colesevelam 625 mg oral BID 4. Creon (lipase-protease-amylase) [MASKED] unit oral TID W/MEALS 5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 6. Fish Oil (Omega 3) 1000 mg PO DAILY 7. Levothyroxine Sodium 125 mcg PO DAILY 8. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea 9. Multivitamins 1 TAB PO DAILY 10. Omeprazole 40 mg PO DAILY 11. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 12. Senna 8.6 mg PO BID:PRN Constipation - First Line 13. turmeric 1 capsule oral DAILY 14. Venlafaxine XR 150 mg PO DINNER 15. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Viral Upper Respiratory Infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], [MASKED] was a pleasure caring for you in the hospital. You were admitted with a recurrent fever and found to have most likely a viral respiratory infection. You had no evidence of pneumonia on x-ray and your blood cultures and urine cultures from [MASKED] have not grown anything. You need to continue your 14-day course of ciprofloxacin (Day [MASKED], to be completed [MASKED]. Followup Instructions: [MASKED]
|
[] |
[
"E785",
"E039",
"K219",
"F329",
"Y929",
"Z87891"
] |
[
"J069: Acute upper respiratory infection, unspecified",
"C7800: Secondary malignant neoplasm of unspecified lung",
"D6481: Anemia due to antineoplastic chemotherapy",
"D630: Anemia in neoplastic disease",
"E785: Hyperlipidemia, unspecified",
"E039: Hypothyroidism, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"F329: Major depressive disorder, single episode, unspecified",
"D72829: Elevated white blood cell count, unspecified",
"T458X5A: Adverse effect of other primarily systemic and hematological agents, initial encounter",
"T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter",
"Y929: Unspecified place or not applicable",
"Z8507: Personal history of malignant neoplasm of pancreas",
"Z87891: Personal history of nicotine dependence"
] |
10,025,862
| 28,335,315
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tetracycline
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ yo woman with metastatic (lung)
recurrence of Stage IA (ypT1N0M0) PDAC (pancreatic CA) s/p
neoadjuvant FOLFIRINOX, SBRT, Whipple (___), adjuvant
FOLFOX,
on Phase ___ DF/HCC ___ trial, who presents after C4D8 of
chemotherapy with fever to ___ F.
Mrs. ___ was admitted twice early this month with fevers.
During her first admission (___) she was found to
have klebsiella bacteremia (pansensitive) possibly from GI
source
and e coli UTI. She was discharged but returned later that day
with recurrent fever and URI symptoms. She completed a 14 day
course of ciprofloxacin ___.
Yesterday (morning of chemotherapy), she had lower abdominal
cramps and loose bowel movement. Her stool was nonbloody and
watery with small "pieces". She otherwise felt well and
presented
for C4D8. When she got home, she called her oncologist with a
fever, initially ___. Her fever persisted over several hours
with Tmax 102.2F. She also had 2 further loose bowel movements
that evening and presented to ___ for evaluation.
At ___, she had low grade temps to 99.5. Basic labs
included WBC 4.9 and normal BMP/LFTs. She had a RUQ US and CXR
which were unrevealing. She received CTX given prior culture
data
of pansensitive e coli and klebsiella and was transferred to
___.
In the ED here, her Tmax was 100.3F.
On arrival to floor, Mrs. ___ states she has a resolving
tension headache, which usually accompanies her fevers. She does
not currently feel feverish or chilled. She denies
nausea/vomiting, dysuria. She reports resolving nasal congestion
and dry cough since her URI symptoms first developed during her
last admission (___). Her husband developed URI symptoms 2
weeks ago after her presumed viral URI. She denies suspicious
food intake or other sick contacts.
Past Medical History:
Hyperlipidemia
Hypothyroidism
GERD
depression
nephrolithiasis
Remote eye surgery to correct strabismus she had when she was
a child
hx right breast ALH ___ s/p excision at OSH
dry eyes
dry mouth since chemotherapy
Metastatic recurrence of pancreatic cancer:
Presented with transaminitis and malignant CBD stricture ___.
CTA showed 1.4 cm pancreatic head mass. She received 3 cycles of
neoadjuvant FOLFIRINOX (___), followed by SBRT
(___), and then Whipple ___. Her final pathologic
staging was T1N0 (1.3 cm PDAC in head of pancreas; ___ nodes,
negative margins, + PNI and grade II large vessel angiolymphatic
invasion). She received 3 cycles of adjuvant FOLFOX (___).
In ___, CT torso showed multiple subcm pulmonary nodules,
which were noted to increase on follow up CTs ___ and
___.
A lung biopsy confirmed metastatic disease ___ and she was
consented and started on Phase ___ open label trial of RX-3117
in
combination with abraxane at ___. C1D1 ___.
Social History:
___
Family History:
She notes that her mother had an episode of "jaundice" at ___ or
___ years, was diagnosed with colon cancer at age ___, and died 6
months later. Grandmother died from "septicemia," abdominal
causes. She is ___ of five children, all in good health. Sister
with ___ disease.
Physical Exam:
General: Well appearing ___ woman sitting in chair
HEENT: Oropharynx clear, MMM, no lesions
CV: RRR no murmur
PULM: Clear bilaterally to auscultation
ABD: Soft nontender nondistended, normoactive bowel sounds
LIMBS: No peripheral edema, WWP
SKIN: No rashes
NEURO: Alert, oriented, provides clear history
ACCESS: R POC is accessed and c/d/i
Pertinent Results:
___ 06:00AM BLOOD WBC-2.5* RBC-2.62* Hgb-8.1* Hct-25.2*
MCV-96 MCH-30.9 MCHC-32.1 RDW-16.8* RDWSD-58.4* Plt ___
TSH 1.5
- Micro -
U/A: bland
UCx No growth
BCx x 2 pending (one from port, one peripheral): NGTD
Flu swab ___ ___ negative
BCx x 2 ___ ___: NGTD
Norovirus negative
C diff PCR positive, but toxin NEGATIVE
Stool culture: negative
=======
IMAGING
=======
RUQ ___ ___:
FINDINGS: The liver is diffusely echogenic consistent with
severe fatty infiltration.
The patient is status post cholecystectomy.
The common duct measures 3 mm.
The right kidney measures 9.8 cm.
The right renal cortex is preserved.
There is no hydronephrosis in the right kidney.
The pancreas is not seen due to bowel gas.
IMPRESSION: Fatty infiltration of the liver.
CXR ___ ___:
The heart is not enlarged.
The lungs are clear bilaterally with normal pulmonary vascular
distribution.
There is no pleural fluid.
A right-sided Port-A-Cath terminates in the distal superior vena
cava.
IMPRESSION: No acute pulmonary infiltrates.
Brief Hospital Course:
___ with metastatic (lung) recurrence of Stage IA (ypT1N0M0)
PDAC (pancreatic CA) s/p neoadjuvant FOLFIRINOX, SBRT, ___
(___), adjuvant FOLFOX, on Phase ___ DF/___ ___ trial,
who presents after C4D8 of chemotherapy with fever to ___ F and
3 episodes of loose stool.
# Fever, diarrhea
Recently admitted (___) for fever after chemotherapy
and was found to have klebsiella bacteremia (pansensitive)
possibly from GI source and e coli UTI. She completed treatment
with ciprofloxacin on ___.
She presented to ___ with fever to ___ shortly after
C4D8 of chemotherapy. Initial workup included RUQ US and CXR
which were unrevealing.
She was started on ceftriaxone to treat empirically for the
previous klebsiella bacteremia. Stool studies were sent and her
C diff PCR returned positive. Ceftriaxone was discontinued and
PO vancomycin was started. However, 12 hours later, her C diff
toxin returned negative. All antibiotics were held and she was
observed for 24 hours without recurrence of fever.
The rest of her infectious workup was negative as noted in the
previous section. This is Mrs. ___ ___ fever that has
occurred after chemotherapy. Her case was discussed with her
outpatient oncologist with the suspicion that her fevers are
caused by her chemotherapy treatment. She will see her
oncologist in follow up the week after discharge for further
recommendations.
[ ] outpatient plan for management of post-chemotherapy fevers
# Metastatic recurrence of Stage IA pancreatic adenocarcinoma
s/p ___
On Phase ___ trial ___ of RX-3117 (oral cytidine analogue) +
abraxane; s/p ___.
Suspicion that fever is in setting of chemotherapy as above. Her
trial drug ___-311___ was held for this cycle due to concern for
infection.
Please note for future admissions that Mrs. ___ home Creon
is 3x the strength of BI formulary Creon. She tolerated a
regular diet in the hospital with Creon 6 capsules with meals
and 4 capsules with snacks.
# Hot flashes
She reported hot flashes since initiation of chemotherapy. A TSH
was checked, which returned normal after patient's discharge.
[ ] inform patient of normal TSH
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Creon (lipase-protease-amylase) ___ unit
oral TID W/MEALS
2. Levothyroxine Sodium 125 mcg PO DAILY
3. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Venlafaxine XR 150 mg PO DINNER
7. Vitamin D ___ UNIT PO DAILY
8. coenzyme Q10 200 mg oral DAILY
9. colesevelam 625 mg oral BID
10. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
11. Fish Oil (Omega 3) 1000 mg PO DAILY
12. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
13. Senna 8.6 mg PO BID:PRN Constipation - First Line
14. turmeric 1 capsule oral DAILY
Discharge Medications:
1. coenzyme Q10 200 mg oral DAILY
2. colesevelam 625 mg oral BID
3. Creon (lipase-protease-amylase) ___ unit
oral TID W/MEALS
4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Levothyroxine Sodium 125 mcg PO DAILY
7. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First
Line
11. Senna 8.6 mg PO BID:PRN Constipation - First Line
12. turmeric 1 capsule oral DAILY
13. Venlafaxine XR 150 mg PO DINNER
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Fever with negative infectious workup
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
___ MD ___
Completed by: ___
|
[
"R509",
"C7800",
"R197",
"E785",
"E039",
"K219",
"F329",
"Z8507",
"Z87891",
"N951"
] |
Allergies: tetracycline Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] is a [MASKED] yo woman with metastatic (lung) recurrence of Stage IA (ypT1N0M0) PDAC (pancreatic CA) s/p neoadjuvant FOLFIRINOX, SBRT, Whipple ([MASKED]), adjuvant FOLFOX, on Phase [MASKED] DF/HCC [MASKED] trial, who presents after C4D8 of chemotherapy with fever to [MASKED] F. Mrs. [MASKED] was admitted twice early this month with fevers. During her first admission ([MASKED]) she was found to have klebsiella bacteremia (pansensitive) possibly from GI source and e coli UTI. She was discharged but returned later that day with recurrent fever and URI symptoms. She completed a 14 day course of ciprofloxacin [MASKED]. Yesterday (morning of chemotherapy), she had lower abdominal cramps and loose bowel movement. Her stool was nonbloody and watery with small "pieces". She otherwise felt well and presented for C4D8. When she got home, she called her oncologist with a fever, initially [MASKED]. Her fever persisted over several hours with Tmax 102.2F. She also had 2 further loose bowel movements that evening and presented to [MASKED] for evaluation. At [MASKED], she had low grade temps to 99.5. Basic labs included WBC 4.9 and normal BMP/LFTs. She had a RUQ US and CXR which were unrevealing. She received CTX given prior culture data of pansensitive e coli and klebsiella and was transferred to [MASKED]. In the ED here, her Tmax was 100.3F. On arrival to floor, Mrs. [MASKED] states she has a resolving tension headache, which usually accompanies her fevers. She does not currently feel feverish or chilled. She denies nausea/vomiting, dysuria. She reports resolving nasal congestion and dry cough since her URI symptoms first developed during her last admission ([MASKED]). Her husband developed URI symptoms 2 weeks ago after her presumed viral URI. She denies suspicious food intake or other sick contacts. Past Medical History: Hyperlipidemia Hypothyroidism GERD depression nephrolithiasis Remote eye surgery to correct strabismus she had when she was a child hx right breast ALH [MASKED] s/p excision at OSH dry eyes dry mouth since chemotherapy Metastatic recurrence of pancreatic cancer: Presented with transaminitis and malignant CBD stricture [MASKED]. CTA showed 1.4 cm pancreatic head mass. She received 3 cycles of neoadjuvant FOLFIRINOX ([MASKED]), followed by SBRT ([MASKED]), and then Whipple [MASKED]. Her final pathologic staging was T1N0 (1.3 cm PDAC in head of pancreas; [MASKED] nodes, negative margins, + PNI and grade II large vessel angiolymphatic invasion). She received 3 cycles of adjuvant FOLFOX ([MASKED]). In [MASKED], CT torso showed multiple subcm pulmonary nodules, which were noted to increase on follow up CTs [MASKED] and [MASKED]. A lung biopsy confirmed metastatic disease [MASKED] and she was consented and started on Phase [MASKED] open label trial of RX-3117 in combination with abraxane at [MASKED]. C1D1 [MASKED]. Social History: [MASKED] Family History: She notes that her mother had an episode of "jaundice" at [MASKED] or [MASKED] years, was diagnosed with colon cancer at age [MASKED], and died 6 months later. Grandmother died from "septicemia," abdominal causes. She is [MASKED] of five children, all in good health. Sister with [MASKED] disease. Physical Exam: General: Well appearing [MASKED] woman sitting in chair HEENT: Oropharynx clear, MMM, no lesions CV: RRR no murmur PULM: Clear bilaterally to auscultation ABD: Soft nontender nondistended, normoactive bowel sounds LIMBS: No peripheral edema, WWP SKIN: No rashes NEURO: Alert, oriented, provides clear history ACCESS: R POC is accessed and c/d/i Pertinent Results: [MASKED] 06:00AM BLOOD WBC-2.5* RBC-2.62* Hgb-8.1* Hct-25.2* MCV-96 MCH-30.9 MCHC-32.1 RDW-16.8* RDWSD-58.4* Plt [MASKED] TSH 1.5 - Micro - U/A: bland UCx No growth BCx x 2 pending (one from port, one peripheral): NGTD Flu swab [MASKED] [MASKED] negative BCx x 2 [MASKED] [MASKED]: NGTD Norovirus negative C diff PCR positive, but toxin NEGATIVE Stool culture: negative ======= IMAGING ======= RUQ [MASKED] [MASKED]: FINDINGS: The liver is diffusely echogenic consistent with severe fatty infiltration. The patient is status post cholecystectomy. The common duct measures 3 mm. The right kidney measures 9.8 cm. The right renal cortex is preserved. There is no hydronephrosis in the right kidney. The pancreas is not seen due to bowel gas. IMPRESSION: Fatty infiltration of the liver. CXR [MASKED] [MASKED]: The heart is not enlarged. The lungs are clear bilaterally with normal pulmonary vascular distribution. There is no pleural fluid. A right-sided Port-A-Cath terminates in the distal superior vena cava. IMPRESSION: No acute pulmonary infiltrates. Brief Hospital Course: [MASKED] with metastatic (lung) recurrence of Stage IA (ypT1N0M0) PDAC (pancreatic CA) s/p neoadjuvant FOLFIRINOX, SBRT, [MASKED] ([MASKED]), adjuvant FOLFOX, on Phase [MASKED] DF/[MASKED] [MASKED] trial, who presents after C4D8 of chemotherapy with fever to [MASKED] F and 3 episodes of loose stool. # Fever, diarrhea Recently admitted ([MASKED]) for fever after chemotherapy and was found to have klebsiella bacteremia (pansensitive) possibly from GI source and e coli UTI. She completed treatment with ciprofloxacin on [MASKED]. She presented to [MASKED] with fever to [MASKED] shortly after C4D8 of chemotherapy. Initial workup included RUQ US and CXR which were unrevealing. She was started on ceftriaxone to treat empirically for the previous klebsiella bacteremia. Stool studies were sent and her C diff PCR returned positive. Ceftriaxone was discontinued and PO vancomycin was started. However, 12 hours later, her C diff toxin returned negative. All antibiotics were held and she was observed for 24 hours without recurrence of fever. The rest of her infectious workup was negative as noted in the previous section. This is Mrs. [MASKED] [MASKED] fever that has occurred after chemotherapy. Her case was discussed with her outpatient oncologist with the suspicion that her fevers are caused by her chemotherapy treatment. She will see her oncologist in follow up the week after discharge for further recommendations. [ ] outpatient plan for management of post-chemotherapy fevers # Metastatic recurrence of Stage IA pancreatic adenocarcinoma s/p [MASKED] On Phase [MASKED] trial [MASKED] of RX-3117 (oral cytidine analogue) + abraxane; s/p [MASKED]. Suspicion that fever is in setting of chemotherapy as above. Her trial drug [MASKED]-311 was held for this cycle due to concern for infection. Please note for future admissions that Mrs. [MASKED] home Creon is 3x the strength of BI formulary Creon. She tolerated a regular diet in the hospital with Creon 6 capsules with meals and 4 capsules with snacks. # Hot flashes She reported hot flashes since initiation of chemotherapy. A TSH was checked, which returned normal after patient's discharge. [ ] inform patient of normal TSH Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon (lipase-protease-amylase) [MASKED] unit oral TID W/MEALS 2. Levothyroxine Sodium 125 mcg PO DAILY 3. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Venlafaxine XR 150 mg PO DINNER 7. Vitamin D [MASKED] UNIT PO DAILY 8. coenzyme Q10 200 mg oral DAILY 9. colesevelam 625 mg oral BID 10. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 11. Fish Oil (Omega 3) 1000 mg PO DAILY 12. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 13. Senna 8.6 mg PO BID:PRN Constipation - First Line 14. turmeric 1 capsule oral DAILY Discharge Medications: 1. coenzyme Q10 200 mg oral DAILY 2. colesevelam 625 mg oral BID 3. Creon (lipase-protease-amylase) [MASKED] unit oral TID W/MEALS 4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 5. Fish Oil (Omega 3) 1000 mg PO DAILY 6. Levothyroxine Sodium 125 mcg PO DAILY 7. LORazepam 0.5 mg PO Q8H:PRN anxiety, nausea 8. Multivitamins 1 TAB PO DAILY 9. Omeprazole 40 mg PO DAILY 10. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 11. Senna 8.6 mg PO BID:PRN Constipation - First Line 12. turmeric 1 capsule oral DAILY 13. Venlafaxine XR 150 mg PO DINNER 14. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Fever with negative infectious workup Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [MASKED] MD [MASKED] Completed by: [MASKED]
|
[] |
[
"E785",
"E039",
"K219",
"F329",
"Z87891"
] |
[
"R509: Fever, unspecified",
"C7800: Secondary malignant neoplasm of unspecified lung",
"R197: Diarrhea, unspecified",
"E785: Hyperlipidemia, unspecified",
"E039: Hypothyroidism, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"F329: Major depressive disorder, single episode, unspecified",
"Z8507: Personal history of malignant neoplasm of pancreas",
"Z87891: Personal history of nicotine dependence",
"N951: Menopausal and female climacteric states"
] |
10,025,981
| 20,580,099
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
aspirin / Penicillins / latex / eggs
Attending: ___.
Chief Complaint:
Right leg pain, r/o compartment syndrome
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ ___ yo F with past medical history significant for
RLE
DVT, polyarthralgias who is ___ s/p right TKA (Dr. ___, who
presents from OSH with acute onset of pain out of proportion and
parathesias of her RLE. Patient states that she had expected
pain
immediate postoperatively however, her pain acutely worsened
over
last 24h. Of note, she recently transitioned from lovenox back
to
her home xarelto.
Past Medical History:
Past Medical History: Noninflammatory polyarthralgia with
myalgias, morbid obesity, currently calculated a BMI 42, hiatal
hernia, right-sided sciatica, right knee arthritis, right leg
traumatic-induced DVT, migraine headaches, complex regional pain
syndrome, asthma, bilateral carpal tunnel syndrome, GERD and
vertigo.
Past Surgical History: In ___, right knee arthroscopic medial
meniscectomy at ___, ___, ___. She has also
had endometrial ablation, right shoulder arthroscopy, tubal
ligation, cholecystectomy and appendectomy.
MEDICATIONS: Advair Diskus, butalbital, APAP caffeine,
gabapentin 300 mg twice a day, glucosamine chondroitin,
loratadine 10 mg daily, multivitamins, omeprazole 20 mg daily,
tramadol 50 mg p.r.n. and zolpidem 10 mg daily.
Allergies: Aspirin, latex and penicillin.
Social History:
___
Family History:
___
Physical Exam:
ADMISSION PHYSICAL EXAM
Right upper extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Left upper extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Right lower extremity:
- Incision intact with some dried bloody drainage.
- Swelling about knee, lower leg and foot, with areas of
ecchymosis
- exquisite tenderness to pROM of great toe and ankle
- ___ fire
- SGILT but diminiahed in SPN/DPN/TN/saph/sural distribution
- foot WWP
Left lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
DISCHARGE PHYSICAL EXAM:
Comfortable, NAD
RLE with minimal pain
Right lower extremity:
- Incision intact with some dried bloody drainage.
- Swelling about knee, lower leg and foot, with areas of
ecchymosis
- No tenderness to pROM of great toe and ankle
- ___ fire
- SILT in all distributions
- foot WWP
Pertinent Results:
___ 06:30PM WBC-8.8 RBC-2.88* HGB-8.0* HCT-25.5* MCV-89
MCH-27.8 MCHC-31.4* RDW-13.2 RDWSD-41.5
___ 06:41PM LACTATE-1.2
___ 06:30PM ___ PTT-39.7* ___
Brief Hospital Course:
___ year old female who presents to ___ with acute onset of
pain and parathesia to RLE after recent R TKA. On exam, she does
have significant pain w/ passive range of motion, but sensation
is diminished but intact at currently. Concern for compartment
syndrome is high.
Recommendations:
- NPO
- please obtain RLE U/S
- serial compartment checks
- please hold narcotics for now.
- final recommendations pending serial examinations
Please see attending addendum for final recommendations.
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have acute onset of pain and parathesia to RLE after recent R
TKA. On exam, she did have significant pain w/ passive range of
motion, but sensation was diminished but intact at currently.
Concern for compartment syndrome was high, ___ compartment
pressures checked with range ___ (DBP 68). Patient was
admitted to the orthopedic surgery service for serial exams and
observation, pain control. Pain improved over a period of
observation. Patient tolerated ___ without issue, and was
ambulatory with minimal pain.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the right lower extremity, and will be discharged on
lovenox 40mg QPM for DVT prophylaxis. The patient will follow up
with Dr. ___ routine. A thorough discussion was had with
the patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
ACLIDINIUM BROMIDE [___] - ___ Pressair 400
mcg/actuation breath activated. 1 puff twice a day -
(Prescribed
by Other Provider)
ALBUTEROL SULFATE [VENTOLIN HFA] - Ventolin HFA 90 mcg/actuation
aerosol inhaler. 2 puffs twice a day as needed for shortness of
breath or wheezing - (Prescribed by Other Provider)
BUDESONIDE-FORMOTEROL [SYMBICORT] - Symbicort 160 mcg-4.5
mcg/actuation HFA aerosol inhaler. 2 puffs twice a day -
(Prescribed by Other Provider)
BUTALBITAL-ACETAMINOPHEN - butalbital-acetaminophen 50 mg-325 mg
tablet. 1 tablet(s) by mouth as needed for pain, headaches -
(Prescribed by Other Provider)
DRONABINOL - dronabinol 5 mg capsule. 1 capsule(s) by mouth
twice
a day - (Prescribed by Other Provider)
GABAPENTIN - gabapentin 800 mg tablet. 1 tablet(s) by mouth four
times a day - (Prescribed by Other Provider)
IBUPROFEN - ibuprofen 800 mg tablet. 1 tablet(s) by mouth every
eight (8) hours as needed for pain
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
capsule(s) by mouth once a day am - (Prescribed by Other
Provider)
OXYCODONE - oxycodone 5 mg tablet. ___ tablet(s) by mouth every
four (4) hours as needed for pain
RIVAROXABAN [XARELTO] - Xarelto 20 mg tablet. 1 tablet(s) by
mouth daily - (Prescribed by Other Provider: ___
TRAMADOL - tramadol 50 mg tablet. 1 tablet(s) by mouth three
times a day - (Prescribed by Other Provider)
Discharge Medications:
As above
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right Leg Pain
Discharge Condition:
Stable, Improved
Discharge Instructions:
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. You may wrap the knee with an ace bandage
for added compression. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
8. ANTICOAGULATION: Please continue your Lovenox 40mg everyday
for three (3) weeks to help prevent deep vein thrombosis (blood
clots). You should resume the rivaroxaban after completing the
3 week course of Lovenox.
9. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed at your follow-up
appointment in two weeks.
10. ___ (once at home): Home ___, dressing changes as
instructed, wound checks.
11. ACTIVITY: Keep the Right leg elevated as much as possible
Weight bearing as tolerated on the operative extremity.
Mobilize. ROM as tolerated. No strenuous exercise or heavy
lifting until follow up appointment.
Physical Therapy:
WBAT
Mobilize frequently
Treatments Frequency:
DSD daily prn drainage
Ice and elevate
*Staples will be removed at your first post-operative visit in
three(3)weeks
Followup Instructions:
___
|
[
"G8918",
"M79604",
"R209",
"M2550",
"M5431",
"M791",
"Z96651",
"G43909",
"Z86718",
"K219",
"Z7902",
"Z6841",
"E6601",
"J45909",
"Z87891",
"J439"
] |
Allergies: aspirin / Penicillins / latex / eggs Chief Complaint: Right leg pain, r/o compartment syndrome Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] [MASKED] yo F with past medical history significant for RLE DVT, polyarthralgias who is [MASKED] s/p right TKA (Dr. [MASKED], who presents from OSH with acute onset of pain out of proportion and parathesias of her RLE. Patient states that she had expected pain immediate postoperatively however, her pain acutely worsened over last 24h. Of note, she recently transitioned from lovenox back to her home xarelto. Past Medical History: Past Medical History: Noninflammatory polyarthralgia with myalgias, morbid obesity, currently calculated a BMI 42, hiatal hernia, right-sided sciatica, right knee arthritis, right leg traumatic-induced DVT, migraine headaches, complex regional pain syndrome, asthma, bilateral carpal tunnel syndrome, GERD and vertigo. Past Surgical History: In [MASKED], right knee arthroscopic medial meniscectomy at [MASKED], [MASKED], [MASKED]. She has also had endometrial ablation, right shoulder arthroscopy, tubal ligation, cholecystectomy and appendectomy. MEDICATIONS: Advair Diskus, butalbital, APAP caffeine, gabapentin 300 mg twice a day, glucosamine chondroitin, loratadine 10 mg daily, multivitamins, omeprazole 20 mg daily, tramadol 50 mg p.r.n. and zolpidem 10 mg daily. Allergies: Aspirin, latex and penicillin. Social History: [MASKED] Family History: [MASKED] Physical Exam: ADMISSION PHYSICAL EXAM Right upper extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender arm and forearm - Full, painless AROM/PROM of shoulder, elbow, wrist, and digits - EPL/FPL/DIO (index) fire - SILT axillary/radial/median/ulnar nerve distributions - 2+ radial pulse Left upper extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender arm and forearm - Full, painless AROM/PROM of shoulder, elbow, wrist, and digits - EPL/FPL/DIO (index) fire - SILT axillary/radial/median/ulnar nerve distributions - 2+ radial pulse Right lower extremity: - Incision intact with some dried bloody drainage. - Swelling about knee, lower leg and foot, with areas of ecchymosis - exquisite tenderness to pROM of great toe and ankle - [MASKED] fire - SGILT but diminiahed in SPN/DPN/TN/saph/sural distribution - foot WWP Left lower extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender thigh and leg - Full, painless AROM/PROM of hip, knee, and ankle - [MASKED] fire - SILT SPN/DPN/TN/saphenous/sural distributions - 1+ [MASKED] pulses, foot warm and well-perfused DISCHARGE PHYSICAL EXAM: Comfortable, NAD RLE with minimal pain Right lower extremity: - Incision intact with some dried bloody drainage. - Swelling about knee, lower leg and foot, with areas of ecchymosis - No tenderness to pROM of great toe and ankle - [MASKED] fire - SILT in all distributions - foot WWP Pertinent Results: [MASKED] 06:30PM WBC-8.8 RBC-2.88* HGB-8.0* HCT-25.5* MCV-89 MCH-27.8 MCHC-31.4* RDW-13.2 RDWSD-41.5 [MASKED] 06:41PM LACTATE-1.2 [MASKED] 06:30PM [MASKED] PTT-39.7* [MASKED] Brief Hospital Course: [MASKED] year old female who presents to [MASKED] with acute onset of pain and parathesia to RLE after recent R TKA. On exam, she does have significant pain w/ passive range of motion, but sensation is diminished but intact at currently. Concern for compartment syndrome is high. Recommendations: - NPO - please obtain RLE U/S - serial compartment checks - please hold narcotics for now. - final recommendations pending serial examinations Please see attending addendum for final recommendations. The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have acute onset of pain and parathesia to RLE after recent R TKA. On exam, she did have significant pain w/ passive range of motion, but sensation was diminished but intact at currently. Concern for compartment syndrome was high, [MASKED] compartment pressures checked with range [MASKED] (DBP 68). Patient was admitted to the orthopedic surgery service for serial exams and observation, pain control. Pain improved over a period of observation. Patient tolerated [MASKED] without issue, and was ambulatory with minimal pain. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is WBAT in the right lower extremity, and will be discharged on lovenox 40mg QPM for DVT prophylaxis. The patient will follow up with Dr. [MASKED] routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: ACLIDINIUM BROMIDE [[MASKED]] - [MASKED] Pressair 400 mcg/actuation breath activated. 1 puff twice a day - (Prescribed by Other Provider) ALBUTEROL SULFATE [VENTOLIN HFA] - Ventolin HFA 90 mcg/actuation aerosol inhaler. 2 puffs twice a day as needed for shortness of breath or wheezing - (Prescribed by Other Provider) BUDESONIDE-FORMOTEROL [SYMBICORT] - Symbicort 160 mcg-4.5 mcg/actuation HFA aerosol inhaler. 2 puffs twice a day - (Prescribed by Other Provider) BUTALBITAL-ACETAMINOPHEN - butalbital-acetaminophen 50 mg-325 mg tablet. 1 tablet(s) by mouth as needed for pain, headaches - (Prescribed by Other Provider) DRONABINOL - dronabinol 5 mg capsule. 1 capsule(s) by mouth twice a day - (Prescribed by Other Provider) GABAPENTIN - gabapentin 800 mg tablet. 1 tablet(s) by mouth four times a day - (Prescribed by Other Provider) IBUPROFEN - ibuprofen 800 mg tablet. 1 tablet(s) by mouth every eight (8) hours as needed for pain OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth once a day am - (Prescribed by Other Provider) OXYCODONE - oxycodone 5 mg tablet. [MASKED] tablet(s) by mouth every four (4) hours as needed for pain RIVAROXABAN [XARELTO] - Xarelto 20 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider: [MASKED] TRAMADOL - tramadol 50 mg tablet. 1 tablet(s) by mouth three times a day - (Prescribed by Other Provider) Discharge Medications: As above Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Right Leg Pain Discharge Condition: Stable, Improved Discharge Instructions: Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Lovenox 40mg everyday for three (3) weeks to help prevent deep vein thrombosis (blood clots). You should resume the rivaroxaban after completing the 3 week course of Lovenox. 9. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed at your follow-up appointment in two weeks. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, wound checks. 11. ACTIVITY: Keep the Right leg elevated as much as possible Weight bearing as tolerated on the operative extremity. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT Mobilize frequently Treatments Frequency: DSD daily prn drainage Ice and elevate *Staples will be removed at your first post-operative visit in three(3)weeks Followup Instructions: [MASKED]
|
[] |
[
"Z86718",
"K219",
"Z7902",
"J45909",
"Z87891"
] |
[
"G8918: Other acute postprocedural pain",
"M79604: Pain in right leg",
"R209: Unspecified disturbances of skin sensation",
"M2550: Pain in unspecified joint",
"M5431: Sciatica, right side",
"M791: Myalgia",
"Z96651: Presence of right artificial knee joint",
"G43909: Migraine, unspecified, not intractable, without status migrainosus",
"Z86718: Personal history of other venous thrombosis and embolism",
"K219: Gastro-esophageal reflux disease without esophagitis",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"Z6841: Body mass index [BMI]40.0-44.9, adult",
"E6601: Morbid (severe) obesity due to excess calories",
"J45909: Unspecified asthma, uncomplicated",
"Z87891: Personal history of nicotine dependence",
"J439: Emphysema, unspecified"
] |
10,025,981
| 22,601,144
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
aspirin / Penicillins / latex
Attending: ___.
Chief Complaint:
Right knee pain
Major Surgical or Invasive Procedure:
Right total knee arthroplasty
History of Present Illness:
Patient was scheduled for Right total knee arthroplasty on
___, however anesthesia was unable to intubate patient.
Her surgery was postponed until she underwent another round of
___ and Weight loss. Below is the initial H&P.
This patient has apparently seen many rheumatologists, as many
as
six of them, over the past several years. She relates joints
pain beginning back in her late ___ with recurrent effusions
especially after longer walks. She has a history of diffuse
myalgias and polyarthralgias since the ___ with right lower
extremity symptoms, specially the right knee being the worse.
She has had some right-sided sciatica and trauma to the knee and
ankle. Dr.
___ list ___ different rheumatologists that this patient has
seen. At one point, she apparently had the diagnosis of
rheumatoid arthritis, subsequent serology studies have all been
normal, and presently it is believed that she does not have
rheumatoid arthritis, she rather has noninflammatory arthritis.
Regardless of the diagnosis, she is very involved with pain.
Her
response to medications typically used for rheumatoid arthritis
were not expected. She has been on etodolac, methotrexate,
prednisone, leflunomide, Relafen and Neurontin. Her most recent
inflammatory markers in ___ showed an ESR of 20 and CRP of 6.7
being Rh factor negative and PCP ___.
___ saw orthopedic doctors out in ___ over the past
several years and then transferred to Dr. ___ at ___ about a year ago. She complains of activity related
right knee pain and stiffness and difficulty achieving full
extension. She has a right ankle instability with lateral pain
for which she has been seeing Dr. ___. She relates
having had numerous accidents over the years. She has been
through physical therapy under various doctors and ___ had a
variety of knee injections and aspirations. In ___, the right
knee was scoped for meniscus tear by Dr. ___ At ___. When seen last year, her range of motion was -___
degrees of the right knee and the knee was found to be stable
with tender medial joint line, and already at that time, the
x-rays showed significant medial and patellofemoral arthritis.
She was advised a year ago that she would be a TKR candidate in
the future and no other surgery would be able to help her.
However, in the interim, she was advised to continue HEP and
weight loss efforts. She states her knee locks up at night.
She
is unable to achieve full extension.
She has an EMG nerve conduction studies done at ___
in ___, where she was evaluated by Neurology. EMG
studies
showed mild diffuse anomalies and bilateral lower extremities
consistent with a mild asymmetric multifocal axonal sensory
motor
neuropathy with the right peritoneal nerve being the most
affected neuropathic segments.
Everything worsened on ___. She says she was a
pedestrian versus a van, driven by drunk driver going about 40
miles an hour. She was knocked down while walking. Her right
leg was forcibly hit. She was seen in the ___ Emergency Room
and sent out later that day without admission. She had
extremity
films, which showed some arthritis, but no fracture and she also
had abdominal CT scan negative. She did, however, ten days
later
develop a right leg DVT, documented on ultrasound and was
treated
with Lovenox and then transferred to Coumadin and ultimately to
Xarelto and which she is still taking, which seems a long period
of time for a provoked DVT. She has been wearing thigh-high
compression stockings. She had no PE issues whatsoever. Of
note, she has seen neurology also in the past for migraines and
was diagnosed as having a complex regional pain syndrome and was
initiated on Neurontin. Some other records indicate that she
was
seen in ___ Orthopedic System as far back as ___ by Dr.
___ medial joint space of the right knee was noted
to
be narrow. She has also been seen for back pain and
radiculopathy on the right side. At the time when she had the
DVT swelling after the injury, she was worked up and found not
to
have a compartment syndrome. She is also seeing a physiatrist
to
assess her gait anomalies and the tendency to fall or nearly
fall
with persistent right knee and right lateral ankle pain. The
notes indicate multiple times that she consider disability.
Presently, she is not working. She had been a personal care
attendant. There is some concern certainly about her ability to
withstand discomfort, pain and physical therapy and that that
may
reduce her risks for optimal outcome following TKR.
In the past physical therapy sessions, she did not apparently
show much improvements. MRIs was documented a partial anterior
tib-fibular ligament tear.
She has been using oxycodone for over a year, has pain
management
issues. She is seeing a nutritionist now for weight loss.
Pain:
She rates her pain as between 8 and ___ depending on her
activity, at rest ___, with weightbearing ___. We filled out
her an ___ Knee Survey and entered in to her database. She
says she is constantly aware of the right knee pain, probably
has
had to downgrade her activity and severely lacks confidence in
the knee. She is unable to squat, run, jump, twist, pivot, or
kneel. She describes extreme pain with heavy domestic activity,
lying in bed, bending the knee deeply, going up or down stairs.
She describes severe pain with transitions from seated
positions,
standing, walking, getting in and out of car, shopping, shoes
and
socks, sitting, getting off wheelchair and the likes. She
describes extreme stiffness throughout the morning and later in
the day. She is never able to achieve full extension nor can
she
never achieve full flexion. She does note the knee tends to
catch up throughout the range of motion and she has often
swelling in the knee and crepitus and clicking sensations.
Imaging studies go back many years. Back in ___ at ___ of the right knee showed moderate arthritis since
___ of that year. Two months later, she had repeat films
at same hospital showing moderately severe patellofemoral
arthritis. Then, in ___, ultrasound was negative for
DVT, this was a few months after her accident. ___, at
___, moderately severe right knee arthritis. Today,
x-rays were obtained including AP, frog lateral, and sunrise
views of the right knee shows a significant 13 degree varus
deformity, complete bone-on-bone medial compartment with
osteophytes. There is a traction spur at the lateral tibial
corner and opposing lateral femoral corner. Contralateral left
knee sets up again 3 degrees of valgus and has about 2 mm of
cartilage remaining medially. Sunrise view right knee shows
medial and lateral facet arthritis.
Physical Examination: A pleasant ___ woman comes in
with
her husband. She uses a cane. Antalgic gait. She is ___ feet 4
inches, 245 pounds, calculated BMI 42 puts her in morbid obesity
category. She seeks nutrition counseling actively. Blood
pressure 128/60 and pulse 66. Normal sinus rhythm. 100% O2
saturation. Right knee sets up in varus as mentioned above 13
degrees. She is painful over the medial joint line. Has intact
medial or lateral collateral ligament. It is impossible to test
her for ACL or PCL. She has pain that seems out of proportion
and even light touch is painful for her. She does of course
have
a history of regional pain syndrome, but there are no trophic
changes on the skin. She will only allow -___nd will only flex ___ degrees from full arc of 50
degrees. She has crepitus behind her kneecap, but again it is
very difficult to exam. The left knee lacks ___nd 110 degrees of flexion. She has bilateral pedal
edema, more so on the right than the left. She is quite tender
over the right lateral ankle, both posterior and anterior to
lateral malleolus consistent with her partial ATFL tear.
Review of Systems: She feels she is not healthy, wears
corrective lenses, has fatigue, frequent headaches, ankle
swelling, palpitations, wheezing, easy bruisability and leg
weakness.
Family History: Positive for osteoarthritis, osteoporosis,
COPD,
rheumatoid arthritis and cancer.
Impression and Plan: The patient has many many issues,
neurologic, orthopedic, rheumatologic, etc. as mentioned above.
Still, however, radiographs show severe osteoarthritis of the
right knee. She is relatively young at ___ years old, but it is
understandable the amount of pain she is having in this knee. I
feel she warrants a right total knee replacement, but she will
be
difficult to rehabilitate, sure the pain will get in the way.
Still, there is clearly indicated surgery for her. What is
unclear is why she still on Xarelto almost a year out from a
trauma-induced DVT of the right leg. We will have to check and
find out why that is and if she can get off it. There is
nothing
to suggest she had a pulmonary embolus nor is there anything to
suggest she has a family history or personal history of
hypercoagulable state. She was consented today for right total
knee replacement. Surgical forms have been forwarded and we
will
get her on the schedule sometimes this ___.
Past Medical History:
Past Medical History: Noninflammatory polyarthralgia with
myalgias, morbid obesity, currently calculated a BMI 42, hiatal
hernia, right-sided sciatica, right knee arthritis, right leg
traumatic-induced DVT, migraine headaches, complex regional pain
syndrome, asthma, bilateral carpal tunnel syndrome, GERD and
vertigo.
Past Surgical History: In ___, right knee arthroscopic medial
meniscectomy at ___, ___, ___. She has also
had endometrial ablation, right shoulder arthroscopy, tubal
ligation, cholecystectomy and appendectomy.
MEDICATIONS: Advair Diskus, butalbital, APAP caffeine,
gabapentin 300 mg twice a day, glucosamine chondroitin,
loratadine 10 mg daily, multivitamins, omeprazole 20 mg daily,
tramadol 50 mg p.r.n. and zolpidem 10 mg daily.
Allergies: Aspirin, latex and penicillin.
Social History:
___
Family History:
NC
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
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:
She was started on CPM. Home CPAP was continued.
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 surgical
dressing was changed and the Silverlon dressing was removed on
POD#2. The surgical incision was found to be clean and intact
without erythema or abnormal drainage. The patient was seen
daily by physical therapy. Labs were checked throughout the
hospital course and repleted accordingly. At the time of
discharge the patient was tolerating a regular diet and feeling
well. The patient was afebrile with stable vital signs. The
patient's hematocrit was acceptable and pain was adequately
controlled on an oral regimen. The operative extremity was
neurovascularly intact and the wound was benign.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity.
Mrs. ___ is discharged to home with services/rehab in stable
condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tudorza Pressair (aclidinium bromide) 400 mcg/actuation
inhalation BID
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
3. Budesonide Nasal Inhaler 180 mcg/actuation nasal BID
4. Dronabinol 5 mg PO BID
5. Gabapentin 800 mg PO QID
6. Omeprazole 20 mg PO DAILY
7. Rivaroxaban 20 mg PO DAILY
8. TraMADol 50 mg PO TID:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe SQ once a day Disp #*21
Syringe Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
5. Senna 8.6 mg PO BID
RX *sennosides [Senexon] 8.6 mg 1 tab by mouth BID PRN Disp #*30
Tablet Refills:*0
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
7. Budesonide Nasal Inhaler 180 mcg/actuation nasal BID
8. Dronabinol 5 mg PO BID
9. Gabapentin 800 mg PO QID
10. Omeprazole 20 mg PO DAILY
11. Tudorza Pressair (aclidinium bromide) 400 mcg/actuation
inhalation BID
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 Lovenox 40mg everyday
for three (3) weeks to help prevent deep vein thrombosis (blood
clots). You should resume the rivaroxaban after completing the
3 week course of Lovenox.
9. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed at your follow-up
appointment in two weeks.
10. ___ (once at home): Home ___, dressing changes as
instructed, wound checks.
11. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Mobilize. ROM as tolerated. No strenuous exercise or
heavy lifting until follow up appointment.
Physical Therapy:
WBAT
Mobilize frequently
Treatments Frequency:
DSD daily prn drainage
Ice and elevate
*Staples will be removed at your first post-operative visit in
three(3)weeks
Followup Instructions:
___
|
[
"M1711",
"Z6841",
"E6601",
"M2550",
"M791",
"K449",
"M5431",
"G43909",
"Z86718",
"J45909",
"J449",
"K219",
"R42",
"Z720",
"Z7902",
"G4733"
] |
Allergies: aspirin / Penicillins / latex Chief Complaint: Right knee pain Major Surgical or Invasive Procedure: Right total knee arthroplasty History of Present Illness: Patient was scheduled for Right total knee arthroplasty on [MASKED], however anesthesia was unable to intubate patient. Her surgery was postponed until she underwent another round of [MASKED] and Weight loss. Below is the initial H&P. This patient has apparently seen many rheumatologists, as many as six of them, over the past several years. She relates joints pain beginning back in her late [MASKED] with recurrent effusions especially after longer walks. She has a history of diffuse myalgias and polyarthralgias since the [MASKED] with right lower extremity symptoms, specially the right knee being the worse. She has had some right-sided sciatica and trauma to the knee and ankle. Dr. [MASKED] list [MASKED] different rheumatologists that this patient has seen. At one point, she apparently had the diagnosis of rheumatoid arthritis, subsequent serology studies have all been normal, and presently it is believed that she does not have rheumatoid arthritis, she rather has noninflammatory arthritis. Regardless of the diagnosis, she is very involved with pain. Her response to medications typically used for rheumatoid arthritis were not expected. She has been on etodolac, methotrexate, prednisone, leflunomide, Relafen and Neurontin. Her most recent inflammatory markers in [MASKED] showed an ESR of 20 and CRP of 6.7 being Rh factor negative and PCP [MASKED]. [MASKED] saw orthopedic doctors out in [MASKED] over the past several years and then transferred to Dr. [MASKED] at [MASKED] about a year ago. She complains of activity related right knee pain and stiffness and difficulty achieving full extension. She has a right ankle instability with lateral pain for which she has been seeing Dr. [MASKED]. She relates having had numerous accidents over the years. She has been through physical therapy under various doctors and [MASKED] had a variety of knee injections and aspirations. In [MASKED], the right knee was scoped for meniscus tear by Dr. [MASKED] At [MASKED]. When seen last year, her range of motion was -[MASKED] degrees of the right knee and the knee was found to be stable with tender medial joint line, and already at that time, the x-rays showed significant medial and patellofemoral arthritis. She was advised a year ago that she would be a TKR candidate in the future and no other surgery would be able to help her. However, in the interim, she was advised to continue HEP and weight loss efforts. She states her knee locks up at night. She is unable to achieve full extension. She has an EMG nerve conduction studies done at [MASKED] in [MASKED], where she was evaluated by Neurology. EMG studies showed mild diffuse anomalies and bilateral lower extremities consistent with a mild asymmetric multifocal axonal sensory motor neuropathy with the right peritoneal nerve being the most affected neuropathic segments. Everything worsened on [MASKED]. She says she was a pedestrian versus a van, driven by drunk driver going about 40 miles an hour. She was knocked down while walking. Her right leg was forcibly hit. She was seen in the [MASKED] Emergency Room and sent out later that day without admission. She had extremity films, which showed some arthritis, but no fracture and she also had abdominal CT scan negative. She did, however, ten days later develop a right leg DVT, documented on ultrasound and was treated with Lovenox and then transferred to Coumadin and ultimately to Xarelto and which she is still taking, which seems a long period of time for a provoked DVT. She has been wearing thigh-high compression stockings. She had no PE issues whatsoever. Of note, she has seen neurology also in the past for migraines and was diagnosed as having a complex regional pain syndrome and was initiated on Neurontin. Some other records indicate that she was seen in [MASKED] Orthopedic System as far back as [MASKED] by Dr. [MASKED] medial joint space of the right knee was noted to be narrow. She has also been seen for back pain and radiculopathy on the right side. At the time when she had the DVT swelling after the injury, she was worked up and found not to have a compartment syndrome. She is also seeing a physiatrist to assess her gait anomalies and the tendency to fall or nearly fall with persistent right knee and right lateral ankle pain. The notes indicate multiple times that she consider disability. Presently, she is not working. She had been a personal care attendant. There is some concern certainly about her ability to withstand discomfort, pain and physical therapy and that that may reduce her risks for optimal outcome following TKR. In the past physical therapy sessions, she did not apparently show much improvements. MRIs was documented a partial anterior tib-fibular ligament tear. She has been using oxycodone for over a year, has pain management issues. She is seeing a nutritionist now for weight loss. Pain: She rates her pain as between 8 and [MASKED] depending on her activity, at rest [MASKED], with weightbearing [MASKED]. We filled out her an [MASKED] Knee Survey and entered in to her database. She says she is constantly aware of the right knee pain, probably has had to downgrade her activity and severely lacks confidence in the knee. She is unable to squat, run, jump, twist, pivot, or kneel. She describes extreme pain with heavy domestic activity, lying in bed, bending the knee deeply, going up or down stairs. She describes severe pain with transitions from seated positions, standing, walking, getting in and out of car, shopping, shoes and socks, sitting, getting off wheelchair and the likes. She describes extreme stiffness throughout the morning and later in the day. She is never able to achieve full extension nor can she never achieve full flexion. She does note the knee tends to catch up throughout the range of motion and she has often swelling in the knee and crepitus and clicking sensations. Imaging studies go back many years. Back in [MASKED] at [MASKED] of the right knee showed moderate arthritis since [MASKED] of that year. Two months later, she had repeat films at same hospital showing moderately severe patellofemoral arthritis. Then, in [MASKED], ultrasound was negative for DVT, this was a few months after her accident. [MASKED], at [MASKED], moderately severe right knee arthritis. Today, x-rays were obtained including AP, frog lateral, and sunrise views of the right knee shows a significant 13 degree varus deformity, complete bone-on-bone medial compartment with osteophytes. There is a traction spur at the lateral tibial corner and opposing lateral femoral corner. Contralateral left knee sets up again 3 degrees of valgus and has about 2 mm of cartilage remaining medially. Sunrise view right knee shows medial and lateral facet arthritis. Physical Examination: A pleasant [MASKED] woman comes in with her husband. She uses a cane. Antalgic gait. She is [MASKED] feet 4 inches, 245 pounds, calculated BMI 42 puts her in morbid obesity category. She seeks nutrition counseling actively. Blood pressure 128/60 and pulse 66. Normal sinus rhythm. 100% O2 saturation. Right knee sets up in varus as mentioned above 13 degrees. She is painful over the medial joint line. Has intact medial or lateral collateral ligament. It is impossible to test her for ACL or PCL. She has pain that seems out of proportion and even light touch is painful for her. She does of course have a history of regional pain syndrome, but there are no trophic changes on the skin. She will only allow - nd will only flex [MASKED] degrees from full arc of 50 degrees. She has crepitus behind her kneecap, but again it is very difficult to exam. The left knee lacks nd 110 degrees of flexion. She has bilateral pedal edema, more so on the right than the left. She is quite tender over the right lateral ankle, both posterior and anterior to lateral malleolus consistent with her partial ATFL tear. Review of Systems: She feels she is not healthy, wears corrective lenses, has fatigue, frequent headaches, ankle swelling, palpitations, wheezing, easy bruisability and leg weakness. Family History: Positive for osteoarthritis, osteoporosis, COPD, rheumatoid arthritis and cancer. Impression and Plan: The patient has many many issues, neurologic, orthopedic, rheumatologic, etc. as mentioned above. Still, however, radiographs show severe osteoarthritis of the right knee. She is relatively young at [MASKED] years old, but it is understandable the amount of pain she is having in this knee. I feel she warrants a right total knee replacement, but she will be difficult to rehabilitate, sure the pain will get in the way. Still, there is clearly indicated surgery for her. What is unclear is why she still on Xarelto almost a year out from a trauma-induced DVT of the right leg. We will have to check and find out why that is and if she can get off it. There is nothing to suggest she had a pulmonary embolus nor is there anything to suggest she has a family history or personal history of hypercoagulable state. She was consented today for right total knee replacement. Surgical forms have been forwarded and we will get her on the schedule sometimes this [MASKED]. Past Medical History: Past Medical History: Noninflammatory polyarthralgia with myalgias, morbid obesity, currently calculated a BMI 42, hiatal hernia, right-sided sciatica, right knee arthritis, right leg traumatic-induced DVT, migraine headaches, complex regional pain syndrome, asthma, bilateral carpal tunnel syndrome, GERD and vertigo. Past Surgical History: In [MASKED], right knee arthroscopic medial meniscectomy at [MASKED], [MASKED], [MASKED]. She has also had endometrial ablation, right shoulder arthroscopy, tubal ligation, cholecystectomy and appendectomy. MEDICATIONS: Advair Diskus, butalbital, APAP caffeine, gabapentin 300 mg twice a day, glucosamine chondroitin, loratadine 10 mg daily, multivitamins, omeprazole 20 mg daily, tramadol 50 mg p.r.n. and zolpidem 10 mg daily. Allergies: Aspirin, latex and penicillin. Social History: [MASKED] Family History: NC 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 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: She was started on CPM. Home CPAP was continued. 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 surgical dressing was changed and the Silverlon dressing was removed on POD#2. The surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Mrs. [MASKED] is discharged to home with services/rehab in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tudorza Pressair (aclidinium bromide) 400 mcg/actuation inhalation BID 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 3. Budesonide Nasal Inhaler 180 mcg/actuation nasal BID 4. Dronabinol 5 mg PO BID 5. Gabapentin 800 mg PO QID 6. Omeprazole 20 mg PO DAILY 7. Rivaroxaban 20 mg PO DAILY 8. TraMADol 50 mg PO TID:PRN Pain - Moderate Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*60 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Enoxaparin Sodium 40 mg SC DAILY Start: Today - [MASKED], First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 1 syringe SQ once a day Disp #*21 Syringe Refills:*0 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain 5. Senna 8.6 mg PO BID RX *sennosides [Senexon] 8.6 mg 1 tab by mouth BID PRN Disp #*30 Tablet Refills:*0 6. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 7. Budesonide Nasal Inhaler 180 mcg/actuation nasal BID 8. Dronabinol 5 mg PO BID 9. Gabapentin 800 mg PO QID 10. Omeprazole 20 mg PO DAILY 11. Tudorza Pressair (aclidinium bromide) 400 mcg/actuation inhalation BID 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 Lovenox 40mg everyday for three (3) weeks to help prevent deep vein thrombosis (blood clots). You should resume the rivaroxaban after completing the 3 week course of Lovenox. 9. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed at your follow-up appointment in two weeks. 10. [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 Mobilize frequently Treatments Frequency: DSD daily prn drainage Ice and elevate *Staples will be removed at your first post-operative visit in three(3)weeks Followup Instructions: [MASKED]
|
[] |
[
"Z86718",
"J45909",
"J449",
"K219",
"Z7902",
"G4733"
] |
[
"M1711: Unilateral primary osteoarthritis, right knee",
"Z6841: Body mass index [BMI]40.0-44.9, adult",
"E6601: Morbid (severe) obesity due to excess calories",
"M2550: Pain in unspecified joint",
"M791: Myalgia",
"K449: Diaphragmatic hernia without obstruction or gangrene",
"M5431: Sciatica, right side",
"G43909: Migraine, unspecified, not intractable, without status migrainosus",
"Z86718: Personal history of other venous thrombosis and embolism",
"J45909: Unspecified asthma, uncomplicated",
"J449: Chronic obstructive pulmonary disease, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"R42: Dizziness and giddiness",
"Z720: Tobacco use",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"G4733: Obstructive sleep apnea (adult) (pediatric)"
] |
10,025,981
| 24,817,425
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
aspirin / Penicillins / latex
Attending: ___.
Chief Complaint:
right knee pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with right knee pain presenting for elective total knee
arthroplasty
Past Medical History:
MVA in ___ with likely R ankle ATFL tear-> no ___ but dev
RLE DVT now on xarelto
-Right knee medial meniscectomy ___ ___, ___
-Asthma
-Bilateral carpal tunnel syndrome
-Osteoarthritis
-Polyarthralgia
-Chronic pain
-Complex regional pain syndrome
-GERD
-Right-sided sciatica
-Right shoulder arthroscopy
-Endometrial ablation
-Tubal ligation
-Cholecystectomy
-Appendectomy
Social History:
___
Family History:
NC
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
Brief Hospital Course:
The patient was admitted to the orthopedic surgery service and
was taken to the operating room for above described procedure.
On day of surgery, patient was unable to be intubated secondary
to airway difficulties; thus surgery was aborted. She will
reschedule her surgery in the next few months.
During her hospitalization, surgery was aborted secondary to
airway difficulty and inability to intubate.
Otherwise, pain was controlled with oral pain medications.
The patient's weight-bearing status is weight bearing as
tolerated on the affected extremity.
Ms ___ is discharged to home in stable condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. butalbital-acetaminophen 50-325 mg oral DAILY:PRN
2. Gabapentin 800 mg PO TID
3. Dronabinol Dose is Unknown PO Frequency is Unknown
4. aclidinium bromide 400 mcg/actuation inhalation BID
5. Zolpidem Tartrate 10 mg PO QHS
6. Rivaroxaban 20 mg PO DAILY
7. TraMADol 50 mg PO TID
8. Budesonide Nasal Inhaler 180 mcg/actuation nasal DAILY
9. Omeprazole 20 mg PO DAILY
10. Loratadine 10 mg PO DAILY
11. albuterol sulfate 90 mcg/actuation inhalation DAILY:PRN
shortness of breath or wheezing
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*100 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*100 Tablet Refills:*0
3. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*100 Tablet Refills:*0
4. Dronabinol unknown PO Frequency is Unknown
5. aclidinium bromide 400 mcg/actuation inhalation BID
6. albuterol sulfate 90 mcg/actuation inhalation DAILY:PRN
7. Budesonide Nasal Inhaler 180 mcg/actuation nasal DAILY
8. butalbital-acetaminophen 50-325 mg oral DAILY:PRN
9. Gabapentin 800 mg PO TID
10. Loratadine 10 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Rivaroxaban 20 mg PO DAILY
13. TraMADol 50 mg PO TID
14. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
right knee pain/osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please reschedule your surgery to ___. You will need
re-evaluation and preoperative assessment.
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.
Please follow up with your primary physician regarding this
admission and any new medications and refills.
Resume your home medications unless otherwise instructed.
ACTIVITY: Weight bearing as tolerated on the operative
extremity. Mobilize. ROM as tolerated.
Physical Therapy:
none
Treatments Frequency:
none
Followup Instructions:
___
|
[
"M179",
"J449",
"J45909",
"G4733",
"G8929",
"M2550",
"M5431",
"E669",
"Z6841",
"K219",
"F17210",
"Z86718",
"Z7902"
] |
Allergies: aspirin / Penicillins / latex Chief Complaint: right knee pain Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] with right knee pain presenting for elective total knee arthroplasty Past Medical History: MVA in [MASKED] with likely R ankle ATFL tear-> no [MASKED] but dev RLE DVT now on xarelto -Right knee medial meniscectomy [MASKED] [MASKED], [MASKED] -Asthma -Bilateral carpal tunnel syndrome -Osteoarthritis -Polyarthralgia -Chronic pain -Complex regional pain syndrome -GERD -Right-sided sciatica -Right shoulder arthroscopy -Endometrial ablation -Tubal ligation -Cholecystectomy -Appendectomy Social History: [MASKED] Family History: NC 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 Brief Hospital Course: The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. On day of surgery, patient was unable to be intubated secondary to airway difficulties; thus surgery was aborted. She will reschedule her surgery in the next few months. During her hospitalization, surgery was aborted secondary to airway difficulty and inability to intubate. Otherwise, pain was controlled with oral pain medications. The patient's weight-bearing status is weight bearing as tolerated on the affected extremity. Ms [MASKED] is discharged to home in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. butalbital-acetaminophen 50-325 mg oral DAILY:PRN 2. Gabapentin 800 mg PO TID 3. Dronabinol Dose is Unknown PO Frequency is Unknown 4. aclidinium bromide 400 mcg/actuation inhalation BID 5. Zolpidem Tartrate 10 mg PO QHS 6. Rivaroxaban 20 mg PO DAILY 7. TraMADol 50 mg PO TID 8. Budesonide Nasal Inhaler 180 mcg/actuation nasal DAILY 9. Omeprazole 20 mg PO DAILY 10. Loratadine 10 mg PO DAILY 11. albuterol sulfate 90 mcg/actuation inhalation DAILY:PRN shortness of breath or wheezing Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*100 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*100 Tablet Refills:*0 3. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp #*100 Tablet Refills:*0 4. Dronabinol unknown PO Frequency is Unknown 5. aclidinium bromide 400 mcg/actuation inhalation BID 6. albuterol sulfate 90 mcg/actuation inhalation DAILY:PRN 7. Budesonide Nasal Inhaler 180 mcg/actuation nasal DAILY 8. butalbital-acetaminophen 50-325 mg oral DAILY:PRN 9. Gabapentin 800 mg PO TID 10. Loratadine 10 mg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Rivaroxaban 20 mg PO DAILY 13. TraMADol 50 mg PO TID 14. Zolpidem Tartrate 10 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: right knee pain/osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please reschedule your surgery to [MASKED]. You will need re-evaluation and preoperative assessment. 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. Please follow up with your primary physician regarding this admission and any new medications and refills. Resume your home medications unless otherwise instructed. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize. ROM as tolerated. Physical Therapy: none Treatments Frequency: none Followup Instructions: [MASKED]
|
[] |
[
"J449",
"J45909",
"G4733",
"G8929",
"E669",
"K219",
"F17210",
"Z86718",
"Z7902"
] |
[
"M179: Osteoarthritis of knee, unspecified",
"J449: Chronic obstructive pulmonary disease, unspecified",
"J45909: Unspecified asthma, uncomplicated",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"G8929: Other chronic pain",
"M2550: Pain in unspecified joint",
"M5431: Sciatica, right side",
"E669: Obesity, unspecified",
"Z6841: Body mass index [BMI]40.0-44.9, adult",
"K219: Gastro-esophageal reflux disease without esophagitis",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"Z86718: Personal history of other venous thrombosis and embolism",
"Z7902: Long term (current) use of antithrombotics/antiplatelets"
] |
10,026,011
| 22,380,796
|
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 hip osteoarthritis
Major Surgical or Invasive Procedure:
left hip replacement (anterior approach) ___, ___
History of Present Illness:
___ year old female with left hip osteoarthritis, who has failed
conservative measures and is here for definitive surgery.
Past Medical History:
HTN
Diverticulosis
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:
___ 05:45AM BLOOD WBC-10.2* RBC-2.36* Hgb-7.6* Hct-24.0*
MCV-102* MCH-32.2* MCHC-31.7* RDW-12.6 RDWSD-46.4* Plt ___
___ 05:45AM BLOOD WBC-14.0* RBC-2.63* Hgb-8.5* Hct-26.3*
MCV-100* MCH-32.3* MCHC-32.3 RDW-12.4 RDWSD-45.1 Plt ___
___ 12:43PM BLOOD Hct-32.4*
___ 05:45AM BLOOD Glucose-115* UreaN-11 Creat-0.6 Na-144
K-4.4 Cl-105 HCO3-27 AnGap-12
___ 05:45AM BLOOD Calcium-8.0* Phos-3.9 Mg-1.9
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:
POD#1- Urinary retention- patient was straight catheterized on
POD#1 for urinary retention. She was then able to void without
incident. She also felt pain and a pop sensation while
transitioning from sitting to standing with OT. A new x-ray was
obtained, which results showed avulsion fracture of the greater
trochanter. Imaging reviewed by Dr. ___ felt this area
was likely known bony fragment seen intra-op. No changes in
weight-bearing status.
POD #2, patient worked again with physical and did well without
further issues.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient received Aspirin 81 mg twice
daily for DVT prophylaxis starting on the morning of POD#1. The
surgical dressing will remain on until POD#7 after surgery. The
patient was seen daily by physical therapy. Labs were checked
throughout the hospital course and repleted accordingly. At the
time of discharge the patient was tolerating a regular diet and
feeling well. The patient was afebrile with stable vital signs.
The patient's hematocrit was acceptable and pain was adequately
controlled on an oral regimen. The operative extremity was
neurovascularly intact and the dressing was intact.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity with anterior precautions.
No hip bridging, no repetitive resistant hip flexion. Walker or
two crutches, wean as able.
Ms. ___ is discharged to home with services in stable
condition.
Medications on Admission:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal ASDIR
5. Losartan Potassium 25 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Gaviscon (Al hyd-Mg tr-alg ac-sod bicarb;<br>aluminum
hydrox-magnesium carb) 80-14.2 mg oral ASDIR
8. raloxifene 60 mg oral DAILY
9. Niacin SR 500 mg PO DAILY
Discharge Medications:
1. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
2. Pantoprazole 40 mg PO Q24H
Continue while on 4-week course of Aspirin 81 mg twice daily.
3. Senna 8.6 mg PO BID
4. Acetaminophen 1000 mg PO Q8H
5. Aspirin EC 81 mg PO BID
Resume Aspirin 81 mg every day after 4-week course of Aspirin 81
mg twice daily.
6. Docusate Sodium 100 mg PO BID
7. Gaviscon (Al hyd-Mg tr-alg ac-sod bicarb;<br>aluminum
hydrox-magnesium carb) 80-14.2 mg oral ASDIR
8. Losartan Potassium 25 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Niacin SR 500 mg PO DAILY
11. HELD- Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal ASDIR
This medication was held. Do not restart Estrace until you've
been cleared by your surgeon
12. HELD- raloxifene 60 mg oral DAILY This medication was held.
Do not restart raloxifene until you've been cleared by your
surgeon
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left hip osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
8. ANTICOAGULATION: Please continue your Aspirin 81 mg twice
daily with food for four (4) weeks to help prevent deep vein
thrombosis (blood clots). Continue Pantoprazole daily while on
Aspirin to prevent GI upset (x 4 weeks). If you were taking
Aspirin prior to your surgery, take it at 81 mg twice daily
until the end of the 4 weeks, then you can go back to your
normal dosing.
9. WOUND CARE: Please remove Aquacel dressing on POD#7 after
surgery. It is okay to shower after surgery after 5 days but no
tub baths, swimming, or submerging your incision until after
your four (4) week checkup. Please place a dry sterile dressing
on the wound after aqaucel is removed each day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
10. ___ (once at home): Home ___, dressing changes as
instructed, and wound checks.
11. ACTIVITY: Weight bearing as tolerated with walker or 2
crutches. Wean assistive device as able. Anterior precautions
- no hip bridging, no repetitive resistant hip flexion. No
strenuous exercise or heavy lifting until follow up appointment.
Mobilize frequently.
Physical Therapy:
WBAT LLE
No hip bridging and no repetitive resistant hip flexion
Wean assistive device as able (i.e. 2 crutches or walker)
Mobilize frequently
Treatments Frequency:
remove aquacel POD#7 after surgery
apply dry sterile dressing daily if needed after aquacel
dressing is removed
wound checks daily after aquacel removed
Followup Instructions:
___
|
[
"M1612",
"I10",
"R339"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: left hip osteoarthritis Major Surgical or Invasive Procedure: left hip replacement (anterior approach) [MASKED], [MASKED] History of Present Illness: [MASKED] year old female with left hip osteoarthritis, who has failed conservative measures and is here for definitive surgery. Past Medical History: HTN Diverticulosis 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] 05:45AM BLOOD WBC-10.2* RBC-2.36* Hgb-7.6* Hct-24.0* MCV-102* MCH-32.2* MCHC-31.7* RDW-12.6 RDWSD-46.4* Plt [MASKED] [MASKED] 05:45AM BLOOD WBC-14.0* RBC-2.63* Hgb-8.5* Hct-26.3* MCV-100* MCH-32.3* MCHC-32.3 RDW-12.4 RDWSD-45.1 Plt [MASKED] [MASKED] 12:43PM BLOOD Hct-32.4* [MASKED] 05:45AM BLOOD Glucose-115* UreaN-11 Creat-0.6 Na-144 K-4.4 Cl-105 HCO3-27 AnGap-12 [MASKED] 05:45AM BLOOD Calcium-8.0* Phos-3.9 Mg-1.9 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: POD#1- Urinary retention- patient was straight catheterized on POD#1 for urinary retention. She was then able to void without incident. She also felt pain and a pop sensation while transitioning from sitting to standing with OT. A new x-ray was obtained, which results showed avulsion fracture of the greater trochanter. Imaging reviewed by Dr. [MASKED] felt this area was likely known bony fragment seen intra-op. No changes in weight-bearing status. POD #2, patient worked again with physical and did well without further issues. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Aspirin 81 mg twice daily for DVT prophylaxis starting on the morning of POD#1. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with anterior precautions. No hip bridging, no repetitive resistant hip flexion. Walker or two crutches, wean as able. Ms. [MASKED] is discharged to home with services in stable condition. Medications on Admission: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal ASDIR 5. Losartan Potassium 25 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Gaviscon (Al hyd-Mg tr-alg ac-sod bicarb;<br>aluminum hydrox-magnesium carb) 80-14.2 mg oral ASDIR 8. raloxifene 60 mg oral DAILY 9. Niacin SR 500 mg PO DAILY Discharge Medications: 1. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain 2. Pantoprazole 40 mg PO Q24H Continue while on 4-week course of Aspirin 81 mg twice daily. 3. Senna 8.6 mg PO BID 4. Acetaminophen 1000 mg PO Q8H 5. Aspirin EC 81 mg PO BID Resume Aspirin 81 mg every day after 4-week course of Aspirin 81 mg twice daily. 6. Docusate Sodium 100 mg PO BID 7. Gaviscon (Al hyd-Mg tr-alg ac-sod bicarb;<br>aluminum hydrox-magnesium carb) 80-14.2 mg oral ASDIR 8. Losartan Potassium 25 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Niacin SR 500 mg PO DAILY 11. HELD- Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal ASDIR This medication was held. Do not restart Estrace until you've been cleared by your surgeon 12. HELD- raloxifene 60 mg oral DAILY This medication was held. Do not restart raloxifene until you've been cleared by your surgeon Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: left hip osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Aspirin 81 mg twice daily with food for four (4) weeks to help prevent deep vein thrombosis (blood clots). Continue Pantoprazole daily while on Aspirin to prevent GI upset (x 4 weeks). If you were taking Aspirin prior to your surgery, take it at 81 mg twice daily until the end of the 4 weeks, then you can go back to your normal dosing. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated with walker or 2 crutches. Wean assistive device as able. Anterior precautions - no hip bridging, no repetitive resistant hip flexion. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. Physical Therapy: WBAT LLE No hip bridging and no repetitive resistant hip flexion Wean assistive device as able (i.e. 2 crutches or walker) Mobilize frequently Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed Followup Instructions: [MASKED]
|
[] |
[
"I10"
] |
[
"M1612: Unilateral primary osteoarthritis, left hip",
"I10: Essential (primary) hypertension",
"R339: Retention of urine, unspecified"
] |
10,026,011
| 28,091,989
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ years old woman with past medical history of hypertension
comes to the ED complaining of abdominal pain. Patient refers
she
was in her usual state of health until 9 days ago when she
started having intermittent severe crampy abdominal pain. She
refers that sometimes the pain was so severe that it was
associated with nausea but no emesis. She also refers some
chills
and subjective fevers but no recorded fevers and loose bowel
movements.
Yesterday her pain worsened so she called her PCP who ordered ___
CBC and UA, both of which were normal so she was sent home. This
morning her pain was again worse so she went back to her PCP and
had done a CT scan of abdomen and pelvis that showed acute
diverticulitis with small abscess so she was referred to the ED
for surgical evaluation.
Past Medical History:
HTN
Diverticulosis
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM: upon admission: ___
VITAL SIGNS: 98.4, 81, 138/79, 18, 100% RA
GENERAL: AAOx3 NAD
HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no
LAD
CARDIOVASCULAR: R/R/R, S1/S2, NO M/R/G
PULMONARY: CTA ___, No crackles or rhonchi
GASTROINTESTINAL: soft, non-distended, mildly tender diffusely
in lower abdomen. No guarding, rebound, or peritoneal signs.
+BSx4
EXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion.
NEUROLOGICAL: Reflexes, strength, and sensation grossly intact
CNII-XII: WNL
Physical examination upon discharge: ___:
GENERAL: NAD
CV: ns1, s2, no murmurs
LUNGS: clear
ABDOMEN: hypoactive BS, soft, non-tender
EXT: no calf tenderness bil., no pedal edema bil
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 04:15AM BLOOD WBC-6.2 RBC-3.96 Hgb-12.7 Hct-36.8 MCV-93
MCH-32.1* MCHC-34.5 RDW-11.1 RDWSD-37.8 Plt ___
___ 04:49AM BLOOD WBC-6.1 RBC-3.74* Hgb-12.1 Hct-34.7
MCV-93 MCH-32.4* MCHC-34.9 RDW-11.1 RDWSD-38.0 Plt ___
___ 01:44PM BLOOD WBC-8.6 RBC-3.86* Hgb-12.5 Hct-37.0
MCV-96 MCH-32.4* MCHC-33.8 RDW-11.4 RDWSD-40.0 Plt ___
___ 04:15AM BLOOD Plt ___
___ 04:15AM BLOOD Glucose-83 UreaN-5* Creat-0.6 Na-142
K-4.3 Cl-105 HCO3-24 AnGap-13
___ 08:30PM BLOOD Glucose-70 UreaN-12 Creat-0.5 Na-136
K-4.2 Cl-95* HCO3-23 AnGap-18
___ 04:15AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.3
___ 08:38PM BLOOD Lactate-1.0
___: CT scan abdomen and pelvis:
Sigmoid diverticulitis with 1.2 cm intramural abscess. No
evidence of
macro-perforation.
-3 mm hypodensity within the pancreatic body likely represents a
benign
intra-ductal papillary mucinous neoplasm. Nonurgent MRCP is
recommended for further evaluation.
RECOMMENDATION(S): Non-urgent MRCP
NOTIFICATION: The findings were discussed with ___, M.D.
by ___
___, M.D. on the telephone on ___ at 4:00 pm, 5 minutes
after discovery of the findings.
Brief Hospital Course:
___ year old female admitted to the hospital with abdominal pain.
Upon admission, the patient was made NPO, given intravenous
fluids, and underwent imaging. She was reported to have sigmoid
diverticulitis with 1.2 cm intramural abscess. The patient was
started on a course of intravenous ciprofloxacin and flagyl and
placed on bowel rest. Her white blood cell count was monitored.
After the patient's abdominal pain decreased, she was started on
clears and advanced to a regular diet.
The patient was discharged home on HD #5. Her vital signs were
stable and she was afebrile. She was tolerating a regular diet
and voiding without difficultly. She was ambulatory and return
of bowel function. Discharge instructions were reviewed and
questions answered. The patient was given a prescription for
completion of a course of ciprofloxacin and flagyl. The patient
was instructed to follow up with her primary care provider.
+++++++++++++++++++++++++++++++++++++++++++++++
Of note: incidental finding on cat scan imaging showed a 3 mm
hypo-density within the pancreatic body likely represents a
benign intra-ductal papillary mucinous neoplasm. Non-urgent
MRCP is recommended for further evaluation. The patient was
informed of this finding and given a copy of her report.
Medications on Admission:
ESTRADIOL [ESTRACE] - Estrace 0.01% (0.1 mg/gram) vaginal cream.
1 gram Use as directed PRN - (Prescribed by Other Provider)
LOSARTAN - losartan 25 mg tablet. 1 tablet(s) by mouth Q Day
NIACIN - niacin ER 500 mg tablet,extended release 24 hr. 1
tablet(s) by mouth once a day
RALOXIFENE - raloxifene 60 mg tablet. 1 tablet(s) by mouth
daily
RHIZINATE X3 - Dosage uncertain - (Prescribed by Other
Provider)
Medications - OTC
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by
mouth Daily - (Prescribed by Other Provider)
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Vitamin D3 4,000
unit
capsule. 1 capsule(s) by mouth Daily - (Prescribed by Other
Provider)
MULTIVIT-MIN-LYCOP-LUT-HERB___ [PHYTOMULTI] - PhytoMulti 3 mg-3
mg-200 mg tablet. 2 tablet(s) by mouth Daily - (Prescribed by
Other Provider)
VIT A AND D3 IN COD LIVER OIL [COD LIVER OIL] - cod liver oil
4,000 unit-400 unit/5 mL oral liquid. 1 Tbsp by mouth Daily -
(Prescribed by Other Provider)
--------------- --------------- --------------- ---------------
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
___
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*14 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H Duration: 7 Days
last dose ___
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*21 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Losartan Potassium 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You
underwent imaging which showed sigmoid diverticulitis with a
intra-mural abscess. You were placed on bowel rest and given a
course of antibiotics. Your abdominal pain has decreased and
you have resumed a diet. You are being discharged home with the
following recommendations:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
___
|
[
"K5720",
"I10"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] years old woman with past medical history of hypertension comes to the ED complaining of abdominal pain. Patient refers she was in her usual state of health until 9 days ago when she started having intermittent severe crampy abdominal pain. She refers that sometimes the pain was so severe that it was associated with nausea but no emesis. She also refers some chills and subjective fevers but no recorded fevers and loose bowel movements. Yesterday her pain worsened so she called her PCP who ordered [MASKED] CBC and UA, both of which were normal so she was sent home. This morning her pain was again worse so she went back to her PCP and had done a CT scan of abdomen and pelvis that showed acute diverticulitis with small abscess so she was referred to the ED for surgical evaluation. Past Medical History: HTN Diverticulosis Social History: [MASKED] Family History: non-contributory Physical Exam: PHYSICAL EXAM: upon admission: [MASKED] VITAL SIGNS: 98.4, 81, 138/79, 18, 100% RA GENERAL: AAOx3 NAD HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no LAD CARDIOVASCULAR: R/R/R, S1/S2, NO M/R/G PULMONARY: CTA [MASKED], No crackles or rhonchi GASTROINTESTINAL: soft, non-distended, mildly tender diffusely in lower abdomen. No guarding, rebound, or peritoneal signs. +BSx4 EXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion. NEUROLOGICAL: Reflexes, strength, and sensation grossly intact CNII-XII: WNL Physical examination upon discharge: [MASKED]: GENERAL: NAD CV: ns1, s2, no murmurs LUNGS: clear ABDOMEN: hypoactive BS, soft, non-tender EXT: no calf tenderness bil., no pedal edema bil NEURO: alert and oriented x 3, speech clear Pertinent Results: [MASKED] 04:15AM BLOOD WBC-6.2 RBC-3.96 Hgb-12.7 Hct-36.8 MCV-93 MCH-32.1* MCHC-34.5 RDW-11.1 RDWSD-37.8 Plt [MASKED] [MASKED] 04:49AM BLOOD WBC-6.1 RBC-3.74* Hgb-12.1 Hct-34.7 MCV-93 MCH-32.4* MCHC-34.9 RDW-11.1 RDWSD-38.0 Plt [MASKED] [MASKED] 01:44PM BLOOD WBC-8.6 RBC-3.86* Hgb-12.5 Hct-37.0 MCV-96 MCH-32.4* MCHC-33.8 RDW-11.4 RDWSD-40.0 Plt [MASKED] [MASKED] 04:15AM BLOOD Plt [MASKED] [MASKED] 04:15AM BLOOD Glucose-83 UreaN-5* Creat-0.6 Na-142 K-4.3 Cl-105 HCO3-24 AnGap-13 [MASKED] 08:30PM BLOOD Glucose-70 UreaN-12 Creat-0.5 Na-136 K-4.2 Cl-95* HCO3-23 AnGap-18 [MASKED] 04:15AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.3 [MASKED] 08:38PM BLOOD Lactate-1.0 [MASKED]: CT scan abdomen and pelvis: Sigmoid diverticulitis with 1.2 cm intramural abscess. No evidence of macro-perforation. -3 mm hypodensity within the pancreatic body likely represents a benign intra-ductal papillary mucinous neoplasm. Nonurgent MRCP is recommended for further evaluation. RECOMMENDATION(S): Non-urgent MRCP NOTIFICATION: The findings were discussed with [MASKED], M.D. by [MASKED] [MASKED], M.D. on the telephone on [MASKED] at 4:00 pm, 5 minutes after discovery of the findings. Brief Hospital Course: [MASKED] year old female admitted to the hospital with abdominal pain. Upon admission, the patient was made NPO, given intravenous fluids, and underwent imaging. She was reported to have sigmoid diverticulitis with 1.2 cm intramural abscess. The patient was started on a course of intravenous ciprofloxacin and flagyl and placed on bowel rest. Her white blood cell count was monitored. After the patient's abdominal pain decreased, she was started on clears and advanced to a regular diet. The patient was discharged home on HD #5. Her vital signs were stable and she was afebrile. She was tolerating a regular diet and voiding without difficultly. She was ambulatory and return of bowel function. Discharge instructions were reviewed and questions answered. The patient was given a prescription for completion of a course of ciprofloxacin and flagyl. The patient was instructed to follow up with her primary care provider. +++++++++++++++++++++++++++++++++++++++++++++++ Of note: incidental finding on cat scan imaging showed a 3 mm hypo-density within the pancreatic body likely represents a benign intra-ductal papillary mucinous neoplasm. Non-urgent MRCP is recommended for further evaluation. The patient was informed of this finding and given a copy of her report. Medications on Admission: ESTRADIOL [ESTRACE] - Estrace 0.01% (0.1 mg/gram) vaginal cream. 1 gram Use as directed PRN - (Prescribed by Other Provider) LOSARTAN - losartan 25 mg tablet. 1 tablet(s) by mouth Q Day NIACIN - niacin ER 500 mg tablet,extended release 24 hr. 1 tablet(s) by mouth once a day RALOXIFENE - raloxifene 60 mg tablet. 1 tablet(s) by mouth daily RHIZINATE X3 - Dosage uncertain - (Prescribed by Other Provider) Medications - OTC ASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by mouth Daily - (Prescribed by Other Provider) CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Vitamin D3 4,000 unit capsule. 1 capsule(s) by mouth Daily - (Prescribed by Other Provider) MULTIVIT-MIN-LYCOP-LUT-HERB [PHYTOMULTI] - PhytoMulti 3 mg-3 mg-200 mg tablet. 2 tablet(s) by mouth Daily - (Prescribed by Other Provider) VIT A AND D3 IN COD LIVER OIL [COD LIVER OIL] - cod liver oil 4,000 unit-400 unit/5 mL oral liquid. 1 Tbsp by mouth Daily - (Prescribed by Other Provider) --------------- --------------- --------------- --------------- Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days [MASKED] RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*14 Tablet Refills:*0 3. MetroNIDAZOLE 500 mg PO Q8H Duration: 7 Days last dose [MASKED] RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*21 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY 5. Losartan Potassium 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with abdominal pain. You underwent imaging which showed sigmoid diverticulitis with a intra-mural abscess. You were placed on bowel rest and given a course of antibiotics. Your abdominal pain has decreased and you have resumed a diet. You are being discharged home with the following recommendations: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Followup Instructions: [MASKED]
|
[] |
[
"I10"
] |
[
"K5720: Diverticulitis of large intestine with perforation and abscess without bleeding",
"I10: Essential (primary) hypertension"
] |
10,026,246
| 27,069,095
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old male with a history of HTN,
hypothyroidism, and a distant history of bladder CA who
presented
as a transfer from OSH with an L1 burst fracture with 4mm
retropulsion. The patient reports that he fell from standing
yesterday hitting his back on a chair. The patient states that
he
was walking to the stairs to go up to bed when he slipped and
fell. No chest pain, palpitations, dizziness or lightheadedness
prior to the fall, and had not just stood up from seated
position. He was able to pull himself up after the fall, but had
severe back pain. He denied bowel or bladder incontinence, had
no
post ictal state, and had no LOC.
On presentation to the ___, he denied
numbness/tingling, weakness or incontinence. The patient takes
no
anticoagulants and no aspirin. He had a CT head non-contrast
which was negative, a CT neck which was negative, and a CT L
spine which showed an L1 burst fracture with retropulsion. At
this point, the patient was transferred to ___ for a
neurosurgical evaluation.
In the ___ he had an MRI which showed an L1 vertebral body with 4
mm posterior fragment retropulsion. The retropulsed fragment
mildly
narrows the central canal. There is mild neural foraminal
narrowing on the left at T12-L1. Spine evaluated the pt and
recommended TLSO brace at all times, pain control and follow up
in 1 month in the ___ clinic.
At 5 a.m. in the ___, he began experiencing relatively acute
onset
of sharp mid abdominal pain and distention. This occurred
shortly
after eating a large pack ___ crackers and drinking
multiple milk cartons. His last bowel movement was the day prior
to admission, and it was completely normal. He had no vomiting,
and was still passing gas. He was found to be focally
exquisitely
tender in his periumbilical area, and thus he had a CT abdomen
and pelvis which showed cholelithiasis with gallbladder
distension and apparent mild intrahepatic biliary ductal
dilation
raising potential concern for choledocholithiasis/cholangitis,
with a RUQ redemonstrating these findings with some concern for
Mirizzi syndrome. He was given a dose of Ciprofloxacin and
Flagyl.
Surgery was consulted given these findings, however in the
setting of an exam which did not correlate with these findings
as
well as normal LFTs, this was thought to be an incidental
findings which did not explain the patient's sudden onset
abdominal pain. The patient's pain resolved with a large bowel
movement in the ___.
The patient's UA showed large leukocytes, negative nitrites, and
the patient's abdominal pain was thought to be secondary to an
underlying UTI. He was given a dose of Ceftriaxone in the ___.
Past Medical History:
Dementia
HTN
Hypothyroidism
BPH
Bladder cancer
Social History:
___
Family History:
Father: ___, ___
Physical Exam:
====================
Admission Physical
====================
VITALS: 97.7PO 174 / 54L Lying 81 18 97 Ra
GENERAL: Alert and interactive. In no acute distress, lying
comfortably in bed, in TLSO brace
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
BACK: TLSO brace in place. Tenderness to palpation over midline
lower back, no notable step off. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended. Very mildly tender
to deep palpation of RLQ, but otherwise non-tender. No
tenderness
in right upper quadrant with a negative ___ sign.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
NEUROLOGIC: CN2-12 intact. ___ strength throughout, including
___
strength in bilateral lower extremities in all proximal and
distal muscle groups. Normal sensation.
=====================
Discharge Physical
=====================
VITALS: 98.0 PO 122 / 47 L Lying 77 20 95 Ra
GENERAL: Alert and interactive. In no acute distress, lying
comfortably in bed
HEENT: Normocephalic, atraumatic. Surgical pupils b/l, OS 1mm,
OD 3mm. Sclera
anicteric and without injection.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Faint bibasilar crackles, otherwise CTA, No increased
work of breathing.
BACK: not wearing brace, mild TTP over the lower right flank, 2
crops of vesicles on L side L3 or L4 dermatome with erythematous
base concerning for Zoster
ABDOMEN: Normal bowels sounds, non distended, non-tender.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DPs 2+
bilaterally.
NEUROLOGIC: CN2-12 intact grossly, normal gait. Normal strength
and sensation grossly Normal. AOx3, at b/l mental status per
family.
Pertinent Results:
ADMISSION LABS
================
___ 06:48PM BLOOD WBC-5.7 RBC-3.91* Hgb-11.6* Hct-33.5*
MCV-86 MCH-29.7 MCHC-34.6 RDW-13.4 RDWSD-41.2 Plt ___
___ 06:48PM BLOOD Neuts-62.7 ___ Monos-8.9 Eos-7.7*
Baso-0.3 Im ___ AbsNeut-3.59 AbsLymp-1.15* AbsMono-0.51
AbsEos-0.44 AbsBaso-0.02
___ 06:48PM BLOOD ___ PTT-27.6 ___
___ 06:48PM BLOOD Glucose-98 UreaN-33* Creat-2.2* Na-139
K-4.3 Cl-100 HCO3-23 AnGap-16
___ 12:55PM BLOOD ALT-24 AST-35 CK(CPK)-96 AlkPhos-90
TotBili-0.5
___ 06:48PM BLOOD cTropnT-<0.01
___ 12:55PM BLOOD Lipase-35
INTERVAL LABS
==============
___ 07:37AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.6 Iron-11*
___ 07:37AM BLOOD calTIBC-220* Ferritn-104 TRF-169*
___ 07:35AM BLOOD VitB12-818
URINE LABS
=============
___ 07:51AM URINE Color-Yellow Appear-Clear Sp ___
___ 07:51AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 07:51AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-1
___ 09:59PM URINE Color-Straw Appear-Clear Sp ___
___ 09:59PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG*
___ 09:59PM URINE RBC-<1 WBC-80* Bacteri-FEW* Yeast-NONE
Epi-<1 TransE-<1
___ 10:12AM URINE Hours-RANDOM Creat-179 Na-42
___ 10:12AM URINE Osmolal-584
___ 09:55PM URINE Hours-RANDOM UreaN-726 Creat-117 Na-100
___ 09:55PM URINE Osmolal-644
DISCHARGE LABS
===============
___ 07:21AM BLOOD WBC-11.6* RBC-3.45* Hgb-10.2* Hct-30.4*
MCV-88 MCH-29.6 MCHC-33.6 RDW-13.6 RDWSD-43.5 Plt ___
___ 08:20AM BLOOD Glucose-95 UreaN-31* Creat-2.0* Na-139
K-4.3 Cl-97 HCO3-27 AnGap-15
___ 08:20AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.8
MICROBIOLOGY
==============
___ 9:59 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 7:51 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ BLOOD CULTURE: no growth
___ BLOOD CULTURE: no growth
___ BLOOD CULTURE: pending
___ BLOOD CULTURE: pending
___ 2:06 pm DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS
SKIN TEST.
DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Pending):
IMAGING
===========
Hip XRay ___
No evidence of acute fracture or dislocation is seen. The pubic
symphysis and sacroiliac joints are intact. Mild degenerative
changes are seen at the hip joints bilaterally. Vascular
calcifications are seen.
MRI Spine ___
1. Moderate to severe, acute L1 vertebral body burst fracture
with bony
retropulsion which combines with background spondylosis to
result in mild
canal narrowing. No spinal cord compression is identified.
2. Subacute appearing, probable Schmorl's node involving the
superior endplate of L5 with approximately 50% loss of height.
3. Background spondylosis of the lumbar spine at multiple
levels, as detailed above. Findings are most notable at L4-L5
with moderate canal narrowing.
4. Foraminal narrowing as described above.
5. Diffusely heterogeneous bone marrow signal, a nonspecific
finding which can be seen with osteopenia..
CT Abdomen Pelvis, with contrast ___
1. Cholelithiasis with gallbladder distension and apparent mild
intrahepatic biliary ductal dilation raises potential concern
for
choledocholithiasis/cholangitis. Please correlate clinically.
2. L1 burst fracture with 4 mm posterior fragment retropulsion,
better
assessed on MR lumbar spine performed ___.
3. Extensive atherosclerotic calcifications with a small
aneurysm of
infrarenal abdominal aorta measuring up to 3.0 x 2.4 cm.
4. Right inguinal hernia containing a portion of the urinary
bladder,
uncomplicated.
5. Calcified pleural plaques the lung bases likely reflect prior
asbestos
exposure.
Liver/Gallbladder U/S ___
Cholelithiasis with gallbladder distension and dilation of the
intrahepatic biliary tree with normal caliber CBD. Findings
raise potential concern for Mirizzi syndrome.
Brief Hospital Course:
Mr. ___ is a ___ year old male with a history of HTN, dementia,
hypothyroidism, and a distant history of bladder CA who
presented as a transfer from OSH with an L1 burst fracture with
4mm retropulsion after a fall, with toxic metabolic
encephalopathy likely ___ UTI, dehydration, and abdominal pain
likely ___ constipation.
Acute Issues
=============
#UTI
#Leukocytosis
#Fever:
Pt presented with increased urinary frequency, but this has been
chronic over the past ___ years. His daughter states that she
noticed him having to go more often as recently as ___. No
recent change in urination, has no burning, frequency or
urgency. Noted incidentally on CT A/P to have a small segment of
bladder entrapped in right inguinal hernia that could be a
stasis nidus for ongoing infection, though upon discussion with
urology, they declined intervention, given that he is ___. DRE
was negative for prostatitis. Post void residuals at 180cc,
confirmed with urology that is appropriate and he is not
retaining pathologically. Febrile to 100.8 initially with WBC
spike to 21K, downtrended on Ceftriaxone (D1 = ___, then
transitioned to cefpodoxime. Urine cultures did not reveal a
source, ___ was contaminated, ___ negative already on
antibiotics, but given his clinical improvement on ceftriaxone,
he will complete a 7d course (end ___.
#L1 burst facture s/p fall:
#Presumed osteoporosis
L1 spinal fracture with 4mm retropulsion. Pt seen by
neurosurgery and recommended TLSO brace at all times while OOB
for next month with follow up in the ___ clinic ___,
will likely need X-rays beforehand. ___ and OT evaluation cleared
him to be discharged home after ___ sessions each. He is not to
drive while wearing TLSO brace (see below). Fracture i/s/o fall
raises concern for osteoporosis, would consider empiric
treatment with bisphosphonate outpatient. DC'd with home ___,
family agreeable for ___ supervision.
#Dementia:
#Toxic metabolic encephalopathy ___ UTI
According to his daughter, ___, his mental state has been
slowly deteriorating as recently as last fall, but began to
decline precipitously in ___ after he contracted pneumonia.
Since then he has been frequently confused and disoriented. He
lives alone and cares for himself, including driving himself.
His daughter came in to see him several times and confirmed that
he at his baseline mental status. His disorientation and
confusion seemed to improve after starting antibiotics for UTI,
so likely had some encephalopathy in addition to baseline
dementia. He was AOx3 and able to complete ___ backwards for
most of his hospital stay. His daughter expressed ongoing
concern with his ability to care for himself at home, but stated
that he is too stubborn to accept input from his family and
continues to drive and live alone. ___ evaluated him and
deemed him safe for discharge home with 24h care while he is
wearing the brace given that he was forgetful of putting it on
while still in bed. Mr. ___ was receptive to staying with his
daughter. Mr. ___ daughter completed a health care proxy
form, which is in his chart. He is DNR/DNI per MOLST, copy of
which was placed in chart.
#Family concern over patient driving
Daughter noted concern for patient still being on the road.
___ eval deemed not safe to drive while wearing TLSO brace.
Patient counseled regarding this. Social work coordinated
Request for Medical Evaluation to DMV but family changed their
mind and would like to readdress this issue in ___ when
driver's license up for renewal. This was discussed w PCP.
Recommend referring patient to Drive Wise program.
___ on CKD:
According to patient charts, baseline Cr 2.2, with increase to
from 2.8 ___, most likely I/s/o poor PO intake. Mr. ___
was given 1L of fluid, encouraged PO intake, and diuretics were
held, and Cr slowly recovered back down to baseline. Discharge
Cr 2.0.
#Abd pain:
#Constipation:
#R inguinal hernia
Pt developed short episode of severe abdominal pain with PO
intake in ___. CT A and P concerning for gallstones with some
obstruction of the CBD and resultant intrahepatic bile duct
dilatation, concerning for Mirizzi syndrome. Surgery evaluated
in ___ and thought symptoms not consistent with biliary
pathology, particularly in the setting of normal LFTs. Got one
dose of Cipro/Flagyl however did not continue. Pt endorsed
improvement of pain with bowel movement, and states that felt
constipated prior. Optimized bowel regimen. Subsequently, pain
continued, but localized much more the RLQ, and clinically
thought to be most likely due to his inguinal hernia.
#Bradycardia: ___ worked with patient in the ___ and noted
bradycardia to ___ at that time. Given this as well as patient's
unclear cause for fall, some concern for intermittent heart
block with exercise which would raise concern for nodal disease.
No further bradycardia noted on Telemetry however noted to have
occasional PVCs and bigeminy.
#Fall: Most likely mechanical based on story. No clear evidence
of orthostasis or vagal symptoms. Low concern for sz given no
post ictal state. Only concern is bradycardia, so monitored on
tele as above. ___ consult recommended discharge to home with
home ___.
#Vesicular Rash: Patient noted to have 2 small crops of vesicles
on approximately L3 or L4 dermatome with erythematous base,
concerning for Shingles. Started empiric 7 day course of
Acyclovir ___, to end ___. DFA was done to confirm diagnosis,
results pending at discharge.
#Iron deficiency anemia: Noted to be mildly anemic with
transferrin saturation 5%, indicative of iron deficiency.
Recommend oral iron supplement, concentrated 65mg daily
(equivalent of 325) in attempt to prevent constipation.
CHRONIC/STABLE:
===============
#HTN: Briefly held home diuretics for ___, restarted on
discharge.
#Hypothyroid: Continued home synthroid
#BPH: Continued home tamsulosin
Transitional Issues:
====================
[ ] Neurosurgery followup scheduled ___, should wear brace when
OOB until then. Family agreeable to ___ supervision until that
time, will get home ___ and ___ care as well.
[ ] Recommend referring patient to Drive Wise program.
[ ] Fracture i/s/o fall raises concern for osteoporosis, would
consider empiric treatment with bisphosphonate outpatient.
[ ] Cefpodoxime for UTI through ___ to finish 7d course
[ ] DNR/DNI per MOLST, copy placed in chart
[ ] Pt given short course oxycodone 2.5mg & Lido TD for back
pain
[ ] Pt started on Miralax and PRN Lactulose for constipation
[ ] Started 7 day course of Acyclovir for Shingles ___, end
date ___, DFA was done to confirm diagnosis, results pending at
discharge.
[ ] Family states they will obtain a shower chair for patient to
use until cleared by NSGY.
[ ] Please recheck iron studies in ___ weeks on iron
supplementation
#CODE: DNR/DNI per MOLST
#CONTACT: HCP: Son (___) ___ Daughter ___
___ H: ___ C: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Meclizine 25 mg PO Q8H:PRN Nausea
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Tamsulosin 0.4 mg PO QHS
5. Betaxolol Ophth Susp 0.25% 1 DROP BOTH EYES BID
6. Hydrochlorothiazide 25 mg PO DAILY
7. Triamterene 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
Do not take more than 4 pills per day.
2. Acyclovir 800 mg PO Q8H
end after ___
RX *acyclovir 800 mg 1 tablet(s) by mouth three times a day Disp
#*20 Tablet Refills:*0
3. Cefpodoxime Proxetil 200 mg PO Q24H Duration: 3 Doses
RX *cefpodoxime 200 mg 1 tablet(s) by mouth once a day Disp #*1
Tablet Refills:*0
4. Ferrous Sulfate 65 mg PO DAILY
5. Lactulose 30 mL PO DAILY:PRN constipation
RX *lactulose 10 gram/15 mL (15 mL) 15 mL by mouth daily:PRN
Disp #*1 Package Refills:*0
6. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % apply to back pain QAM Disp #*30 Patch
Refills:*0
7. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q8h:prn
Disp #*8 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY Constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth once a day Disp #*24 Packet Refills:*0
9. Betaxolol Ophth Susp 0.25% 1 DROP BOTH EYES BID
10. Hydrochlorothiazide 25 mg PO DAILY
11. Levothyroxine Sodium 100 mcg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Tamsulosin 0.4 mg PO QHS
14. Triamterene 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
L1 burst fracture
R flank pain ___ fall
History of fall
Toxic metabolic encephalopathy ___ Urinary Tract Infection
Constipation
R inguinal hernia
Episode of Bradycardia, PVCs, Bigeminy
___ on CKD ___ dehydration
Herpes Zoster Infection (local)
Iron deficiency anemia
Secondary Diagnoses:
CKD
HTN
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were initially transferred to the ___ from another
hospital because a picture of your back showed that the pain in
your back you were feeling was from a fracture in one of the
bones in your lower spine (L1 burst fracture).
While you were here, we imaged your back and found that you had
broken a bone in your lower back (L1 burst fracture) when you
fell, and that was causing your pain. The spine doctors
___ and ___ you a brace to wear, all the time when
you are not sleeping, for 1 month. You will see Dr.
___ to see how your back is doing. While
you were in the hospital you also had some pain in your stomach
and a small fever, which was likely because of an infection in
your urinary tract. We gave you some antibiotics to take, which
you should continue to take after you leave (until ___ in
order to treat the infection.
You had some spots on your back that look like Shingles, so you
need to take medicine for it for the next 7 days.
When you leave the hospital, please call Dr. ___ at
the number listed below to see if you need X-rays of your back
before your appointment.
Please wear your back brace every day until then, all day when
you aren't in bed. Please continue to take all your medication,
including your antibiotics.
It is very important that you do not DRIVE AT ALL until you ___ Wise program and are cleared from your neurosurgeon to
take the brace off. Driving with the brace puts other people on
the road in danger and puts you in danger.
It was a pleasure caring for you and we wish you the best.
Your ___ Team
Followup Instructions:
___
|
[
"S32011A",
"G92",
"E860",
"G309",
"B029",
"F0280",
"N390",
"F0390",
"E039",
"W1809XA",
"Y92003",
"Z8551",
"N400",
"Z87891",
"K5900",
"M810",
"Z66",
"I129",
"N189",
"K4090",
"R001",
"D509"
] |
Allergies: Penicillins Chief Complaint: Back Pain Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a [MASKED] year old male with a history of HTN, hypothyroidism, and a distant history of bladder CA who presented as a transfer from OSH with an L1 burst fracture with 4mm retropulsion. The patient reports that he fell from standing yesterday hitting his back on a chair. The patient states that he was walking to the stairs to go up to bed when he slipped and fell. No chest pain, palpitations, dizziness or lightheadedness prior to the fall, and had not just stood up from seated position. He was able to pull himself up after the fall, but had severe back pain. He denied bowel or bladder incontinence, had no post ictal state, and had no LOC. On presentation to the [MASKED], he denied numbness/tingling, weakness or incontinence. The patient takes no anticoagulants and no aspirin. He had a CT head non-contrast which was negative, a CT neck which was negative, and a CT L spine which showed an L1 burst fracture with retropulsion. At this point, the patient was transferred to [MASKED] for a neurosurgical evaluation. In the [MASKED] he had an MRI which showed an L1 vertebral body with 4 mm posterior fragment retropulsion. The retropulsed fragment mildly narrows the central canal. There is mild neural foraminal narrowing on the left at T12-L1. Spine evaluated the pt and recommended TLSO brace at all times, pain control and follow up in 1 month in the [MASKED] clinic. At 5 a.m. in the [MASKED], he began experiencing relatively acute onset of sharp mid abdominal pain and distention. This occurred shortly after eating a large pack [MASKED] crackers and drinking multiple milk cartons. His last bowel movement was the day prior to admission, and it was completely normal. He had no vomiting, and was still passing gas. He was found to be focally exquisitely tender in his periumbilical area, and thus he had a CT abdomen and pelvis which showed cholelithiasis with gallbladder distension and apparent mild intrahepatic biliary ductal dilation raising potential concern for choledocholithiasis/cholangitis, with a RUQ redemonstrating these findings with some concern for Mirizzi syndrome. He was given a dose of Ciprofloxacin and Flagyl. Surgery was consulted given these findings, however in the setting of an exam which did not correlate with these findings as well as normal LFTs, this was thought to be an incidental findings which did not explain the patient's sudden onset abdominal pain. The patient's pain resolved with a large bowel movement in the [MASKED]. The patient's UA showed large leukocytes, negative nitrites, and the patient's abdominal pain was thought to be secondary to an underlying UTI. He was given a dose of Ceftriaxone in the [MASKED]. Past Medical History: Dementia HTN Hypothyroidism BPH Bladder cancer Social History: [MASKED] Family History: Father: [MASKED], [MASKED] Physical Exam: ==================== Admission Physical ==================== VITALS: 97.7PO 174 / 54L Lying 81 18 97 Ra GENERAL: Alert and interactive. In no acute distress, lying comfortably in bed, in TLSO brace HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive bilaterally, extraocular muscles intact. Sclera anicteric and without injection. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. No increased work of breathing. BACK: TLSO brace in place. Tenderness to palpation over midline lower back, no notable step off. No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended. Very mildly tender to deep palpation of RLQ, but otherwise non-tender. No tenderness in right upper quadrant with a negative [MASKED] sign. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. NEUROLOGIC: CN2-12 intact. [MASKED] strength throughout, including [MASKED] strength in bilateral lower extremities in all proximal and distal muscle groups. Normal sensation. ===================== Discharge Physical ===================== VITALS: 98.0 PO 122 / 47 L Lying 77 20 95 Ra GENERAL: Alert and interactive. In no acute distress, lying comfortably in bed HEENT: Normocephalic, atraumatic. Surgical pupils b/l, OS 1mm, OD 3mm. Sclera anicteric and without injection. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Faint bibasilar crackles, otherwise CTA, No increased work of breathing. BACK: not wearing brace, mild TTP over the lower right flank, 2 crops of vesicles on L side L3 or L4 dermatome with erythematous base concerning for Zoster ABDOMEN: Normal bowels sounds, non distended, non-tender. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DPs 2+ bilaterally. NEUROLOGIC: CN2-12 intact grossly, normal gait. Normal strength and sensation grossly Normal. AOx3, at b/l mental status per family. Pertinent Results: ADMISSION LABS ================ [MASKED] 06:48PM BLOOD WBC-5.7 RBC-3.91* Hgb-11.6* Hct-33.5* MCV-86 MCH-29.7 MCHC-34.6 RDW-13.4 RDWSD-41.2 Plt [MASKED] [MASKED] 06:48PM BLOOD Neuts-62.7 [MASKED] Monos-8.9 Eos-7.7* Baso-0.3 Im [MASKED] AbsNeut-3.59 AbsLymp-1.15* AbsMono-0.51 AbsEos-0.44 AbsBaso-0.02 [MASKED] 06:48PM BLOOD [MASKED] PTT-27.6 [MASKED] [MASKED] 06:48PM BLOOD Glucose-98 UreaN-33* Creat-2.2* Na-139 K-4.3 Cl-100 HCO3-23 AnGap-16 [MASKED] 12:55PM BLOOD ALT-24 AST-35 CK(CPK)-96 AlkPhos-90 TotBili-0.5 [MASKED] 06:48PM BLOOD cTropnT-<0.01 [MASKED] 12:55PM BLOOD Lipase-35 INTERVAL LABS ============== [MASKED] 07:37AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.6 Iron-11* [MASKED] 07:37AM BLOOD calTIBC-220* Ferritn-104 TRF-169* [MASKED] 07:35AM BLOOD VitB12-818 URINE LABS ============= [MASKED] 07:51AM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 07:51AM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [MASKED] 07:51AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-1 [MASKED] 09:59PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 09:59PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG* [MASKED] 09:59PM URINE RBC-<1 WBC-80* Bacteri-FEW* Yeast-NONE Epi-<1 TransE-<1 [MASKED] 10:12AM URINE Hours-RANDOM Creat-179 Na-42 [MASKED] 10:12AM URINE Osmolal-584 [MASKED] 09:55PM URINE Hours-RANDOM UreaN-726 Creat-117 Na-100 [MASKED] 09:55PM URINE Osmolal-644 DISCHARGE LABS =============== [MASKED] 07:21AM BLOOD WBC-11.6* RBC-3.45* Hgb-10.2* Hct-30.4* MCV-88 MCH-29.6 MCHC-33.6 RDW-13.6 RDWSD-43.5 Plt [MASKED] [MASKED] 08:20AM BLOOD Glucose-95 UreaN-31* Creat-2.0* Na-139 K-4.3 Cl-97 HCO3-27 AnGap-15 [MASKED] 08:20AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.8 MICROBIOLOGY ============== [MASKED] 9:59 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] 7:51 am URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] BLOOD CULTURE: no growth [MASKED] BLOOD CULTURE: no growth [MASKED] BLOOD CULTURE: pending [MASKED] BLOOD CULTURE: pending [MASKED] 2:06 pm DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS SKIN TEST. DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Pending): IMAGING =========== Hip XRay [MASKED] No evidence of acute fracture or dislocation is seen. The pubic symphysis and sacroiliac joints are intact. Mild degenerative changes are seen at the hip joints bilaterally. Vascular calcifications are seen. MRI Spine [MASKED] 1. Moderate to severe, acute L1 vertebral body burst fracture with bony retropulsion which combines with background spondylosis to result in mild canal narrowing. No spinal cord compression is identified. 2. Subacute appearing, probable Schmorl's node involving the superior endplate of L5 with approximately 50% loss of height. 3. Background spondylosis of the lumbar spine at multiple levels, as detailed above. Findings are most notable at L4-L5 with moderate canal narrowing. 4. Foraminal narrowing as described above. 5. Diffusely heterogeneous bone marrow signal, a nonspecific finding which can be seen with osteopenia.. CT Abdomen Pelvis, with contrast [MASKED] 1. Cholelithiasis with gallbladder distension and apparent mild intrahepatic biliary ductal dilation raises potential concern for choledocholithiasis/cholangitis. Please correlate clinically. 2. L1 burst fracture with 4 mm posterior fragment retropulsion, better assessed on MR lumbar spine performed [MASKED]. 3. Extensive atherosclerotic calcifications with a small aneurysm of infrarenal abdominal aorta measuring up to 3.0 x 2.4 cm. 4. Right inguinal hernia containing a portion of the urinary bladder, uncomplicated. 5. Calcified pleural plaques the lung bases likely reflect prior asbestos exposure. Liver/Gallbladder U/S [MASKED] Cholelithiasis with gallbladder distension and dilation of the intrahepatic biliary tree with normal caliber CBD. Findings raise potential concern for Mirizzi syndrome. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old male with a history of HTN, dementia, hypothyroidism, and a distant history of bladder CA who presented as a transfer from OSH with an L1 burst fracture with 4mm retropulsion after a fall, with toxic metabolic encephalopathy likely [MASKED] UTI, dehydration, and abdominal pain likely [MASKED] constipation. Acute Issues ============= #UTI #Leukocytosis #Fever: Pt presented with increased urinary frequency, but this has been chronic over the past [MASKED] years. His daughter states that she noticed him having to go more often as recently as [MASKED]. No recent change in urination, has no burning, frequency or urgency. Noted incidentally on CT A/P to have a small segment of bladder entrapped in right inguinal hernia that could be a stasis nidus for ongoing infection, though upon discussion with urology, they declined intervention, given that he is [MASKED]. DRE was negative for prostatitis. Post void residuals at 180cc, confirmed with urology that is appropriate and he is not retaining pathologically. Febrile to 100.8 initially with WBC spike to 21K, downtrended on Ceftriaxone (D1 = [MASKED], then transitioned to cefpodoxime. Urine cultures did not reveal a source, [MASKED] was contaminated, [MASKED] negative already on antibiotics, but given his clinical improvement on ceftriaxone, he will complete a 7d course (end [MASKED]. #L1 burst facture s/p fall: #Presumed osteoporosis L1 spinal fracture with 4mm retropulsion. Pt seen by neurosurgery and recommended TLSO brace at all times while OOB for next month with follow up in the [MASKED] clinic [MASKED], will likely need X-rays beforehand. [MASKED] and OT evaluation cleared him to be discharged home after [MASKED] sessions each. He is not to drive while wearing TLSO brace (see below). Fracture i/s/o fall raises concern for osteoporosis, would consider empiric treatment with bisphosphonate outpatient. DC'd with home [MASKED], family agreeable for [MASKED] supervision. #Dementia: #Toxic metabolic encephalopathy [MASKED] UTI According to his daughter, [MASKED], his mental state has been slowly deteriorating as recently as last fall, but began to decline precipitously in [MASKED] after he contracted pneumonia. Since then he has been frequently confused and disoriented. He lives alone and cares for himself, including driving himself. His daughter came in to see him several times and confirmed that he at his baseline mental status. His disorientation and confusion seemed to improve after starting antibiotics for UTI, so likely had some encephalopathy in addition to baseline dementia. He was AOx3 and able to complete [MASKED] backwards for most of his hospital stay. His daughter expressed ongoing concern with his ability to care for himself at home, but stated that he is too stubborn to accept input from his family and continues to drive and live alone. [MASKED] evaluated him and deemed him safe for discharge home with 24h care while he is wearing the brace given that he was forgetful of putting it on while still in bed. Mr. [MASKED] was receptive to staying with his daughter. Mr. [MASKED] daughter completed a health care proxy form, which is in his chart. He is DNR/DNI per MOLST, copy of which was placed in chart. #Family concern over patient driving Daughter noted concern for patient still being on the road. [MASKED] eval deemed not safe to drive while wearing TLSO brace. Patient counseled regarding this. Social work coordinated Request for Medical Evaluation to DMV but family changed their mind and would like to readdress this issue in [MASKED] when driver's license up for renewal. This was discussed w PCP. Recommend referring patient to Drive Wise program. [MASKED] on CKD: According to patient charts, baseline Cr 2.2, with increase to from 2.8 [MASKED], most likely I/s/o poor PO intake. Mr. [MASKED] was given 1L of fluid, encouraged PO intake, and diuretics were held, and Cr slowly recovered back down to baseline. Discharge Cr 2.0. #Abd pain: #Constipation: #R inguinal hernia Pt developed short episode of severe abdominal pain with PO intake in [MASKED]. CT A and P concerning for gallstones with some obstruction of the CBD and resultant intrahepatic bile duct dilatation, concerning for Mirizzi syndrome. Surgery evaluated in [MASKED] and thought symptoms not consistent with biliary pathology, particularly in the setting of normal LFTs. Got one dose of Cipro/Flagyl however did not continue. Pt endorsed improvement of pain with bowel movement, and states that felt constipated prior. Optimized bowel regimen. Subsequently, pain continued, but localized much more the RLQ, and clinically thought to be most likely due to his inguinal hernia. #Bradycardia: [MASKED] worked with patient in the [MASKED] and noted bradycardia to [MASKED] at that time. Given this as well as patient's unclear cause for fall, some concern for intermittent heart block with exercise which would raise concern for nodal disease. No further bradycardia noted on Telemetry however noted to have occasional PVCs and bigeminy. #Fall: Most likely mechanical based on story. No clear evidence of orthostasis or vagal symptoms. Low concern for sz given no post ictal state. Only concern is bradycardia, so monitored on tele as above. [MASKED] consult recommended discharge to home with home [MASKED]. #Vesicular Rash: Patient noted to have 2 small crops of vesicles on approximately L3 or L4 dermatome with erythematous base, concerning for Shingles. Started empiric 7 day course of Acyclovir [MASKED], to end [MASKED]. DFA was done to confirm diagnosis, results pending at discharge. #Iron deficiency anemia: Noted to be mildly anemic with transferrin saturation 5%, indicative of iron deficiency. Recommend oral iron supplement, concentrated 65mg daily (equivalent of 325) in attempt to prevent constipation. CHRONIC/STABLE: =============== #HTN: Briefly held home diuretics for [MASKED], restarted on discharge. #Hypothyroid: Continued home synthroid #BPH: Continued home tamsulosin Transitional Issues: ==================== [ ] Neurosurgery followup scheduled [MASKED], should wear brace when OOB until then. Family agreeable to [MASKED] supervision until that time, will get home [MASKED] and [MASKED] care as well. [ ] Recommend referring patient to Drive Wise program. [ ] Fracture i/s/o fall raises concern for osteoporosis, would consider empiric treatment with bisphosphonate outpatient. [ ] Cefpodoxime for UTI through [MASKED] to finish 7d course [ ] DNR/DNI per MOLST, copy placed in chart [ ] Pt given short course oxycodone 2.5mg & Lido TD for back pain [ ] Pt started on Miralax and PRN Lactulose for constipation [ ] Started 7 day course of Acyclovir for Shingles [MASKED], end date [MASKED], DFA was done to confirm diagnosis, results pending at discharge. [ ] Family states they will obtain a shower chair for patient to use until cleared by NSGY. [ ] Please recheck iron studies in [MASKED] weeks on iron supplementation #CODE: DNR/DNI per MOLST #CONTACT: HCP: Son ([MASKED]) [MASKED] Daughter [MASKED] [MASKED] H: [MASKED] C: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Meclizine 25 mg PO Q8H:PRN Nausea 2. Levothyroxine Sodium 100 mcg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Tamsulosin 0.4 mg PO QHS 5. Betaxolol Ophth Susp 0.25% 1 DROP BOTH EYES BID 6. Hydrochlorothiazide 25 mg PO DAILY 7. Triamterene 50 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO TID Do not take more than 4 pills per day. 2. Acyclovir 800 mg PO Q8H end after [MASKED] RX *acyclovir 800 mg 1 tablet(s) by mouth three times a day Disp #*20 Tablet Refills:*0 3. Cefpodoxime Proxetil 200 mg PO Q24H Duration: 3 Doses RX *cefpodoxime 200 mg 1 tablet(s) by mouth once a day Disp #*1 Tablet Refills:*0 4. Ferrous Sulfate 65 mg PO DAILY 5. Lactulose 30 mL PO DAILY:PRN constipation RX *lactulose 10 gram/15 mL (15 mL) 15 mL by mouth daily:PRN Disp #*1 Package Refills:*0 6. Lidocaine 5% Patch 1 PTCH TD QAM RX *lidocaine 5 % apply to back pain QAM Disp #*30 Patch Refills:*0 7. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q8h:prn Disp #*8 Tablet Refills:*0 8. Polyethylene Glycol 17 g PO DAILY Constipation RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by mouth once a day Disp #*24 Packet Refills:*0 9. Betaxolol Ophth Susp 0.25% 1 DROP BOTH EYES BID 10. Hydrochlorothiazide 25 mg PO DAILY 11. Levothyroxine Sodium 100 mcg PO DAILY 12. Omeprazole 20 mg PO DAILY 13. Tamsulosin 0.4 mg PO QHS 14. Triamterene 50 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary Diagnoses: L1 burst fracture R flank pain [MASKED] fall History of fall Toxic metabolic encephalopathy [MASKED] Urinary Tract Infection Constipation R inguinal hernia Episode of Bradycardia, PVCs, Bigeminy [MASKED] on CKD [MASKED] dehydration Herpes Zoster Infection (local) Iron deficiency anemia Secondary Diagnoses: CKD HTN Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were initially transferred to the [MASKED] from another hospital because a picture of your back showed that the pain in your back you were feeling was from a fracture in one of the bones in your lower spine (L1 burst fracture). While you were here, we imaged your back and found that you had broken a bone in your lower back (L1 burst fracture) when you fell, and that was causing your pain. The spine doctors [MASKED] and [MASKED] you a brace to wear, all the time when you are not sleeping, for 1 month. You will see Dr. [MASKED] to see how your back is doing. While you were in the hospital you also had some pain in your stomach and a small fever, which was likely because of an infection in your urinary tract. We gave you some antibiotics to take, which you should continue to take after you leave (until [MASKED] in order to treat the infection. You had some spots on your back that look like Shingles, so you need to take medicine for it for the next 7 days. When you leave the hospital, please call Dr. [MASKED] at the number listed below to see if you need X-rays of your back before your appointment. Please wear your back brace every day until then, all day when you aren't in bed. Please continue to take all your medication, including your antibiotics. It is very important that you do not DRIVE AT ALL until you [MASKED] Wise program and are cleared from your neurosurgeon to take the brace off. Driving with the brace puts other people on the road in danger and puts you in danger. It was a pleasure caring for you and we wish you the best. Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"N390",
"E039",
"N400",
"Z87891",
"K5900",
"Z66",
"I129",
"N189",
"D509"
] |
[
"S32011A: Stable burst fracture of first lumbar vertebra, initial encounter for closed fracture",
"G92: Toxic encephalopathy",
"E860: Dehydration",
"G309: Alzheimer's disease, unspecified",
"B029: Zoster without complications",
"F0280: Dementia in other diseases classified elsewhere without behavioral disturbance",
"N390: Urinary tract infection, site not specified",
"F0390: Unspecified dementia without behavioral disturbance",
"E039: Hypothyroidism, unspecified",
"W1809XA: Striking against other object with subsequent fall, initial encounter",
"Y92003: Bedroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause",
"Z8551: Personal history of malignant neoplasm of bladder",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"Z87891: Personal history of nicotine dependence",
"K5900: Constipation, unspecified",
"M810: Age-related osteoporosis without current pathological fracture",
"Z66: Do not resuscitate",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"N189: Chronic kidney disease, unspecified",
"K4090: Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent",
"R001: Bradycardia, unspecified",
"D509: Iron deficiency anemia, unspecified"
] |
10,026,354
| 24,547,356
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma; stabbing left flank, facial trauma
Major Surgical or Invasive Procedure:
___ ORIF of Right mandibular fracture, MMF left mandible
___ ex-lap and control of left intercostal artery bleed
History of Present Illness:
___ year old male who was stabbed in the left flank as
well as struck the left side of face. Patient went to an outside
hospital where he was found to have facial fracture as well as
states
left-sided jaw pain. Patient denies any nausea or vomiting.
Past Medical History:
none
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Constitutional: Comfortable
HEENT: Laceration underneath chin 1.9cm
Blood from left tympanic membrane
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Left flank stab wound
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood
Exam on discharge:
VS: 98.6 97.7 57 121/70 18 98RA
Gen: NAD, A+Ox3
Neuro; WNL
HEENT: PEERL EOMI
Neck: WNL
Cardiac: RRR No MRG
Abd: Soft, NT/ND w/o R/G
Wound: C/d/I w/o erythema or induration
Pertinent Results:
___ 04:20AM BLOOD WBC-9.4 RBC-3.93* Hgb-12.4* Hct-37.2*
MCV-95 MCH-31.6 MCHC-33.3 RDW-12.9 RDWSD-44.6 Plt ___
___ 04:35AM BLOOD WBC-9.0 RBC-3.80* Hgb-12.0* Hct-36.3*
MCV-96 MCH-31.6 MCHC-33.1 RDW-13.1 RDWSD-45.4 Plt ___
___ 02:32AM BLOOD WBC-15.1* RBC-4.14* Hgb-13.3* Hct-40.0
MCV-97 MCH-32.1* MCHC-33.3 RDW-13.8 RDWSD-48.9* Plt ___
___ 06:00AM BLOOD WBC-19.1* RBC-5.28 Hgb-17.3 Hct-50.5
MCV-96 MCH-32.8* MCHC-34.3 RDW-13.4 RDWSD-47.0* Plt ___
___ 04:20AM BLOOD Plt ___
___ 09:00AM BLOOD ___ PTT-24.3* ___
___ 04:20AM BLOOD Glucose-120* UreaN-15 Creat-0.9 Na-136
K-3.9 Cl-99 HCO3-24 AnGap-17
___ 04:20AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.9
___ 09:12AM BLOOD Type-ART pO2-455* pCO2-40 pH-7.30*
calTCO2-20* Base XS--5
___ 07:22AM BLOOD Glucose-125* Lactate-2.6* Na-140 K-4.5
Cl-110*
___ 07:22AM BLOOD Hgb-14.9 calcHCT-45 O2 Sat-97
___ 07:22AM BLOOD freeCa-1.04*
___: cat scan of the orbit:
1. No temporal bone fracture.
2. Partially visualized left mandibular fracture, better seen on
the dedicated facial bone CT.
___: CTA head:
1. Normal head and neck CTA.
2. No acute intracranial abnormality.
3. Displaced fracture involving the left mandibular condyle and
a non-displaced fracture involving the anterior body of the
right mandible between the first and second premolar extending
posteriorly and superiorly.
4. Soft tissue swelling and laceration involving the chin.
___: CT of the sinus:
Comminuted impacted fracture of the left mandibular condyle with
involvement of the temporal-mandibular joint with associated
small foci of air.
Brief Hospital Course:
Mr. ___ is a ___ year old male who was admitted to ___ on
___ with a stab wound to the left flank and facial
fractures. On ___ he was taken to the operating room with
the acute care surgery team for an exploratory laparotomy.
___ was consulted for the right body mandible fracture and left
subcondylar mandible fracture. On ___ he was taken to the
operating room with OMFS for ORIF right body fracture and closed
reduction maxillomandibular fixation.
ICU course:
Patient was taken to the operating room for an exploratory
laparotomy, please see operative note for further details. He
was taken to the ICU intubated post-op not on any pressors. He
remained hemodynamically stable with stable Hcts. He was
extubated on POD0 without issues. OMFS was consulted for his
open mandibular fracture. His ICU course by systems is as
follows:
Neuro: his pain was well controlled with fent and then
intermittent dilaudid
CV: HD stable
Resp: He was extubated on POD0 without issues.
GI: He was initially NPO/IVF until his Hcts remained stable
Heme: Hcts remained stable.
ID: Unasyn was started for an open mandibular fracture
He completed 5 days of Ciprodex ear drops. The patient worked
with ___ who determined that discharge to ___ was
appropriate. The ___ hospital course was otherwise
unremarkable, and only significant for disposition and placement
due to the fact the patient is homeless.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
able to ambulate ad lib. The patient will follow up with Dr.
___ at ___ of Dental Medicine, ___, unit ___, ___ for ___, the Acute Care
Surgery Clinic on ___, and ___ for
outpatient Audiogram on ___
A thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care.
Medications on Admission:
none
Discharge Medications:
1. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL 5 ml by mouth q4hrs Disp #*100
Milliliter Refills:*0
2. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
4. Docusate Sodium (Liquid) 100 mg PO BID
5. Milk of Magnesia 30 mL PO Q6H:PRN Constipation
6. Pseudoephedrine 60 mg PO Q6H:PRN congestion
7. Senna 8.6 mg PO BID:PRN constipation
8. Sodium Chloride Nasal ___ SPRY NU QID:PRN congestion
9. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Trauma:
Left RP abdominal wall bleeding
left mandibular condyle fracture
left mandibular fossa fracture
left TMJ dislocation
Discharge Condition:
Mental Status: Clear and coherent( ___ speaking)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after you involved in an
altercation which resulted in a stabbing injury to the left
flank and injuries to the left side of the face. You sustained a
fracture to your jaw and an abdominal wall bleed. You were taken
to the operating room for an exploratory laparotomy and repair
of your jaw. You incisional pain has been controlled with oral
analgesia. Your vital signs have been stable and you are
preparing for discharge with the following instructions:
Followup Instructions:
___
|
[
"S0262XA",
"S25512A",
"S36892A",
"D696",
"S030XXA",
"D649",
"F1010",
"Y040XXA"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Trauma; stabbing left flank, facial trauma Major Surgical or Invasive Procedure: [MASKED] ORIF of Right mandibular fracture, MMF left mandible [MASKED] ex-lap and control of left intercostal artery bleed History of Present Illness: [MASKED] year old male who was stabbed in the left flank as well as struck the left side of face. Patient went to an outside hospital where he was found to have facial fracture as well as states left-sided jaw pain. Patient denies any nausea or vomiting. Past Medical History: none Social History: [MASKED] Family History: non-contributory Physical Exam: PHYSICAL EXAMINATION: upon admission: [MASKED] Constitutional: Comfortable HEENT: Laceration underneath chin 1.9cm Blood from left tympanic membrane Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Left flank stab wound GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: No rash Neuro: Speech fluent Psych: Normal mood Exam on discharge: VS: 98.6 97.7 57 121/70 18 98RA Gen: NAD, A+Ox3 Neuro; WNL HEENT: PEERL EOMI Neck: WNL Cardiac: RRR No MRG Abd: Soft, NT/ND w/o R/G Wound: C/d/I w/o erythema or induration Pertinent Results: [MASKED] 04:20AM BLOOD WBC-9.4 RBC-3.93* Hgb-12.4* Hct-37.2* MCV-95 MCH-31.6 MCHC-33.3 RDW-12.9 RDWSD-44.6 Plt [MASKED] [MASKED] 04:35AM BLOOD WBC-9.0 RBC-3.80* Hgb-12.0* Hct-36.3* MCV-96 MCH-31.6 MCHC-33.1 RDW-13.1 RDWSD-45.4 Plt [MASKED] [MASKED] 02:32AM BLOOD WBC-15.1* RBC-4.14* Hgb-13.3* Hct-40.0 MCV-97 MCH-32.1* MCHC-33.3 RDW-13.8 RDWSD-48.9* Plt [MASKED] [MASKED] 06:00AM BLOOD WBC-19.1* RBC-5.28 Hgb-17.3 Hct-50.5 MCV-96 MCH-32.8* MCHC-34.3 RDW-13.4 RDWSD-47.0* Plt [MASKED] [MASKED] 04:20AM BLOOD Plt [MASKED] [MASKED] 09:00AM BLOOD [MASKED] PTT-24.3* [MASKED] [MASKED] 04:20AM BLOOD Glucose-120* UreaN-15 Creat-0.9 Na-136 K-3.9 Cl-99 HCO3-24 AnGap-17 [MASKED] 04:20AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.9 [MASKED] 09:12AM BLOOD Type-ART pO2-455* pCO2-40 pH-7.30* calTCO2-20* Base XS--5 [MASKED] 07:22AM BLOOD Glucose-125* Lactate-2.6* Na-140 K-4.5 Cl-110* [MASKED] 07:22AM BLOOD Hgb-14.9 calcHCT-45 O2 Sat-97 [MASKED] 07:22AM BLOOD freeCa-1.04* [MASKED]: cat scan of the orbit: 1. No temporal bone fracture. 2. Partially visualized left mandibular fracture, better seen on the dedicated facial bone CT. [MASKED]: CTA head: 1. Normal head and neck CTA. 2. No acute intracranial abnormality. 3. Displaced fracture involving the left mandibular condyle and a non-displaced fracture involving the anterior body of the right mandible between the first and second premolar extending posteriorly and superiorly. 4. Soft tissue swelling and laceration involving the chin. [MASKED]: CT of the sinus: Comminuted impacted fracture of the left mandibular condyle with involvement of the temporal-mandibular joint with associated small foci of air. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old male who was admitted to [MASKED] on [MASKED] with a stab wound to the left flank and facial fractures. On [MASKED] he was taken to the operating room with the acute care surgery team for an exploratory laparotomy. [MASKED] was consulted for the right body mandible fracture and left subcondylar mandible fracture. On [MASKED] he was taken to the operating room with OMFS for ORIF right body fracture and closed reduction maxillomandibular fixation. ICU course: Patient was taken to the operating room for an exploratory laparotomy, please see operative note for further details. He was taken to the ICU intubated post-op not on any pressors. He remained hemodynamically stable with stable Hcts. He was extubated on POD0 without issues. OMFS was consulted for his open mandibular fracture. His ICU course by systems is as follows: Neuro: his pain was well controlled with fent and then intermittent dilaudid CV: HD stable Resp: He was extubated on POD0 without issues. GI: He was initially NPO/IVF until his Hcts remained stable Heme: Hcts remained stable. ID: Unasyn was started for an open mandibular fracture He completed 5 days of Ciprodex ear drops. The patient worked with [MASKED] who determined that discharge to [MASKED] was appropriate. The [MASKED] hospital course was otherwise unremarkable, and only significant for disposition and placement due to the fact the patient is homeless. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is able to ambulate ad lib. The patient will follow up with Dr. [MASKED] at [MASKED] of Dental Medicine, [MASKED], unit [MASKED], [MASKED] for [MASKED], the Acute Care Surgery Clinic on [MASKED], and [MASKED] for outpatient Audiogram on [MASKED] A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. Medications on Admission: none Discharge Medications: 1. OxycoDONE Liquid [MASKED] mg PO Q4H:PRN pain RX *oxycodone 5 mg/5 mL 5 ml by mouth q4hrs Disp #*100 Milliliter Refills:*0 2. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain 3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 4. Docusate Sodium (Liquid) 100 mg PO BID 5. Milk of Magnesia 30 mL PO Q6H:PRN Constipation 6. Pseudoephedrine 60 mg PO Q6H:PRN congestion 7. Senna 8.6 mg PO BID:PRN constipation 8. Sodium Chloride Nasal [MASKED] SPRY NU QID:PRN congestion 9. TraZODone 50 mg PO QHS:PRN insomnia Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Trauma: Left RP abdominal wall bleeding left mandibular condyle fracture left mandibular fossa fracture left TMJ dislocation Discharge Condition: Mental Status: Clear and coherent( [MASKED] speaking) Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after you involved in an altercation which resulted in a stabbing injury to the left flank and injuries to the left side of the face. You sustained a fracture to your jaw and an abdominal wall bleed. You were taken to the operating room for an exploratory laparotomy and repair of your jaw. You incisional pain has been controlled with oral analgesia. Your vital signs have been stable and you are preparing for discharge with the following instructions: Followup Instructions: [MASKED]
|
[] |
[
"D696",
"D649"
] |
[
"S0262XA: Fracture of subcondylar process of mandible",
"S25512A: Laceration of intercostal blood vessels, left side, initial encounter",
"S36892A: Contusion of other intra-abdominal organs, initial encounter",
"D696: Thrombocytopenia, unspecified",
"S030XXA: Dislocation of jaw",
"D649: Anemia, unspecified",
"F1010: Alcohol abuse, uncomplicated",
"Y040XXA: Assault by unarmed brawl or fight, initial encounter"
] |
10,026,404
| 21,375,571
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
High blood pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___-speaking man w/ PMH of HTN who presents the
emergency room for evaluation of high blood pressure.
Patient was in usual state of health and was asymptomatic but
decided to go to his PCP's office for routine care because he
hadn't seen a doctor for years, and was found to have BP:
260/150 left arm, 248/140 right arm. He was asymptomatic. He was
previously on 4 antihypertensives but stopped these medications
in ___ because he says he felt fine without them, which is the
last time he saw a doctor. He reports a mild headache that
started earlier, was not sudden in onset, and has gotten better
since this morning. He has not had consistent headaches prior to
this one. Denies vision changes, blurry vision, chest pain or
shortness of breath, nausea, vomiting, difficulties urinating,
lightheadedness, both recently and in the past. His PCP then
sent him to the ED.
In the ED, initial vital signs were: 99.1; 74; 216/130; 20; 99%
RA.
- Labs were notable for:
Cr 1.1, WBC 11.1, ALT/AST 46/53, AP 99, TB 0.6, BNP 731 Trop
negative x2
- Imaging:
CXR showed "enlarged cardiomediastinal silhouette. Mild
pulmonary vascular congestion. Subtle right base opacity most
likely relates to vascular congestion although underlying
infection is difficult to exclude."
CT head showed "No acute intracranial process. Possible subtle
ectasia of the distal left vertebral artery and proximal basilar
artery."
- The patient was given:
___ 19:05 IV Labetalol 5 mg
___ 21:09 IV Labetalol 5 mg
___ 21:59 PO/NG Labetalol 100 mg
___ 01:07 PO Aspirin 324 mg
Vitals prior to transfer were: 98.2 63 174/113 21 97%RA
Upon arrival to the floor, patient reports ongoing headache
which is frontal and not associated with change in vision or
other neurologic complaints. Continues to deny other symptoms as
mentioned above.
Past Medical History:
Hypertension
Social History:
___
Family History:
Negative for known cancers, CAD, DM. Mom with HTN, alive. Father
died in his ___ of unknown causes.
Physical Exam:
ADMISSION
=========
VITALS - afebrile ___ 100RA
GENERAL - pleasant, well-appearing, in no apparent distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear
NECK - supple, no LAD, no thyromegaly, JVP not elevated
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - normal bowel sounds, soft, non-tender, non-distended,
no organomegaly
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. No pronator drift, cerebellar
function intact. Gait assessment deferred
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
DISCHARGE
=========
GENERAL - pleasant, well-appearing, in no apparent distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear
NECK - supple, no LAD, no thyromegaly, JVP not elevated
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - normal bowel sounds, soft, non-tender, non-distended,
no organomegaly
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, strength and
sensation grossly intact.
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
Pertinent Results:
ADMISSION
=========
___ 06:55PM BLOOD WBC-11.1* RBC-5.16 Hgb-14.4 Hct-44.4
MCV-86 MCH-27.9 MCHC-32.4 RDW-14.2 RDWSD-43.8 Plt ___
___ 06:55PM BLOOD Neuts-67.8 ___ Monos-9.0 Eos-1.0
Baso-0.5 Im ___ AbsNeut-7.53* AbsLymp-2.38 AbsMono-1.00*
AbsEos-0.11 AbsBaso-0.06
___ 06:55PM BLOOD ___ PTT-32.5 ___
___ 06:55PM BLOOD Glucose-165* UreaN-23* Creat-1.1 Na-139
K-3.4 Cl-101 HCO3-27 AnGap-14
___ 06:55PM BLOOD ALT-46* AST-53* AlkPhos-99 TotBili-0.6
___ 06:55PM BLOOD proBNP-731*
___ 06:55PM BLOOD cTropnT-<0.01
___ 12:21AM BLOOD cTropnT-<0.01
___ 06:55PM BLOOD Albumin-4.0 Calcium-9.2 Phos-3.4 Mg-1.8
PERTINENT
=========
___ 07:05AM BLOOD ALT-29 AST-24 LD(LDH)-247 AlkPhos-99
TotBili-0.9
___ 06:55PM BLOOD Lipase-24
___ 07:05AM BLOOD Albumin-4.1 Calcium-9.5 Phos-3.9 Mg-2.1
Cholest-224*
___ 07:05AM BLOOD %HbA1c-5.9 eAG-123
___ 07:05AM BLOOD Triglyc-154* HDL-49 CHOL/HD-4.6
LDLcalc-144*
___ 07:05AM BLOOD TSH-1.2
DISCHARGE
=========
___ 06:40AM BLOOD WBC-9.1 RBC-5.82 Hgb-16.1 Hct-49.9 MCV-86
MCH-27.7 MCHC-32.3 RDW-14.6 RDWSD-44.8 Plt ___
___ 06:40AM BLOOD Glucose-116* UreaN-29* Creat-1.2 Na-137
K-4.0 Cl-98 HCO3-25 AnGap-18
___ 06:40AM BLOOD Calcium-9.8 Phos-4.4 Mg-1.9
IMAGING
=======
___ CXR PA/L:
Enlarged cardiomediastinal silhouette. Mild pulmonary vascular
congestion. Subtle right base opacity most likely relates to
vascular congestion although underlying infection is difficult
to exclude.
___ NCHCT:
No acute intracranial process. Possible subtle ectasia of the
distal left vertebral artery and proximal basilar artery.
EKG: NSR @ 69 bpm, normal axis, incomplete RBBB, LVH w/
secondary repolarization abnormalities, LAE
___ Renal artery Doppler:
No evidence of renal artery stenosis in the left kidney and
likely no stenosis in the right kidney however the Doppler
examination is somewhat limited due to the patient's limited
ability to hold his breath.
___ TTE:
The left atrial volume index is moderately increased. The
estimated right atrial pressure is ___ mmHg. There is severe
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is mildly depressed (Quantitative (biplane) LVEF = 46%)
secondary to mild global hypokinesis with slightly worse
function of the basal-mid inferior and inferoseptal walls.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The right ventricular free wall
is hypertrophied. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic arch is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is a very small pericardial
effusion. There are no echocardiographic signs of tamponade.
IMPRESSION: Severe concentric left ventricular hypertrophy with
mildly depressed global and regional systolic dysfunction and
increased filling pressure. Mild mitral regurgitation. Mild
pulmonary artery systolic hypertension. Mild dilatation of the
ascending aorta and arch. Very small pericardial effusion.
Findings are suggestive of hypertensive myopathy (with possible
underlying CAD), although an infiltrative process cannot be
excluded.
Brief Hospital Course:
___ Portugese-speaking man w/ PMH of HTN who presents the
emergency room for evaluation of high blood pressure.
#Hypertensive urgency:
Patient presenting with BP of 260/150 at his PCP ___.
Asymptomatic other than a headache, without signs/symptoms of
end organ damage. BNP mildly elevated without prior comparison,
EKG w/ LVH, trop neg x 2, Cr at baseline. Renal artery Doppler
with no evidence of renal artery stenosis. He was previously on
a 4-drug regimen of hctz, lisinopril, nifedipine, and
metoprolol. Labetalol was initiated in the ED with resultant
bradycardia to ___. Started on chlorthalidone 25mg daily,
amlodipine 10mg daily, lisinopril 20mg daily, and carvedilol
12.5mg BID with improvement in blood pressures.
#Cardiovascular disease risk
Patient at increased risk for cardiovascular disease given
longstanding poorly controlled hypertension. Significant LVH
noted on EKG. EF 45% with significant LVH and wall motion
abnormalities seen on TTE. ASCVD risk 16% based on TC of 224,
HDL 49. ___ 154. HbA1c 5.9%. Started on ASA 81 daily,
Atorvastatin 40mg daily.
#Transaminitis: Mild elevation, AST:ALT ~1:1. Initially thought
to be due to NASH given obesity (BMI 31.5). Last viral
serologies from ___ showed hep A immunity, otherwise
unremarkable. Hepatitis serologies sent, which were negative.
Transaminitis resolved on repeat labs, suggesting it may have
been to mild hepatic ischemia in the setting of hypertension.
Transitional Issues
===================
-Continue to monitor BP and adjust blood pressure medications
-Patient started on lisinopril, should have lytes checked at
follow up appointment
-He needs outpatient work up for CAD given focal wall motion
abnormalities on TTE
-Continue counseling on importance of medication compliance
-Continue ASA/statin; continue to monitor cholesterol and
consider titration to high intensity statin if inadequate
response to moderate intensity.
# CONTACT: Wife, ___, ___ or ___
# CODE STATUS: Full code (confirmed)
Medications on Admission:
None
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
Please take in the EVENING
RX *amlodipine 10 mg 1 tablet(s) by mouth daily in the evening
Disp #*30 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Chlorthalidone 25 mg PO DAILY
please take in the MORNING
RX *chlorthalidone 25 mg 1 tablet(s) by mouth daily in the
morning Disp #*30 Tablet Refills:*0
6. Lisinopril 20 mg PO DAILY
please take in the EVENING
RX *lisinopril 20 mg 1 tablet(s) by mouth daily in the evening
Disp #*1 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Hypertensive urgency
SECONDARY
Congestive Heart Failure
Hyperlipidemia
Pre-diabetes
Cardiovascular disease risk
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for choosing to receive your care at ___. You were
admitted for a very high blood pressure, in the setting of
stopping taking your blood pressure medications several years
ago. We restarted your blood pressure medications, with good
improvement in your pressures. We also did an ultrasound study
of your heart, which showed that the high blood pressure has
decreased its efficiency. You had blood tests for cholesterol
and diabetes, which showed high cholesterol and risk for
diabetes; you should try to minimize sugary and fatty foods and
limit carbohydrates in your diet moving forward.
You were prescribed 6 new medications here in the hospital,
which you should take moving forward. You should also follow up
with your primary care provider at the appointment listed below.
Moving forward, you should exercise caution when standing up
quickly because your body is used to the higher pressures; it
will eventually adjust, so that you don't become dizzy when you
stand.
We wish you the best with your ongoing recovery.
Sincerely,
your ___ care team
Followup Instructions:
___
|
[
"I110",
"I43",
"I5042",
"G4489",
"Z7982",
"E785",
"R7309",
"I2510",
"I256"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: High blood pressure Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] [MASKED]-speaking man w/ PMH of HTN who presents the emergency room for evaluation of high blood pressure. Patient was in usual state of health and was asymptomatic but decided to go to his PCP's office for routine care because he hadn't seen a doctor for years, and was found to have BP: 260/150 left arm, 248/140 right arm. He was asymptomatic. He was previously on 4 antihypertensives but stopped these medications in [MASKED] because he says he felt fine without them, which is the last time he saw a doctor. He reports a mild headache that started earlier, was not sudden in onset, and has gotten better since this morning. He has not had consistent headaches prior to this one. Denies vision changes, blurry vision, chest pain or shortness of breath, nausea, vomiting, difficulties urinating, lightheadedness, both recently and in the past. His PCP then sent him to the ED. In the ED, initial vital signs were: 99.1; 74; 216/130; 20; 99% RA. - Labs were notable for: Cr 1.1, WBC 11.1, ALT/AST 46/53, AP 99, TB 0.6, BNP 731 Trop negative x2 - Imaging: CXR showed "enlarged cardiomediastinal silhouette. Mild pulmonary vascular congestion. Subtle right base opacity most likely relates to vascular congestion although underlying infection is difficult to exclude." CT head showed "No acute intracranial process. Possible subtle ectasia of the distal left vertebral artery and proximal basilar artery." - The patient was given: [MASKED] 19:05 IV Labetalol 5 mg [MASKED] 21:09 IV Labetalol 5 mg [MASKED] 21:59 PO/NG Labetalol 100 mg [MASKED] 01:07 PO Aspirin 324 mg Vitals prior to transfer were: 98.2 63 174/113 21 97%RA Upon arrival to the floor, patient reports ongoing headache which is frontal and not associated with change in vision or other neurologic complaints. Continues to deny other symptoms as mentioned above. Past Medical History: Hypertension Social History: [MASKED] Family History: Negative for known cancers, CAD, DM. Mom with HTN, alive. Father died in his [MASKED] of unknown causes. Physical Exam: ADMISSION ========= VITALS - afebrile [MASKED] 100RA GENERAL - pleasant, well-appearing, in no apparent distress HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear NECK - supple, no LAD, no thyromegaly, JVP not elevated CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs or gallops PULMONARY - clear to auscultation bilaterally, without wheezes or rhonchi ABDOMEN - normal bowel sounds, soft, non-tender, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema SKIN - without rash NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation, with strength [MASKED] throughout. No pronator drift, cerebellar function intact. Gait assessment deferred PSYCHIATRIC - listen & responds to questions appropriately, pleasant DISCHARGE ========= GENERAL - pleasant, well-appearing, in no apparent distress HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear NECK - supple, no LAD, no thyromegaly, JVP not elevated CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs or gallops PULMONARY - clear to auscultation bilaterally, without wheezes or rhonchi ABDOMEN - normal bowel sounds, soft, non-tender, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema SKIN - without rash NEUROLOGIC - A&Ox3, CN II-XII grossly normal, strength and sensation grossly intact. PSYCHIATRIC - listen & responds to questions appropriately, pleasant Pertinent Results: ADMISSION ========= [MASKED] 06:55PM BLOOD WBC-11.1* RBC-5.16 Hgb-14.4 Hct-44.4 MCV-86 MCH-27.9 MCHC-32.4 RDW-14.2 RDWSD-43.8 Plt [MASKED] [MASKED] 06:55PM BLOOD Neuts-67.8 [MASKED] Monos-9.0 Eos-1.0 Baso-0.5 Im [MASKED] AbsNeut-7.53* AbsLymp-2.38 AbsMono-1.00* AbsEos-0.11 AbsBaso-0.06 [MASKED] 06:55PM BLOOD [MASKED] PTT-32.5 [MASKED] [MASKED] 06:55PM BLOOD Glucose-165* UreaN-23* Creat-1.1 Na-139 K-3.4 Cl-101 HCO3-27 AnGap-14 [MASKED] 06:55PM BLOOD ALT-46* AST-53* AlkPhos-99 TotBili-0.6 [MASKED] 06:55PM BLOOD proBNP-731* [MASKED] 06:55PM BLOOD cTropnT-<0.01 [MASKED] 12:21AM BLOOD cTropnT-<0.01 [MASKED] 06:55PM BLOOD Albumin-4.0 Calcium-9.2 Phos-3.4 Mg-1.8 PERTINENT ========= [MASKED] 07:05AM BLOOD ALT-29 AST-24 LD(LDH)-247 AlkPhos-99 TotBili-0.9 [MASKED] 06:55PM BLOOD Lipase-24 [MASKED] 07:05AM BLOOD Albumin-4.1 Calcium-9.5 Phos-3.9 Mg-2.1 Cholest-224* [MASKED] 07:05AM BLOOD %HbA1c-5.9 eAG-123 [MASKED] 07:05AM BLOOD Triglyc-154* HDL-49 CHOL/HD-4.6 LDLcalc-144* [MASKED] 07:05AM BLOOD TSH-1.2 DISCHARGE ========= [MASKED] 06:40AM BLOOD WBC-9.1 RBC-5.82 Hgb-16.1 Hct-49.9 MCV-86 MCH-27.7 MCHC-32.3 RDW-14.6 RDWSD-44.8 Plt [MASKED] [MASKED] 06:40AM BLOOD Glucose-116* UreaN-29* Creat-1.2 Na-137 K-4.0 Cl-98 HCO3-25 AnGap-18 [MASKED] 06:40AM BLOOD Calcium-9.8 Phos-4.4 Mg-1.9 IMAGING ======= [MASKED] CXR PA/L: Enlarged cardiomediastinal silhouette. Mild pulmonary vascular congestion. Subtle right base opacity most likely relates to vascular congestion although underlying infection is difficult to exclude. [MASKED] NCHCT: No acute intracranial process. Possible subtle ectasia of the distal left vertebral artery and proximal basilar artery. EKG: NSR @ 69 bpm, normal axis, incomplete RBBB, LVH w/ secondary repolarization abnormalities, LAE [MASKED] Renal artery Doppler: No evidence of renal artery stenosis in the left kidney and likely no stenosis in the right kidney however the Doppler examination is somewhat limited due to the patient's limited ability to hold his breath. [MASKED] TTE: The left atrial volume index is moderately increased. The estimated right atrial pressure is [MASKED] mmHg. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (Quantitative (biplane) LVEF = 46%) secondary to mild global hypokinesis with slightly worse function of the basal-mid inferior and inferoseptal walls. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The right ventricular free wall is hypertrophied. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Severe concentric left ventricular hypertrophy with mildly depressed global and regional systolic dysfunction and increased filling pressure. Mild mitral regurgitation. Mild pulmonary artery systolic hypertension. Mild dilatation of the ascending aorta and arch. Very small pericardial effusion. Findings are suggestive of hypertensive myopathy (with possible underlying CAD), although an infiltrative process cannot be excluded. Brief Hospital Course: [MASKED] Portugese-speaking man w/ PMH of HTN who presents the emergency room for evaluation of high blood pressure. #Hypertensive urgency: Patient presenting with BP of 260/150 at his PCP [MASKED]. Asymptomatic other than a headache, without signs/symptoms of end organ damage. BNP mildly elevated without prior comparison, EKG w/ LVH, trop neg x 2, Cr at baseline. Renal artery Doppler with no evidence of renal artery stenosis. He was previously on a 4-drug regimen of hctz, lisinopril, nifedipine, and metoprolol. Labetalol was initiated in the ED with resultant bradycardia to [MASKED]. Started on chlorthalidone 25mg daily, amlodipine 10mg daily, lisinopril 20mg daily, and carvedilol 12.5mg BID with improvement in blood pressures. #Cardiovascular disease risk Patient at increased risk for cardiovascular disease given longstanding poorly controlled hypertension. Significant LVH noted on EKG. EF 45% with significant LVH and wall motion abnormalities seen on TTE. ASCVD risk 16% based on TC of 224, HDL 49. [MASKED] 154. HbA1c 5.9%. Started on ASA 81 daily, Atorvastatin 40mg daily. #Transaminitis: Mild elevation, AST:ALT ~1:1. Initially thought to be due to NASH given obesity (BMI 31.5). Last viral serologies from [MASKED] showed hep A immunity, otherwise unremarkable. Hepatitis serologies sent, which were negative. Transaminitis resolved on repeat labs, suggesting it may have been to mild hepatic ischemia in the setting of hypertension. Transitional Issues =================== -Continue to monitor BP and adjust blood pressure medications -Patient started on lisinopril, should have lytes checked at follow up appointment -He needs outpatient work up for CAD given focal wall motion abnormalities on TTE -Continue counseling on importance of medication compliance -Continue ASA/statin; continue to monitor cholesterol and consider titration to high intensity statin if inadequate response to moderate intensity. # CONTACT: Wife, [MASKED], [MASKED] or [MASKED] # CODE STATUS: Full code (confirmed) Medications on Admission: None Discharge Medications: 1. Amlodipine 10 mg PO DAILY Please take in the EVENING RX *amlodipine 10 mg 1 tablet(s) by mouth daily in the evening Disp #*30 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Carvedilol 12.5 mg PO BID RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Chlorthalidone 25 mg PO DAILY please take in the MORNING RX *chlorthalidone 25 mg 1 tablet(s) by mouth daily in the morning Disp #*30 Tablet Refills:*0 6. Lisinopril 20 mg PO DAILY please take in the EVENING RX *lisinopril 20 mg 1 tablet(s) by mouth daily in the evening Disp #*1 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY Hypertensive urgency SECONDARY Congestive Heart Failure Hyperlipidemia Pre-diabetes Cardiovascular disease risk Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], Thank you for choosing to receive your care at [MASKED]. You were admitted for a very high blood pressure, in the setting of stopping taking your blood pressure medications several years ago. We restarted your blood pressure medications, with good improvement in your pressures. We also did an ultrasound study of your heart, which showed that the high blood pressure has decreased its efficiency. You had blood tests for cholesterol and diabetes, which showed high cholesterol and risk for diabetes; you should try to minimize sugary and fatty foods and limit carbohydrates in your diet moving forward. You were prescribed 6 new medications here in the hospital, which you should take moving forward. You should also follow up with your primary care provider at the appointment listed below. Moving forward, you should exercise caution when standing up quickly because your body is used to the higher pressures; it will eventually adjust, so that you don't become dizzy when you stand. We wish you the best with your ongoing recovery. Sincerely, your [MASKED] care team Followup Instructions: [MASKED]
|
[] |
[
"I110",
"E785",
"I2510"
] |
[
"I110: Hypertensive heart disease with heart failure",
"I43: Cardiomyopathy in diseases classified elsewhere",
"I5042: Chronic combined systolic (congestive) and diastolic (congestive) heart failure",
"G4489: Other headache syndrome",
"Z7982: Long term (current) use of aspirin",
"E785: Hyperlipidemia, unspecified",
"R7309: Other abnormal glucose",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"I256: Silent myocardial ischemia"
] |
10,026,754
| 22,691,839
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PSYCHIATRY
Allergies:
Opioids - Morphine Analogues / Sulfa (Sulfonamide Antibiotics) /
fluoxetine / naproxen / oxcarbazepine
Attending: ___.
Chief Complaint:
"I don't feel safe in my apartment."
Major Surgical or Invasive Procedure:
none
History of Present Illness:
For further details of the history and presentation, please see
OMR including Dr. ___ initial consultation note dated
___ and Dr. ___ admission note.
.
Briefly, this is a ___ year old single woman with medical history
significant for congenital deafness, PE (on Eloquis), HTN,
fibromyalgia with numerous psychiatric diagnoses (bipolar
disorder, schizoaffective disorder, PTSD, depression with
psychotic features) characterized by chronic depression,
reactive mood and chronic irritability, history of aggressive
and assaultive behaviors in the past with prior diagnoses of
borderline personality disorder, who presented to ___
complaining of knee pain. Psychiatry was initially consulted as
the patient reported feeling unsafe.
.
Upon initial interview in the ED, patient reported she did not
feel safe in her apartment but was notably a vague historian
stating, "I can't share all the information yet." Denied plan to
harm herself and when asked if she was worried someone else
might harm her she said, "not really." Of note, patient refused
to
continue the remainder of the interview with Dr. ___.
.
ED Course: patient was in good behavioral control and did not
require physical or chemical restraints.
.
On initial interview with Dr. ___, patient was
notably irritable and difficult to engage in the interview,
firing one video ASL interpreter after she was asked for
clarification telling the interpreter to "fuck off." Patient
admitted she often has "a lot of emotions" and can become "very
angry." Notably
angry when asked to relinquish her iPad per unit protocol,
signing, "don't you know who I am?" stating she used to be a
priest. She then became hostile directing multiple expletives at
nursing, demanding discharge from the unit. She eventually
calmed following the establishment of a compromise allowing her
to use the device during three agreed upon hours daily.
.
On my interview with Ms. ___, who was see in the presence of
an ASL interpreter and was notably irritable and hostile on
examination, she stated she is here because "I was having
medical problems." Of note, she begins the interview stating, "I
have a ___ degree in education and I could be a
psychiatrist too." Noted she came to the hospital because "I
need treatment for my medications and my emotional problems-- I
was really angry because I found out that ___ (the phone
company) fooled me... it's a long story but I prefer not to talk
to you about it." She then went on to state she came to ___ ED
because of edema and was subsequently diagnosed with a ___
cyst, "then they sent me up here and I don't know why... it's
not my decision."
.
Ms. ___ reported she is currently being followed by ___ Mental ___, but has been "trying to dissociate
with them because there are only two good people there and they
are short on staff." Although vague, patient did report that
recently she had a team meeting with her outpatient providers
where, "I got angry because I have more education than all 3 of
them... they feel I am getting worse and I accused them of
neglect." Reported she has been depressed but would not clarify
when it started or what her symptoms were. However, denies
suicidal ideation or thoughts of self harm.
.
When asked what would be helpful, patient stated she needed to
be transferred to the "deaf unit" at ___
for "24 hour care" but could not state why she felt she needed
to be there other than, "I want to understand why I have edema
and a blood clot. She does note that she recently had to move
from ___ area to ___, and felt this was unfair. I did
attempt to discuss the risks and benefits of increasing her
Latuda vs. changing to a different antipsychotic-- patient was
initially agreeable to increasing the medication but then later
changed her mind, stating, "don't touch my medications... fuck
off."
.
Psychiatric review of systems were not obtained as patient
refused to answer, frequently giving the treatment team the
finger during the interview.
Past Medical History:
Past psychiatric history: Per OMR, patient:
Per Dr. ___ consultation note dated ___,
there was a questionable history of depression at age ___ when
she
had a possible suicide attempt by cutting herself while shaving
with subsequent hospitalization. She is s/p numerous psychiatric
hospitalizations including ___, ___ and
___. She carries numerous psychiatric
diagnoses including schizoaffective disorder, depression with
psychotic features. She has had numerous medication trials
including venlafaxine, lamotrigine, lorazepam, quetiapine,
topiramate, trazodone, olanzapine, risperidone, gabapentin,
bupropion, buspirone. She currently receives ___ services
including ___ (therapist)
* PCP ___ ___
* ___ worker ___ ___
* ___ ___
* ___ case manager ___ ___
PAST MEDICAL HISTORY:
- Congenital deafness
- COPD
- GERD
- H/o atypical chest pain
- Restless leg syndrome
- Fibromyalgia
- OA
- Obesity
- HTN
- T2DM
- s/p CCY
- s/p hysterectomy and oophorectomy
Social History:
Personal and Social History: Per patient and OMR: Patient
reportedly born in ___ and raised in ___. She is
the youngest of two children and has a brother who is ___ years
older and is her legal guardian. Of note, her brother is also
deaf. Patient described her childhood as, "good... happy, my
parents were great and I was not easy to raise-- I was angry but
high functioning." Parents reportedly divorced when she was ___
years. Reported she attended the ___ where she was
"forced to learn how to speak." Of note, the patient reported
her parents were unable to learn ASL when she was a child and it
is unclear how they communicated. Ms. ___ reported, "my
parents
wanted me to become hearing," which she found difficult, but
patient stated that "my mother's last words were that she was
sorry for what I went through." Stated that she was able to
communicate with her brother, who is also deaf, but that they
grew apart ("fuck him") when he retired. Stated he is currently
married and she and her sister in law used to be close. Patient
reported her mother died in ___.
.
In terms of education, after ___, patient stated she then
attended ___ and did well there, graduating and
studying at ___ where she was
studying social work. However, she was involved in a physical
altercation with another student and forced to leave the dorms.
At that point she then transferred to another ___ and
reportedly obtained a ___ degree in educational technology.
Of note, patient stated, "if I get a lot of support then I can
succeed." Reports she has worked in the past with her last "good
job" in ___ as an ___. Currently single,
lives alone in an apartment in ___.
.
Substance use history:
- Alcohol: history of alcohol use disorder with patient
reporting she has been in remission for approximately ___ years.
However, her discharge summary dated ___, patient was
hospitalized in ___ at ___ for alcohol relapse and has a
history in ___ of opiate medication misuse
- Illicits: history of opiate use in the past, patient reports
she has been sober for approximately ___ years
- Tobacco: smokes 10 cigarettes per day
Family History:
Father with depression and alcohol/prescription drug abuse.
Mother with alcohol abuse, per OMR, brother also with alcohol
use disorder
Physical Exam:
VS: T 97.7 PO; BP 147 / 93; HR 69; SpO2 97%
General: Middle-aged female in NAD. Well-nourished,
well-developed. Appears stated age.
HEENT: Normocephalic, atraumatic. PERRL, EOMI. Oropharynx clear.
Missing several teeth.
Neck: Supple.
Back: No significant deformity.
Lungs: CTA ___. No crackles, wheezes, or rhonchi.
CV: RRR, no murmurs/rubs/gallops.
Abdomen: +BS, soft, nontender, non-distended.
Extremities: No clubbing or cyanosis, trace pitting edema BLE.
Skin: No rashes, abrasions, scars, or lesions.
Neurological:
Cranial Nerves:
-Pupils symmetry and responsiveness to light and accommodation:
PERRLA
-Visual fields: full to confrontation
-EOM: full
-Facial sensation to light touch in all 3 divisions: equal
-Facial symmetry on eye closure and smile: symmetric
-Hearing bilaterally to rubbing fingers: impaired (wearing
bilateral hearing aids)
-Phonation: normal
-Shoulder shrug: intact
-Tongue: midline
Motor: Normal bulk and tone bilaterally. No abnormal movements,
no tremor.
Strength: Moves all four extremities spontaneously and equally.
Sensation: Intact to light touch throughout.
Gait: Steady. Normal stance and posture. No truncal ataxia.
Cognition:
Wakefulness/alertness: awake and alert
Attention: attends to interview
Orientation: oriented to person, time, place, situation
Memory: intact to recent and past history
Fund of knowledge: consistent with education
Calculations: will not answer per agitation
Abstraction: will not answer per agitation
Speech: does not produce audible language
Language: per interpreter fluent and coherent ASL; does not
produce interpretable audible speech
Mental Status:
Appearance: No apparent distress, appears stated age, missing
several teeth, somewhat disheveled, appropriately dressed in
hospital gown, wearing glasses and bilateral hearing aids
Behavior: Initially calm and cooperative, signing fluently, but
later becomes irritable, signing a number of expletives
Mood and Affect: "I'm not safe" / full range, initially
euthymic,
later irritable
Thought Process: Tangential, answers questions only after
several
attempts; positive LOA; difficult to interrupt or redirect
Thought Content: denies explicit SI/HI but states that she does
not feel safe and alludes to someone she attempted to hurt
outside the hospital; no evidence of AVH, no evidence of bizarre
delusions, cannot fully assess paranoia due to patient's
tangentiality and later irritability
Judgment and Insight: Limited/limited
.
Discharge Examination:
VS: T 97.6 BP 140/84 HR 71 RR 16 O2 sat 95
A/B: Appears stated age, dressed casually with good hygiene and
grooming, calm, cooperative with interviewer, good eye contact,
no psychomotor agitation or retardation noted
S: N/A (deaf)
M: "okay"
A: euthymic, mood congruent, appropriate
TC: Denies SI/HI, AVH
TP: linear, goal and future oriented
C: awake, alert and oriented x3
I/J: fair/fair
Activity Status: Ambulatory - Independent
Pertinent Results:
Labs:
___: Na: 133
___: K: 4.9 (Hemolysis falsely elevates this test)
___: Cl: 98
___: CO2: 20*
___: BUN: 12
___: Creat: 1.0
___: Glucose: 95 (If fasting, 70-100 normal, >125
provisional diabetes)
___: Ca: 9.7
___: Mg: 2.3
___: PO4: 2.7 (HEMOLYSIS FALSELY ELEVATES P.)
___: WBC: 7.4
___: HGB: 14.3
___: HCT: 43.9
___: Plt Count: 174
___: Urine Glucose (Hem): NEG
___: Urine Protein (Hem): NEG
___: Urine Bilirubin (Hem): NEG
___: Urobilinogen: NEG
___: Urine Ketone (Hem): NEG
___: Urine Blood (Hem): NEG
___: Urine Nitrite (Hem): NEG
___: Urine Leuks (Hem): NEG
___: TSH: 1.9
-Urine tox: Negative for benzos, barbituates, opiates, cocaine,
amphetamine, and methadone.
-Serum tox: Negative for aspirin, benzos, barbituates, ethanol,
TCAs and acetaminophen.
Brief Hospital Course:
HOSPITAL COURSE SECTION OF DISCHARGE SUMMARY
This is a ___ year old single woman with medical history
significant for congenital deafness, PE (on Eloquis), HTN,
fibromyalgia with numerous psychiatric diagnoses (bipolar
disorder, schizoaffective disorder, PTSD, depression with
psychotic features) characterized by chronic depression,
reactive mood and chronic irritability, history of aggressive
and assaultive behaviors in the past with prior diagnoses of
borderline personality disorder, who presented to ___
complaining of knee pain. Psychiatry was initially consulted as
the patient reported feeling unsafe with subsequent admission to
___ for diagnostic clarification and treatment
.
Interview with Ms. ___ is somewhat limited given her
irritability and vague nature of relating the history, but
review of the medical record reveals history of chronic
depression and diagnosis of borderline personality disorder with
patient reporting a longstanding history of feeling "angry"
beginning in childhood with apparent chronic depression,
affective instability, irritability and poor psychosocial
functioning, with last period of employment being in ___.
.
Diagnostically, differential is broad and includes bipolar
disorder, although I am unclear if she has had a history of
mania in the past-- she is certainly not manic on my examination
although is admittedly quite irritable on examination. Patient
has reported some periods of paranoia regarding the FBI and was
somewhat disorganized on the admission examination, however, she
does not appear to be responding to internal stimuli, and is
mostly linear and organized on my examination-- I do not believe
she is schizophrenic although there may be underlying psychosis.
Given her history and examination, I am concerned for underlying
character pathology with poor frustration tolerance, affective
instability, maladaptive coping skills and difficulty with
interpersonal relationships. Of note, given her unremarkable
medical workup and reports of abstinence from substances with
negative tox screen, I do not believe that an underlying medical
condition or substances are contributing to her presentation at
this time.
1. LEGAL & SAFETY:
Patient was admitted to Deaconess 4 on a ___, upon
admission, she signed a conditional voluntary form, which was
accepted. She maintained her safety throughout her
hospitalization on 15 minute checks and did not require physical
or chemical restraints during her admission.
2. PSYCHIATRIC:
#) Mood disorder: with etiology likely multifactorial as noted
above
- Patient was compliant in attending groups, where she was
intermittently noted to have underlying paranoia and affective
instability, irritability
- Collateral was obtained from the patients outpatient
providers and brother and they were collaborated with in regards
to discharge and safety planning (see collateral contacts
section below)
She was provided the following psychiatric medications:
-Her home Lamictal 100 mg BID was increased to 100 mg PO QAM
and 125 mg PO QHS
-She was continued on her home Trazodone 100 mg PO QHS
-Her home Lurasidone 80 mg QHS was increased to 120 mg PO QHS
to target underlying paranoia that was consistent with
underlying psychosis in addition to affective instability
-Her home Lorazepam 1 mg PO BID PRN anxiety/insomnia was
downtitrated to Lorazepam 0.5 mg BID given her history of
addiction
-She was offered Ramelteon 8 mg QHS PRN: insomnia with good
effect and was advised to try melatonin over the counter at the
time of discharge.
- Of note, during her hospitalization, patient would frequently
become affective dysregulated and agitated with her treatment
team, cursing, slamming doors. She was also noted to be
provocative at times with staff and peers, nearly assaulting
vulnerable peers, requiring her to be held out of groups at
times. Patient was able to intermittently understand that her
chronic anger was interfering with her ability to work or
sustain relationships. She noted that DBT had been helpful in
the past, and prior to discharge she committed to seeing her
outpatient therapist for DBT for 3 months
- Despite her periods of irritability and agitation, which per
the patient, her family, and her outpatient treaters were
baseline for the patient, she consistently denied suicidal
ideation or thoughts of self harm throughout her hospitalization
and stated she understood that should she become violent and
assault someone she would likely be arrested and face legal
charges
3. MEDICAL
#) History of PE: unprovoked in ___ stable
- Continued on home Eliquis 5 mg po bid
#. GERD: stable
- Continued on home famotidine 40 mg PO daily and ompeprazole 20
mg
daily
#. Urinary incontinence: stable
- Continued on home oxybutynin 5 mg PO TID
#. Hypothyroidism: stable
- Continued on home levothyroxine 50 mcg PO daily
#. HTN: Stable
- Continued on home atenolol 75 mg PO daily
- daily vital signs were monitored
#. Fibromyalgia/chronic pain: stable
- Continued on home gabapentin 600 mg PO TID, cyclobenzaprine 5
mg PO TID, and lidocaine cream was substituted for her home
lidocaine 2% jelly
#. Constipation: The patient was continued on docusate 100 mg PO
TID and senna 8.6 mg
PO QID as well as miralax PRN.
5. PSYCHOSOCIAL
#) GROUPS/MILIEU:
The patient was encouraged to participate in the various groups
and milieu therapy opportunities offered by the unit, which she
was often compliant in attending. The patient was visible in
the milieu, often sitting with others, often coloring, however
at times she had some difficulties, getting into arguments with
other patients and at times giving them the finger.
#) COLLATERAL CONTACTS & FAMILY INVOLVEMENT:
On ___ a meeting was held along with the ___ interpreter,
Attending Psychiatrist, SW, her outpatient team from ___ ___ and ___ and (via phone) her brother
___. The outpt team and pt's brother expressed their concerns
about ongoing anger issues for pt, intermittent compliance with
treatment, simultaneous desire and rejection of help. ___
also raised some of the issues around money for pt and her
difficulties in managing it well. Pt was upset at times and said
she was justified in her feelings. We tried to validate pt's
feelings while inviting her to look at what had been happening
vis-à-vis her behaviors. Pt was open to agreeing to DBT
treatment, to once-weekly therapy, and to dealing more
thoughtfully with her outpatient team. ___ noted that pt had
been wanting more help for past ___ years and hoped she would take
advantage of the help she had available to her. Of note, her
treatment team was in agreement with this plan.
The team was also in touch with ___ NP, the patient's
psychopharmacologist as well as her PCP ___ her
medication regimen.
RISK ASSESSMENT
On presentation, the patient was evaluated and felt to be at an
increased risk of harm to herself and/or others based upon
static risk factors including Caucasian race, single status,
chronic medical illnesses, and modifiable risk factors including
difficult relationship with outpatient providers, irritability
and impulsivity, and inability to deny SI at the time of
admission. The modifiable risk factors were addressed during
this hospitalization through the provision of individual, group
and milieu therapy aimed at improving coping skills, a family
meeting held with her outpatient providers and brother with the
goal of improving her relationship with them and improving her
willingness to engage in treatment, and medication adjustments
targeting her impulsivity and irritability. Finally, the
patient is being discharged with many protective risk factors
including help-seeking nature, future oriented viewpoint,
patient not endorsing SI or HI, no current substance abuse, and
agreement to work with her outpatient treaters in a more
thoughtful manner and to engage in once a week DBT therapy.
Overall based on the totality of our assessment at this time,
the patient is not at an acutely elevated risk of self-harm nor
danger to others.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LamoTRIgine 100 mg PO BID
2. Polyethylene Glycol 17 g PO Frequency is Unknown
3. Acetaminophen 325 mg PO Frequency is Unknown
4. Lidocaine Jelly 2% 1 Appl TP TID PRN pain
5. Gabapentin 300 mg PO TID
6. Apixaban 5 mg PO BID
7. Docusate Sodium 100 mg PO TID
8. Cyclobenzaprine 5 mg PO TID
9. Nicotine Polacrilex 2 mg PO Q1H:PRN nicotine cravings
10. Vitamin D ___ UNIT PO DAILY
11. Oxybutynin 5 mg PO TID
12. Famotidine 40 mg PO DAILY
13. TraZODone 100 mg PO QHS
14. Senna 8.6 mg PO QID
15. Omeprazole 20 mg PO DAILY
16. Levothyroxine Sodium 50 mcg PO DAILY
17. Ketoconazole Shampoo 1 Appl TP Frequency is Unknown
18. Atenolol 75 mg PO DAILY
19. LORazepam 1 mg PO BID
20. Latuda (lurasidone) 80 mg oral QHS
Discharge Medications:
1. HydrOXYzine 25 mg PO Q6H:PRN anxiety or agitation
RX *hydroxyzine HCl 25 mg 1 tab by mouth every 6 hours Disp #*40
Tablet Refills:*0
2. lurasidone 120 mg oral Q1700
RX *lurasidone [Latuda] 120 mg 1 tablet(s) by mouth daily Disp
#*15 Tablet Refills:*0
3. melatonin 300 mcg oral QHS:PRN insomnia
RX *melatonin 300 mcg 1 tablet(s) by mouth nightly as needed
Disp #*14 Tablet Refills:*0
4. Ketoconazole Shampoo 1 Appl TP ASDIR
5. LamoTRIgine 100 mg PO QAM
RX *lamotrigine 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
6. LamoTRIgine 125 mg PO QHS
RX *lamotrigine 25 mg 1 tablet(s) by mouth QPM Disp #*15 Tablet
Refills:*0
7. LORazepam 0.5 mg PO BID
RX *lorazepam [Ativan] 0.5 mg 1 tab by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Apixaban 5 mg PO BID
10. Atenolol 75 mg PO DAILY
11. Cyclobenzaprine 5 mg PO TID
12. Docusate Sodium 100 mg PO TID
13. Famotidine 40 mg PO DAILY
14. Gabapentin 300 mg PO TID
15. Levothyroxine Sodium 50 mcg PO DAILY
16. Lidocaine Jelly 2% 1 Appl TP TID PRN pain
17. Omeprazole 20 mg PO DAILY
18. Oxybutynin 5 mg PO TID
19. Senna 8.6 mg PO QID
20. TraZODone 100 mg PO QHS
21. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Unspecified psychotic disorder
Unspecified mood disorder
Borderline personality disorder
Discharge Condition:
VS: T 97.6 BP 140/84 HR 71 RR 16 O2 sat 95
A/B: Appears stated age, dressed casually with good hygiene and
grooming, calm, cooperative with interviewer, good eye contact,
no psychomotor agitation or retardation noted
S: N/A (deaf)
M: 'okay'
A: euthymic, mood congruent, appropriate
TC: Denies SI/HI, AVH
TP: linear, goal and future oriented
C: awake, alert and oriented x3
I/J: fair/fair
Activity Status: Ambulatory - Independent.
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:
___
|
[
"F315",
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"Z6841",
"F17213",
"H903",
"F603",
"Z86711",
"Z7902",
"M797",
"I10",
"E119",
"J449",
"E039",
"K219",
"G2581",
"M1990",
"E669",
"R32",
"K5900",
"M25561",
"M25471",
"F4310",
"X58XXXD",
"R21",
"L853",
"J029",
"G4700"
] |
Allergies: Opioids - Morphine Analogues / Sulfa (Sulfonamide Antibiotics) / fluoxetine / naproxen / oxcarbazepine Chief Complaint: "I don't feel safe in my apartment." Major Surgical or Invasive Procedure: none History of Present Illness: For further details of the history and presentation, please see OMR including Dr. [MASKED] initial consultation note dated [MASKED] and Dr. [MASKED] admission note. . Briefly, this is a [MASKED] year old single woman with medical history significant for congenital deafness, PE (on Eloquis), HTN, fibromyalgia with numerous psychiatric diagnoses (bipolar disorder, schizoaffective disorder, PTSD, depression with psychotic features) characterized by chronic depression, reactive mood and chronic irritability, history of aggressive and assaultive behaviors in the past with prior diagnoses of borderline personality disorder, who presented to [MASKED] complaining of knee pain. Psychiatry was initially consulted as the patient reported feeling unsafe. . Upon initial interview in the ED, patient reported she did not feel safe in her apartment but was notably a vague historian stating, "I can't share all the information yet." Denied plan to harm herself and when asked if she was worried someone else might harm her she said, "not really." Of note, patient refused to continue the remainder of the interview with Dr. [MASKED]. . ED Course: patient was in good behavioral control and did not require physical or chemical restraints. . On initial interview with Dr. [MASKED], patient was notably irritable and difficult to engage in the interview, firing one video ASL interpreter after she was asked for clarification telling the interpreter to "fuck off." Patient admitted she often has "a lot of emotions" and can become "very angry." Notably angry when asked to relinquish her iPad per unit protocol, signing, "don't you know who I am?" stating she used to be a priest. She then became hostile directing multiple expletives at nursing, demanding discharge from the unit. She eventually calmed following the establishment of a compromise allowing her to use the device during three agreed upon hours daily. . On my interview with Ms. [MASKED], who was see in the presence of an ASL interpreter and was notably irritable and hostile on examination, she stated she is here because "I was having medical problems." Of note, she begins the interview stating, "I have a [MASKED] degree in education and I could be a psychiatrist too." Noted she came to the hospital because "I need treatment for my medications and my emotional problems-- I was really angry because I found out that [MASKED] (the phone company) fooled me... it's a long story but I prefer not to talk to you about it." She then went on to state she came to [MASKED] ED because of edema and was subsequently diagnosed with a [MASKED] cyst, "then they sent me up here and I don't know why... it's not my decision." . Ms. [MASKED] reported she is currently being followed by [MASKED] Mental [MASKED], but has been "trying to dissociate with them because there are only two good people there and they are short on staff." Although vague, patient did report that recently she had a team meeting with her outpatient providers where, "I got angry because I have more education than all 3 of them... they feel I am getting worse and I accused them of neglect." Reported she has been depressed but would not clarify when it started or what her symptoms were. However, denies suicidal ideation or thoughts of self harm. . When asked what would be helpful, patient stated she needed to be transferred to the "deaf unit" at [MASKED] for "24 hour care" but could not state why she felt she needed to be there other than, "I want to understand why I have edema and a blood clot. She does note that she recently had to move from [MASKED] area to [MASKED], and felt this was unfair. I did attempt to discuss the risks and benefits of increasing her Latuda vs. changing to a different antipsychotic-- patient was initially agreeable to increasing the medication but then later changed her mind, stating, "don't touch my medications... fuck off." . Psychiatric review of systems were not obtained as patient refused to answer, frequently giving the treatment team the finger during the interview. Past Medical History: Past psychiatric history: Per OMR, patient: Per Dr. [MASKED] consultation note dated [MASKED], there was a questionable history of depression at age [MASKED] when she had a possible suicide attempt by cutting herself while shaving with subsequent hospitalization. She is s/p numerous psychiatric hospitalizations including [MASKED], [MASKED] and [MASKED]. She carries numerous psychiatric diagnoses including schizoaffective disorder, depression with psychotic features. She has had numerous medication trials including venlafaxine, lamotrigine, lorazepam, quetiapine, topiramate, trazodone, olanzapine, risperidone, gabapentin, bupropion, buspirone. She currently receives [MASKED] services including [MASKED] (therapist) * PCP [MASKED] [MASKED] * [MASKED] worker [MASKED] [MASKED] * [MASKED] [MASKED] * [MASKED] case manager [MASKED] [MASKED] PAST MEDICAL HISTORY: - Congenital deafness - COPD - GERD - H/o atypical chest pain - Restless leg syndrome - Fibromyalgia - OA - Obesity - HTN - T2DM - s/p CCY - s/p hysterectomy and oophorectomy Social History: Personal and Social History: Per patient and OMR: Patient reportedly born in [MASKED] and raised in [MASKED]. She is the youngest of two children and has a brother who is [MASKED] years older and is her legal guardian. Of note, her brother is also deaf. Patient described her childhood as, "good... happy, my parents were great and I was not easy to raise-- I was angry but high functioning." Parents reportedly divorced when she was [MASKED] years. Reported she attended the [MASKED] where she was "forced to learn how to speak." Of note, the patient reported her parents were unable to learn ASL when she was a child and it is unclear how they communicated. Ms. [MASKED] reported, "my parents wanted me to become hearing," which she found difficult, but patient stated that "my mother's last words were that she was sorry for what I went through." Stated that she was able to communicate with her brother, who is also deaf, but that they grew apart ("fuck him") when he retired. Stated he is currently married and she and her sister in law used to be close. Patient reported her mother died in [MASKED]. . In terms of education, after [MASKED], patient stated she then attended [MASKED] and did well there, graduating and studying at [MASKED] where she was studying social work. However, she was involved in a physical altercation with another student and forced to leave the dorms. At that point she then transferred to another [MASKED] and reportedly obtained a [MASKED] degree in educational technology. Of note, patient stated, "if I get a lot of support then I can succeed." Reports she has worked in the past with her last "good job" in [MASKED] as an [MASKED]. Currently single, lives alone in an apartment in [MASKED]. . Substance use history: - Alcohol: history of alcohol use disorder with patient reporting she has been in remission for approximately [MASKED] years. However, her discharge summary dated [MASKED], patient was hospitalized in [MASKED] at [MASKED] for alcohol relapse and has a history in [MASKED] of opiate medication misuse - Illicits: history of opiate use in the past, patient reports she has been sober for approximately [MASKED] years - Tobacco: smokes 10 cigarettes per day Family History: Father with depression and alcohol/prescription drug abuse. Mother with alcohol abuse, per OMR, brother also with alcohol use disorder Physical Exam: VS: T 97.7 PO; BP 147 / 93; HR 69; SpO2 97% General: Middle-aged female in NAD. Well-nourished, well-developed. Appears stated age. HEENT: Normocephalic, atraumatic. PERRL, EOMI. Oropharynx clear. Missing several teeth. Neck: Supple. Back: No significant deformity. Lungs: CTA [MASKED]. No crackles, wheezes, or rhonchi. CV: RRR, no murmurs/rubs/gallops. Abdomen: +BS, soft, nontender, non-distended. Extremities: No clubbing or cyanosis, trace pitting edema BLE. Skin: No rashes, abrasions, scars, or lesions. Neurological: Cranial Nerves: -Pupils symmetry and responsiveness to light and accommodation: PERRLA -Visual fields: full to confrontation -EOM: full -Facial sensation to light touch in all 3 divisions: equal -Facial symmetry on eye closure and smile: symmetric -Hearing bilaterally to rubbing fingers: impaired (wearing bilateral hearing aids) -Phonation: normal -Shoulder shrug: intact -Tongue: midline Motor: Normal bulk and tone bilaterally. No abnormal movements, no tremor. Strength: Moves all four extremities spontaneously and equally. Sensation: Intact to light touch throughout. Gait: Steady. Normal stance and posture. No truncal ataxia. Cognition: Wakefulness/alertness: awake and alert Attention: attends to interview Orientation: oriented to person, time, place, situation Memory: intact to recent and past history Fund of knowledge: consistent with education Calculations: will not answer per agitation Abstraction: will not answer per agitation Speech: does not produce audible language Language: per interpreter fluent and coherent ASL; does not produce interpretable audible speech Mental Status: Appearance: No apparent distress, appears stated age, missing several teeth, somewhat disheveled, appropriately dressed in hospital gown, wearing glasses and bilateral hearing aids Behavior: Initially calm and cooperative, signing fluently, but later becomes irritable, signing a number of expletives Mood and Affect: "I'm not safe" / full range, initially euthymic, later irritable Thought Process: Tangential, answers questions only after several attempts; positive LOA; difficult to interrupt or redirect Thought Content: denies explicit SI/HI but states that she does not feel safe and alludes to someone she attempted to hurt outside the hospital; no evidence of AVH, no evidence of bizarre delusions, cannot fully assess paranoia due to patient's tangentiality and later irritability Judgment and Insight: Limited/limited . Discharge Examination: VS: T 97.6 BP 140/84 HR 71 RR 16 O2 sat 95 A/B: Appears stated age, dressed casually with good hygiene and grooming, calm, cooperative with interviewer, good eye contact, no psychomotor agitation or retardation noted S: N/A (deaf) M: "okay" A: euthymic, mood congruent, appropriate TC: Denies SI/HI, AVH TP: linear, goal and future oriented C: awake, alert and oriented x3 I/J: fair/fair Activity Status: Ambulatory - Independent Pertinent Results: Labs: [MASKED]: Na: 133 [MASKED]: K: 4.9 (Hemolysis falsely elevates this test) [MASKED]: Cl: 98 [MASKED]: CO2: 20* [MASKED]: BUN: 12 [MASKED]: Creat: 1.0 [MASKED]: Glucose: 95 (If fasting, 70-100 normal, >125 provisional diabetes) [MASKED]: Ca: 9.7 [MASKED]: Mg: 2.3 [MASKED]: PO4: 2.7 (HEMOLYSIS FALSELY ELEVATES P.) [MASKED]: WBC: 7.4 [MASKED]: HGB: 14.3 [MASKED]: HCT: 43.9 [MASKED]: Plt Count: 174 [MASKED]: Urine Glucose (Hem): NEG [MASKED]: Urine Protein (Hem): NEG [MASKED]: Urine Bilirubin (Hem): NEG [MASKED]: Urobilinogen: NEG [MASKED]: Urine Ketone (Hem): NEG [MASKED]: Urine Blood (Hem): NEG [MASKED]: Urine Nitrite (Hem): NEG [MASKED]: Urine Leuks (Hem): NEG [MASKED]: TSH: 1.9 -Urine tox: Negative for benzos, barbituates, opiates, cocaine, amphetamine, and methadone. -Serum tox: Negative for aspirin, benzos, barbituates, ethanol, TCAs and acetaminophen. Brief Hospital Course: HOSPITAL COURSE SECTION OF DISCHARGE SUMMARY This is a [MASKED] year old single woman with medical history significant for congenital deafness, PE (on Eloquis), HTN, fibromyalgia with numerous psychiatric diagnoses (bipolar disorder, schizoaffective disorder, PTSD, depression with psychotic features) characterized by chronic depression, reactive mood and chronic irritability, history of aggressive and assaultive behaviors in the past with prior diagnoses of borderline personality disorder, who presented to [MASKED] complaining of knee pain. Psychiatry was initially consulted as the patient reported feeling unsafe with subsequent admission to [MASKED] for diagnostic clarification and treatment . Interview with Ms. [MASKED] is somewhat limited given her irritability and vague nature of relating the history, but review of the medical record reveals history of chronic depression and diagnosis of borderline personality disorder with patient reporting a longstanding history of feeling "angry" beginning in childhood with apparent chronic depression, affective instability, irritability and poor psychosocial functioning, with last period of employment being in [MASKED]. . Diagnostically, differential is broad and includes bipolar disorder, although I am unclear if she has had a history of mania in the past-- she is certainly not manic on my examination although is admittedly quite irritable on examination. Patient has reported some periods of paranoia regarding the FBI and was somewhat disorganized on the admission examination, however, she does not appear to be responding to internal stimuli, and is mostly linear and organized on my examination-- I do not believe she is schizophrenic although there may be underlying psychosis. Given her history and examination, I am concerned for underlying character pathology with poor frustration tolerance, affective instability, maladaptive coping skills and difficulty with interpersonal relationships. Of note, given her unremarkable medical workup and reports of abstinence from substances with negative tox screen, I do not believe that an underlying medical condition or substances are contributing to her presentation at this time. 1. LEGAL & SAFETY: Patient was admitted to Deaconess 4 on a [MASKED], upon admission, she signed a conditional voluntary form, which was accepted. She maintained her safety throughout her hospitalization on 15 minute checks and did not require physical or chemical restraints during her admission. 2. PSYCHIATRIC: #) Mood disorder: with etiology likely multifactorial as noted above - Patient was compliant in attending groups, where she was intermittently noted to have underlying paranoia and affective instability, irritability - Collateral was obtained from the patients outpatient providers and brother and they were collaborated with in regards to discharge and safety planning (see collateral contacts section below) She was provided the following psychiatric medications: -Her home Lamictal 100 mg BID was increased to 100 mg PO QAM and 125 mg PO QHS -She was continued on her home Trazodone 100 mg PO QHS -Her home Lurasidone 80 mg QHS was increased to 120 mg PO QHS to target underlying paranoia that was consistent with underlying psychosis in addition to affective instability -Her home Lorazepam 1 mg PO BID PRN anxiety/insomnia was downtitrated to Lorazepam 0.5 mg BID given her history of addiction -She was offered Ramelteon 8 mg QHS PRN: insomnia with good effect and was advised to try melatonin over the counter at the time of discharge. - Of note, during her hospitalization, patient would frequently become affective dysregulated and agitated with her treatment team, cursing, slamming doors. She was also noted to be provocative at times with staff and peers, nearly assaulting vulnerable peers, requiring her to be held out of groups at times. Patient was able to intermittently understand that her chronic anger was interfering with her ability to work or sustain relationships. She noted that DBT had been helpful in the past, and prior to discharge she committed to seeing her outpatient therapist for DBT for 3 months - Despite her periods of irritability and agitation, which per the patient, her family, and her outpatient treaters were baseline for the patient, she consistently denied suicidal ideation or thoughts of self harm throughout her hospitalization and stated she understood that should she become violent and assault someone she would likely be arrested and face legal charges 3. MEDICAL #) History of PE: unprovoked in [MASKED] stable - Continued on home Eliquis 5 mg po bid #. GERD: stable - Continued on home famotidine 40 mg PO daily and ompeprazole 20 mg daily #. Urinary incontinence: stable - Continued on home oxybutynin 5 mg PO TID #. Hypothyroidism: stable - Continued on home levothyroxine 50 mcg PO daily #. HTN: Stable - Continued on home atenolol 75 mg PO daily - daily vital signs were monitored #. Fibromyalgia/chronic pain: stable - Continued on home gabapentin 600 mg PO TID, cyclobenzaprine 5 mg PO TID, and lidocaine cream was substituted for her home lidocaine 2% jelly #. Constipation: The patient was continued on docusate 100 mg PO TID and senna 8.6 mg PO QID as well as miralax PRN. 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit, which she was often compliant in attending. The patient was visible in the milieu, often sitting with others, often coloring, however at times she had some difficulties, getting into arguments with other patients and at times giving them the finger. #) COLLATERAL CONTACTS & FAMILY INVOLVEMENT: On [MASKED] a meeting was held along with the [MASKED] interpreter, Attending Psychiatrist, SW, her outpatient team from [MASKED] [MASKED] and [MASKED] and (via phone) her brother [MASKED]. The outpt team and pt's brother expressed their concerns about ongoing anger issues for pt, intermittent compliance with treatment, simultaneous desire and rejection of help. [MASKED] also raised some of the issues around money for pt and her difficulties in managing it well. Pt was upset at times and said she was justified in her feelings. We tried to validate pt's feelings while inviting her to look at what had been happening vis-à-vis her behaviors. Pt was open to agreeing to DBT treatment, to once-weekly therapy, and to dealing more thoughtfully with her outpatient team. [MASKED] noted that pt had been wanting more help for past [MASKED] years and hoped she would take advantage of the help she had available to her. Of note, her treatment team was in agreement with this plan. The team was also in touch with [MASKED] NP, the patient's psychopharmacologist as well as her PCP [MASKED] her medication regimen. RISK ASSESSMENT On presentation, the patient was evaluated and felt to be at an increased risk of harm to herself and/or others based upon static risk factors including Caucasian race, single status, chronic medical illnesses, and modifiable risk factors including difficult relationship with outpatient providers, irritability and impulsivity, and inability to deny SI at the time of admission. The modifiable risk factors were addressed during this hospitalization through the provision of individual, group and milieu therapy aimed at improving coping skills, a family meeting held with her outpatient providers and brother with the goal of improving her relationship with them and improving her willingness to engage in treatment, and medication adjustments targeting her impulsivity and irritability. Finally, the patient is being discharged with many protective risk factors including help-seeking nature, future oriented viewpoint, patient not endorsing SI or HI, no current substance abuse, and agreement to work with her outpatient treaters in a more thoughtful manner and to engage in once a week DBT therapy. Overall based on the totality of our assessment at this time, the patient is not at an acutely elevated risk of self-harm nor danger to others. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LamoTRIgine 100 mg PO BID 2. Polyethylene Glycol 17 g PO Frequency is Unknown 3. Acetaminophen 325 mg PO Frequency is Unknown 4. Lidocaine Jelly 2% 1 Appl TP TID PRN pain 5. Gabapentin 300 mg PO TID 6. Apixaban 5 mg PO BID 7. Docusate Sodium 100 mg PO TID 8. Cyclobenzaprine 5 mg PO TID 9. Nicotine Polacrilex 2 mg PO Q1H:PRN nicotine cravings 10. Vitamin D [MASKED] UNIT PO DAILY 11. Oxybutynin 5 mg PO TID 12. Famotidine 40 mg PO DAILY 13. TraZODone 100 mg PO QHS 14. Senna 8.6 mg PO QID 15. Omeprazole 20 mg PO DAILY 16. Levothyroxine Sodium 50 mcg PO DAILY 17. Ketoconazole Shampoo 1 Appl TP Frequency is Unknown 18. Atenolol 75 mg PO DAILY 19. LORazepam 1 mg PO BID 20. Latuda (lurasidone) 80 mg oral QHS Discharge Medications: 1. HydrOXYzine 25 mg PO Q6H:PRN anxiety or agitation RX *hydroxyzine HCl 25 mg 1 tab by mouth every 6 hours Disp #*40 Tablet Refills:*0 2. lurasidone 120 mg oral Q1700 RX *lurasidone [Latuda] 120 mg 1 tablet(s) by mouth daily Disp #*15 Tablet Refills:*0 3. melatonin 300 mcg oral QHS:PRN insomnia RX *melatonin 300 mcg 1 tablet(s) by mouth nightly as needed Disp #*14 Tablet Refills:*0 4. Ketoconazole Shampoo 1 Appl TP ASDIR 5. LamoTRIgine 100 mg PO QAM RX *lamotrigine 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 6. LamoTRIgine 125 mg PO QHS RX *lamotrigine 25 mg 1 tablet(s) by mouth QPM Disp #*15 Tablet Refills:*0 7. LORazepam 0.5 mg PO BID RX *lorazepam [Ativan] 0.5 mg 1 tab by mouth twice a day Disp #*30 Tablet Refills:*0 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. Apixaban 5 mg PO BID 10. Atenolol 75 mg PO DAILY 11. Cyclobenzaprine 5 mg PO TID 12. Docusate Sodium 100 mg PO TID 13. Famotidine 40 mg PO DAILY 14. Gabapentin 300 mg PO TID 15. Levothyroxine Sodium 50 mcg PO DAILY 16. Lidocaine Jelly 2% 1 Appl TP TID PRN pain 17. Omeprazole 20 mg PO DAILY 18. Oxybutynin 5 mg PO TID 19. Senna 8.6 mg PO QID 20. TraZODone 100 mg PO QHS 21. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Unspecified psychotic disorder Unspecified mood disorder Borderline personality disorder Discharge Condition: VS: T 97.6 BP 140/84 HR 71 RR 16 O2 sat 95 A/B: Appears stated age, dressed casually with good hygiene and grooming, calm, cooperative with interviewer, good eye contact, no psychomotor agitation or retardation noted S: N/A (deaf) M: 'okay' A: euthymic, mood congruent, appropriate TC: Denies SI/HI, AVH TP: linear, goal and future oriented C: awake, alert and oriented x3 I/J: fair/fair Activity Status: Ambulatory - Independent. 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]
|
[] |
[
"Z7902",
"I10",
"E119",
"J449",
"E039",
"K219",
"E669",
"K5900",
"G4700"
] |
[
"F315: Bipolar disorder, current episode depressed, severe, with psychotic features",
"R45851: Suicidal ideations",
"Z6841: Body mass index [BMI]40.0-44.9, adult",
"F17213: Nicotine dependence, cigarettes, with withdrawal",
"H903: Sensorineural hearing loss, bilateral",
"F603: Borderline personality disorder",
"Z86711: Personal history of pulmonary embolism",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"M797: Fibromyalgia",
"I10: Essential (primary) hypertension",
"E119: Type 2 diabetes mellitus without complications",
"J449: Chronic obstructive pulmonary disease, unspecified",
"E039: Hypothyroidism, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"G2581: Restless legs syndrome",
"M1990: Unspecified osteoarthritis, unspecified site",
"E669: Obesity, unspecified",
"R32: Unspecified urinary incontinence",
"K5900: Constipation, unspecified",
"M25561: Pain in right knee",
"M25471: Effusion, right ankle",
"F4310: Post-traumatic stress disorder, unspecified",
"X58XXXD: Exposure to other specified factors, subsequent encounter",
"R21: Rash and other nonspecific skin eruption",
"L853: Xerosis cutis",
"J029: Acute pharyngitis, unspecified",
"G4700: Insomnia, unspecified"
] |
10,026,754
| 25,864,142
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Opioids - Morphine Analogues / Sulfa (Sulfonamide Antibiotics) /
fluoxetine / naproxen / oxcarbazepine
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year-old woman with PMH significant for
congenital deafness, bipolar disorder, borderline personality
disorder, COPD not on home O2, HTN, and T2DM who presents with
shortness of breath.
Of note, patient's history is very difficult to obtain
secondary to her underlying psychiatric illness. Based on ___
records, the patient is well known to their system with 12 ED
visits per month for a variety of complaints. The patient and
___ documentation both report that she as recently hospitalized
at ___ ("the week ___ where she
as initially admitted to Psychiatric ward then transitioned to
medical floor after being diagnosed with a PE. Patient reports
that her Psychiatric medications were changed, and currently
include "lamictal" and "Risperdal" though she is unaware of
doses, and that she was started on a blood thinner (documented
in ___ system at apixiban 10mg BID). Per ___ Social Work consult
note, there was a plan to discharge the patient to rehab, which
ultimately did not happen. The patient was subsequently
discharged home and has presented to ___ ED several times over
the last week for symptoms of shortness of breath, ear pain, and
asking for help taking care of herself, specifically asking to
be admitted to longterm care. Review of ___ ED records
demonstrates that during her ED visit, work-up included UA, CXR,
EKG all which where unremarkable and treatment with nebulizers.
The patient now presents to ___ ED with similar complaints.
In ___ ED:
- Initial VS 98.6 137 147/98 26 100% RA
- Labs notable for Chem-10 wnl (K 6.2 hemolyzed, repeat whole
blood 4.5), CBC wnl, Trop <0.01, coags wnl, D-dimer 4124,
lactate 2.4
- EKG with SR@95, NANI, TWI III, TW-flattening in aVF and V2-V3
otherwise without evidence of ischemia
- CXR with no acute cardiopulmonary process. CTA chest with
"bilateral lobar, segmental, and subsegmental pulmonary emboli"
of unknown chronicity.
- The patient was administered:
___ 17:53 PO Nicotine Polacrilex 2 mg
___ 17:53 IVF 1000 mL NS 1000 mL
___ 20:04 IV Ondansetron 4 mg
___ 21:34 IV Ondansetron 4 mg
___ 21:34 IVF 1000 mL NS 1000 mL
___ 22:33 PO Nicotine Polacrilex 2 mg
___ 22:47 PO/NG LORazepam 1 mg
___ 22:47 PO/NG LamoTRIgine 200 mg Aumu
___ 22:47 PO/NG QUEtiapine Fumarate 50 mg
___ 22:47 SC Enoxaparin Sodium 120 mg
___ 22:52 PO/NG LORazepam .5 mg
___ 23:24 PO Nicotine Polacrilex 2 mg
- VS prior to transfer 98.3 101 128/61 18 97% RA
Upon arrival to the floor, VS 97.9 148/80 101 20 92%RA. Using
video ASL interpreter, the patient reports that she is coming in
for shortness of breath, emphasizes that she "need[s] help with
her medications" and wants to have "long term placement." She
also endorses slight abdominal pain and nausea. Upon questioning
patient about medical history, medications, and in particular,
with regards to recent Psychiatric hospitalization, patient
becomes easily angered and yells in ASL.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies Denies chest pain or tightness, palpitations.
Denies diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
COPD
Laryngopharyngel areflux
Atypical chest pain
Restless leg syndrome
Fibromyalgia
Osteoarthritis of knee
Obesity
Hypertension
Bipolar disorder
Borderline personality disorder
PTSD
T2DM
Social History:
___
Family History:
Patient did not answer
Physical Exam:
PHYSICAL EXAM UPON ADMISSION:
Vital Signs: 97.9 148/80 101 20 92%RA
General: Obese woman, sitting in bed, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rhythm, slightly tachycardic normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Distant breath sounds secondary to body habitus,
otherwise clear to auscultation bilaterally
Abdomen: Obese, distended, soft with mild tenderness to
palpation, 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.
Psych: Communicated via ASL. Per interpreted, "does not speak
in full sentences." Easily agitated and angry.
PHYSICAL EXAM UPON DISCHARGE:
VS - 98.1 80-101 114/65 16 94 r/a
General: Elderly appearing, obese
HEENT: MMM
CV: RRR, s1 and s2 heard, no m/r/g
Lungs: CTABL, no wheezes/rhonci/crackles
Abdomen: Obese, soft, n/t, no organomegaly, no rebound/garuding
Ext: No ___ edema
Pertinent Results:
LABS UPON ADMISSION:
___ 04:48PM BLOOD WBC-10.1* RBC-4.61 Hgb-14.5 Hct-44.7
MCV-97# MCH-31.5 MCHC-32.4 RDW-15.4 RDWSD-53.2* Plt ___
___ 04:48PM BLOOD Neuts-75.9* Lymphs-15.9* Monos-6.4
Eos-0.9* Baso-0.4 Im ___ AbsNeut-7.66* AbsLymp-1.60
AbsMono-0.65 AbsEos-0.09 AbsBaso-0.04
___ 04:48PM BLOOD ___ PTT-31.9 ___
___ 04:48PM BLOOD ALT-26 AST-50* AlkPhos-92 TotBili-0.4
___ 04:48PM BLOOD Lipase-55
___ 04:48PM BLOOD cTropnT-<0.01 proBNP-1226*
___ 04:48PM BLOOD Albumin-4.0 Calcium-9.9 Phos-2.7 Mg-2.3
___ 04:58PM BLOOD D-Dimer-4124*
___ 04:54PM BLOOD Lactate-2.4* K-4.5
RADIOLOGY:
CTA CHEST ___
IMPRESSION:
1. Bilateral lobar, segmental, and subsegmental pulmonary
emboli. The exact chronicity of these pulmonary emboli is
difficult to determine in the absence of prior studies for
comparison.
2. Minimal reflux of contrast into the inferior vena cava. If
there is
clinical concern for right heart strain recommend echocardiogram
for further evaluation.
KUB ___
IMPRESSION:
No air-fluid levels and gas is seen to the level of the rectum.
No evidence of obstruction. Residual contrast in the kidneys
and bladder.
CARDIOVASCULAR ECHO ___:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The right ventricular
free wall thickness is normal. The right ventricular cavity is
mildly dilated with borderline normal free wall function. The
diameters of aorta at the sinus, ascending and arch levels are
normal. There is no aortic valve stenosis. No aortic
regurgitation is seen. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Normal global and reigonal left ventricular systolic
function. Mild right ventricular dilation/systolic dysfunction.
Mild pulmonary hypertension.
Brief Hospital Course:
___ yo F with congenital deafness, bipolar disorder, borderline
personality disorder, COPD not on home O2, HTN, and T2DM who
presented to ___ on ___ with shortness of breath and
palpitations found to have bilateral submassive PE.
# Submassive pulmonary emboli:
Patient was recently diagnosed with PE at ___
___ for which the patient was started on apixiban earlier
this month. Upon admission, pt reported not taking apixaban on a
daily basis. She noted nausea and dysgeusia ___ apixaban. Given
tachycardia and dyspnea, a CTA was performed which revealed
"bilateral lobar, segmental, and subsegmental pulmonary emboli"
of unknown chronicity. Trop <0.01 and BNP elevated. Patient was
treated with sub q lovenox. An echo was performed which revealed
"normal global and reigonal left ventricular systolic function
and mild right ventricular dilation/systolic dysfunction as well
as mild pulmonary hypertension." Pt remained hemoydnamically
stable thoughout hospitalization. She will remain on
subcutaneous enoxaparin after discharge for treatment of her
pulmonary emboli, while at rehab.
# Psych:
Patient carries diagnoses of bipolar disorder, depression,
borderline personality disorder, and PTSD in ___ records. Upon
admission, she did not know her current psychiatric medications
but is able to name "lamictal" and "risperdal," which is
somewhat inconsistent with ___ documentation. She later noted
that she took all of her psychiatric medications, but given her
history and initial report of non compliance, only some of her
medications were initiated in the hospital. There were also
discrepancies between her PCP medication list (dated in ___
and her ___ discharge medication list (dated in ___. She was
continued on lamotrigine, lorazepam (PRN and scheduled), and
seroquel for agitation. Pt was agitated upon admission but mood
was stable throughout hospitalization. She did refuse lab draws
and urine monitoring during her hospitalization. Psychiatry was
consulted and they agreed with our plan to only continue
medications that the patient said she was taking (lamictal) and
those that she may withdrawal from (lorazepam).
# Social:
Patient reported having a difficult time taking care of herself
at home. Our social work team and case management team were
involved and the patient was discharged to a rehab facility.
# Nausea/vomiting: Patient with nausea/vomiting in ED x1, and
again on arrival to floor x1 upon admission. KUB was normal and
LFTS without evidence of GB pathology, lipase normal. Pt was
initially started on clear liquid diet. When n/v improved, pt
was transitioned to regular diet without further symptoms.
# Largyngopharyngeal reflux:
- Continued home famotidine 40mg daily
- Continued home omeprazole 20mg QHS
# COPD: Currently without evidence of exacerbation. Will
continue home inhalers.
- Continued home tiotroprium
- Continued home Flovent inhaler
- Continued home albuterol inhaler
# Allergies:
- Continued home Flonase PRN
- Continude home loratidine PRN
**Transitional issues**
-Patient reported very poor compliance with her medications
-Patient could not name her medications and had two separate
medication lists, which were different from one another
-Not all of her psychiatric medications were re started during
hospitalization given her poor compliance
-Please ensure follow up with psychiatry
-Patient is on enoxaparin for treatment of her pulmonary emboli.
Please evaluate her likelihood for compliance with this therapy
before discharge from rehab, as if not optimal, she may need to
go back on PO anticoagulation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 10 mg PO BID
2. Cyclobenzaprine 10 mg PO HS:PRN spasticity
3. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
4. Nicotine Patch 14 mg TD DAILY
5. Nicotine Polacrilex 2 mg PO Q2H:PRN tobacco craving
6. Polyethylene Glycol 17 g PO BID
7. Tiotropium Bromide 1 CAP IH DAILY
8. Oxybutynin 5 mg PO TID
9. Lidocaine 5% Patch 1 PTCH TD DAILY
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergy
symptomes
12. Docusate Sodium 100 mg PO TID
13. LamoTRIgine 200 mg PO BID
14. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
15. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze/SOB
16. Benzonatate 200 mg PO TID:PRN cough
17. Atenolol 75 mg PO DAILY
18. Famotidine 40 mg PO DAILY
19. Fluticasone Propionate 110mcg 2 PUFF IH BID
20. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
21. Ibuprofen 800 mg PO Q8H:PRN pain
22. Loratadine 10 mg PO DAILY:PRN allergies
23. LORazepam 0.5 mg PO BID
24. LORazepam 1 mg PO QHS
25. Omeprazole 20 mg PO QHS
26. QUEtiapine Fumarate 50 mg PO TID:PRN agitation
27. Topiramate (Topamax) 150 mg PO BID
28. TraZODone 200 mg PO QHS
29. Venlafaxine 25 mg PO BID
30. Vitamin D ___ UNIT PO DAILY
31. melatonin 5 mg oral DAILY
32. Mupirocin Ointment 2% 1 Appl TP TID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Cyclobenzaprine 10 mg PO HS:PRN spasticity
3. Docusate Sodium 200 mg PO TID
4. Famotidine 40 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergy
symptomes
7. LamoTRIgine 200 mg PO BID
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Loratadine 10 mg PO DAILY:PRN allergies
10. LORazepam 0.5 mg PO BID
11. LORazepam 1 mg PO QHS:PRN insomnia/anxiety
12. Nicotine Patch 14 mg TD DAILY
13. Nicotine Polacrilex 2 mg PO Q2H:PRN tobacco craving
14. Omeprazole 20 mg PO QHS
15. Oxybutynin 5 mg PO TID
16. Polyethylene Glycol 17 g PO BID
17. Tiotropium Bromide 1 CAP IH DAILY
18. TraZODone 200 mg PO QHS
19. Acetaminophen ___ mg PO Q6H:PRN pain/headache
20. Enoxaparin Sodium 110 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
21. Hydrocortisone Cream 1% 1 Appl TP QID:PRN itching right
pinna of affected area
22. Senna 8.6 mg PO BID
23. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze/SOB
24. melatonin 5 mg oral DAILY
25. Mupirocin Ointment 2% 1 Appl TP TID
26. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Bilateral pulmonary emboli
Secondary diagnoses:
COPD
Laryngopharyngel areflux
Atypical chest pain
Restless leg syndrome
Fibromyalgia
Osteoarthritis of knee
Obesity
Hypertension
Bipolar disorder
Borderline personality disorder
PTSD
T2DM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
Why did I come to the hospital?
-You came to the hospital because your heart was racing and you
were having difficulty breathing
What happened while I was in the hospital
-We took a picture of your chest and we found that you have
clots in your lungs
-We treated you with an injectable medication called lovenox.
This medication helps to break up the clot and prevent clots in
the future
What should I do when I leave the hospital?
-You should continue taking all of your medications
-You should take your lovenox every day, twice per day. If you
stop taking this medication, you could have another clot in your
lungs which can cause death.
Followup Instructions:
___
|
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Allergies: Opioids - Morphine Analogues / Sulfa (Sulfonamide Antibiotics) / fluoxetine / naproxen / oxcarbazepine Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [MASKED] is a [MASKED] year-old woman with PMH significant for congenital deafness, bipolar disorder, borderline personality disorder, COPD not on home O2, HTN, and T2DM who presents with shortness of breath. Of note, patient's history is very difficult to obtain secondary to her underlying psychiatric illness. Based on [MASKED] records, the patient is well known to their system with 12 ED visits per month for a variety of complaints. The patient and [MASKED] documentation both report that she as recently hospitalized at [MASKED] ("the week [MASKED] where she as initially admitted to Psychiatric ward then transitioned to medical floor after being diagnosed with a PE. Patient reports that her Psychiatric medications were changed, and currently include "lamictal" and "Risperdal" though she is unaware of doses, and that she was started on a blood thinner (documented in [MASKED] system at apixiban 10mg BID). Per [MASKED] Social Work consult note, there was a plan to discharge the patient to rehab, which ultimately did not happen. The patient was subsequently discharged home and has presented to [MASKED] ED several times over the last week for symptoms of shortness of breath, ear pain, and asking for help taking care of herself, specifically asking to be admitted to longterm care. Review of [MASKED] ED records demonstrates that during her ED visit, work-up included UA, CXR, EKG all which where unremarkable and treatment with nebulizers. The patient now presents to [MASKED] ED with similar complaints. In [MASKED] ED: - Initial VS 98.6 137 147/98 26 100% RA - Labs notable for Chem-10 wnl (K 6.2 hemolyzed, repeat whole blood 4.5), CBC wnl, Trop <0.01, coags wnl, D-dimer 4124, lactate 2.4 - EKG with SR@95, NANI, TWI III, TW-flattening in aVF and V2-V3 otherwise without evidence of ischemia - CXR with no acute cardiopulmonary process. CTA chest with "bilateral lobar, segmental, and subsegmental pulmonary emboli" of unknown chronicity. - The patient was administered: [MASKED] 17:53 PO Nicotine Polacrilex 2 mg [MASKED] 17:53 IVF 1000 mL NS 1000 mL [MASKED] 20:04 IV Ondansetron 4 mg [MASKED] 21:34 IV Ondansetron 4 mg [MASKED] 21:34 IVF 1000 mL NS 1000 mL [MASKED] 22:33 PO Nicotine Polacrilex 2 mg [MASKED] 22:47 PO/NG LORazepam 1 mg [MASKED] 22:47 PO/NG LamoTRIgine 200 mg Aumu [MASKED] 22:47 PO/NG QUEtiapine Fumarate 50 mg [MASKED] 22:47 SC Enoxaparin Sodium 120 mg [MASKED] 22:52 PO/NG LORazepam .5 mg [MASKED] 23:24 PO Nicotine Polacrilex 2 mg - VS prior to transfer 98.3 101 128/61 18 97% RA Upon arrival to the floor, VS 97.9 148/80 101 20 92%RA. Using video ASL interpreter, the patient reports that she is coming in for shortness of breath, emphasizes that she "need[s] help with her medications" and wants to have "long term placement." She also endorses slight abdominal pain and nausea. Upon questioning patient about medical history, medications, and in particular, with regards to recent Psychiatric hospitalization, patient becomes easily angered and yells in ASL. ROS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies Denies chest pain or tightness, palpitations. Denies diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: COPD Laryngopharyngel areflux Atypical chest pain Restless leg syndrome Fibromyalgia Osteoarthritis of knee Obesity Hypertension Bipolar disorder Borderline personality disorder PTSD T2DM Social History: [MASKED] Family History: Patient did not answer Physical Exam: PHYSICAL EXAM UPON ADMISSION: Vital Signs: 97.9 148/80 101 20 92%RA General: Obese woman, sitting in bed, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rhythm, slightly tachycardic normal S1 + S2, no murmurs, rubs, gallops Lungs: Distant breath sounds secondary to body habitus, otherwise clear to auscultation bilaterally Abdomen: Obese, distended, soft with mild tenderness to palpation, 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. Psych: Communicated via ASL. Per interpreted, "does not speak in full sentences." Easily agitated and angry. PHYSICAL EXAM UPON DISCHARGE: VS - 98.1 80-101 114/65 16 94 r/a General: Elderly appearing, obese HEENT: MMM CV: RRR, s1 and s2 heard, no m/r/g Lungs: CTABL, no wheezes/rhonci/crackles Abdomen: Obese, soft, n/t, no organomegaly, no rebound/garuding Ext: No [MASKED] edema Pertinent Results: LABS UPON ADMISSION: [MASKED] 04:48PM BLOOD WBC-10.1* RBC-4.61 Hgb-14.5 Hct-44.7 MCV-97# MCH-31.5 MCHC-32.4 RDW-15.4 RDWSD-53.2* Plt [MASKED] [MASKED] 04:48PM BLOOD Neuts-75.9* Lymphs-15.9* Monos-6.4 Eos-0.9* Baso-0.4 Im [MASKED] AbsNeut-7.66* AbsLymp-1.60 AbsMono-0.65 AbsEos-0.09 AbsBaso-0.04 [MASKED] 04:48PM BLOOD [MASKED] PTT-31.9 [MASKED] [MASKED] 04:48PM BLOOD ALT-26 AST-50* AlkPhos-92 TotBili-0.4 [MASKED] 04:48PM BLOOD Lipase-55 [MASKED] 04:48PM BLOOD cTropnT-<0.01 proBNP-1226* [MASKED] 04:48PM BLOOD Albumin-4.0 Calcium-9.9 Phos-2.7 Mg-2.3 [MASKED] 04:58PM BLOOD D-Dimer-4124* [MASKED] 04:54PM BLOOD Lactate-2.4* K-4.5 RADIOLOGY: CTA CHEST [MASKED] IMPRESSION: 1. Bilateral lobar, segmental, and subsegmental pulmonary emboli. The exact chronicity of these pulmonary emboli is difficult to determine in the absence of prior studies for comparison. 2. Minimal reflux of contrast into the inferior vena cava. If there is clinical concern for right heart strain recommend echocardiogram for further evaluation. KUB [MASKED] IMPRESSION: No air-fluid levels and gas is seen to the level of the rectum. No evidence of obstruction. Residual contrast in the kidneys and bladder. CARDIOVASCULAR ECHO [MASKED]: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular free wall thickness is normal. The right ventricular cavity is mildly dilated with borderline normal free wall function. The diameters of aorta at the sinus, ascending and arch levels are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and reigonal left ventricular systolic function. Mild right ventricular dilation/systolic dysfunction. Mild pulmonary hypertension. Brief Hospital Course: [MASKED] yo F with congenital deafness, bipolar disorder, borderline personality disorder, COPD not on home O2, HTN, and T2DM who presented to [MASKED] on [MASKED] with shortness of breath and palpitations found to have bilateral submassive PE. # Submassive pulmonary emboli: Patient was recently diagnosed with PE at [MASKED] [MASKED] for which the patient was started on apixiban earlier this month. Upon admission, pt reported not taking apixaban on a daily basis. She noted nausea and dysgeusia [MASKED] apixaban. Given tachycardia and dyspnea, a CTA was performed which revealed "bilateral lobar, segmental, and subsegmental pulmonary emboli" of unknown chronicity. Trop <0.01 and BNP elevated. Patient was treated with sub q lovenox. An echo was performed which revealed "normal global and reigonal left ventricular systolic function and mild right ventricular dilation/systolic dysfunction as well as mild pulmonary hypertension." Pt remained hemoydnamically stable thoughout hospitalization. She will remain on subcutaneous enoxaparin after discharge for treatment of her pulmonary emboli, while at rehab. # Psych: Patient carries diagnoses of bipolar disorder, depression, borderline personality disorder, and PTSD in [MASKED] records. Upon admission, she did not know her current psychiatric medications but is able to name "lamictal" and "risperdal," which is somewhat inconsistent with [MASKED] documentation. She later noted that she took all of her psychiatric medications, but given her history and initial report of non compliance, only some of her medications were initiated in the hospital. There were also discrepancies between her PCP medication list (dated in [MASKED] and her [MASKED] discharge medication list (dated in [MASKED]. She was continued on lamotrigine, lorazepam (PRN and scheduled), and seroquel for agitation. Pt was agitated upon admission but mood was stable throughout hospitalization. She did refuse lab draws and urine monitoring during her hospitalization. Psychiatry was consulted and they agreed with our plan to only continue medications that the patient said she was taking (lamictal) and those that she may withdrawal from (lorazepam). # Social: Patient reported having a difficult time taking care of herself at home. Our social work team and case management team were involved and the patient was discharged to a rehab facility. # Nausea/vomiting: Patient with nausea/vomiting in ED x1, and again on arrival to floor x1 upon admission. KUB was normal and LFTS without evidence of GB pathology, lipase normal. Pt was initially started on clear liquid diet. When n/v improved, pt was transitioned to regular diet without further symptoms. # Largyngopharyngeal reflux: - Continued home famotidine 40mg daily - Continued home omeprazole 20mg QHS # COPD: Currently without evidence of exacerbation. Will continue home inhalers. - Continued home tiotroprium - Continued home Flovent inhaler - Continued home albuterol inhaler # Allergies: - Continued home Flonase PRN - Continude home loratidine PRN **Transitional issues** -Patient reported very poor compliance with her medications -Patient could not name her medications and had two separate medication lists, which were different from one another -Not all of her psychiatric medications were re started during hospitalization given her poor compliance -Please ensure follow up with psychiatry -Patient is on enoxaparin for treatment of her pulmonary emboli. Please evaluate her likelihood for compliance with this therapy before discharge from rehab, as if not optimal, she may need to go back on PO anticoagulation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 10 mg PO BID 2. Cyclobenzaprine 10 mg PO HS:PRN spasticity 3. DiphenhydrAMINE 25 mg PO Q6H:PRN itching 4. Nicotine Patch 14 mg TD DAILY 5. Nicotine Polacrilex 2 mg PO Q2H:PRN tobacco craving 6. Polyethylene Glycol 17 g PO BID 7. Tiotropium Bromide 1 CAP IH DAILY 8. Oxybutynin 5 mg PO TID 9. Lidocaine 5% Patch 1 PTCH TD DAILY 10. Levothyroxine Sodium 50 mcg PO DAILY 11. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergy symptomes 12. Docusate Sodium 100 mg PO TID 13. LamoTRIgine 200 mg PO BID 14. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 15. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze/SOB 16. Benzonatate 200 mg PO TID:PRN cough 17. Atenolol 75 mg PO DAILY 18. Famotidine 40 mg PO DAILY 19. Fluticasone Propionate 110mcg 2 PUFF IH BID 20. Ipratropium-Albuterol Neb 1 NEB NEB Q4H 21. Ibuprofen 800 mg PO Q8H:PRN pain 22. Loratadine 10 mg PO DAILY:PRN allergies 23. LORazepam 0.5 mg PO BID 24. LORazepam 1 mg PO QHS 25. Omeprazole 20 mg PO QHS 26. QUEtiapine Fumarate 50 mg PO TID:PRN agitation 27. Topiramate (Topamax) 150 mg PO BID 28. TraZODone 200 mg PO QHS 29. Venlafaxine 25 mg PO BID 30. Vitamin D [MASKED] UNIT PO DAILY 31. melatonin 5 mg oral DAILY 32. Mupirocin Ointment 2% 1 Appl TP TID Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing 2. Cyclobenzaprine 10 mg PO HS:PRN spasticity 3. Docusate Sodium 200 mg PO TID 4. Famotidine 40 mg PO DAILY 5. Fluticasone Propionate 110mcg 2 PUFF IH BID 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergy symptomes 7. LamoTRIgine 200 mg PO BID 8. Levothyroxine Sodium 50 mcg PO DAILY 9. Loratadine 10 mg PO DAILY:PRN allergies 10. LORazepam 0.5 mg PO BID 11. LORazepam 1 mg PO QHS:PRN insomnia/anxiety 12. Nicotine Patch 14 mg TD DAILY 13. Nicotine Polacrilex 2 mg PO Q2H:PRN tobacco craving 14. Omeprazole 20 mg PO QHS 15. Oxybutynin 5 mg PO TID 16. Polyethylene Glycol 17 g PO BID 17. Tiotropium Bromide 1 CAP IH DAILY 18. TraZODone 200 mg PO QHS 19. Acetaminophen [MASKED] mg PO Q6H:PRN pain/headache 20. Enoxaparin Sodium 110 mg SC Q12H Start: Today - [MASKED], First Dose: Next Routine Administration Time 21. Hydrocortisone Cream 1% 1 Appl TP QID:PRN itching right pinna of affected area 22. Senna 8.6 mg PO BID 23. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze/SOB 24. melatonin 5 mg oral DAILY 25. Mupirocin Ointment 2% 1 Appl TP TID 26. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary diagnosis: Bilateral pulmonary emboli Secondary diagnoses: COPD Laryngopharyngel areflux Atypical chest pain Restless leg syndrome Fibromyalgia Osteoarthritis of knee Obesity Hypertension Bipolar disorder Borderline personality disorder PTSD T2DM Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms [MASKED], Why did I come to the hospital? -You came to the hospital because your heart was racing and you were having difficulty breathing What happened while I was in the hospital -We took a picture of your chest and we found that you have clots in your lungs -We treated you with an injectable medication called lovenox. This medication helps to break up the clot and prevent clots in the future What should I do when I leave the hospital? -You should continue taking all of your medications -You should take your lovenox every day, twice per day. If you stop taking this medication, you could have another clot in your lungs which can cause death. Followup Instructions: [MASKED]
|
[] |
[
"J449",
"I10",
"F17210",
"E119",
"E669"
] |
[
"I2699: Other pulmonary embolism without acute cor pulmonale",
"J449: Chronic obstructive pulmonary disease, unspecified",
"I10: Essential (primary) hypertension",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"H9193: Unspecified hearing loss, bilateral",
"F319: Bipolar disorder, unspecified",
"F603: Borderline personality disorder",
"F4310: Post-traumatic stress disorder, unspecified",
"E119: Type 2 diabetes mellitus without complications",
"E669: Obesity, unspecified",
"Z6839: Body mass index [BMI] 39.0-39.9, adult",
"G2581: Restless legs syndrome"
] |
10,026,879
| 29,403,608
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ether
Attending: ___
Chief Complaint:
Arm and leg paralysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with history of squamous
cell carcinoma of the oral cavity s/p chemoXRT, intellectual
disability presenting with change in mental status.
Per review of chart, the patient was in his usual state of
health
prior to today. last seen well around 1600. He was at a nursing
facility and developed sudden onset of left-sided weakness and
garbled speech, noted around ___. He was taken by EMS to ___,
where a CTA of the head and neck was performed that did not show
any large vessel occlusion but did demonstrate osseous
metastatic
disease of the cervical spine and spinal canal narrowing at
C3-C4. He was subsequently transferred to ___ for further
care.
Of note, per review of records the patient follows at ___ for
his
oncologic care. He was found by his dentist to have a left
facial
mass in ___. He was initially treated with antibiotics for
presumed infection, and subsequently referred to ENT and the
mass
was biopsied, which demonstrated a poorly-differentiated
squamous
cell carcinoma. He underwent PET CT in ___ that demonstrated
FDG avid uptake associated with the mass in the left maxillary
sinus, the left pterygoid plate with extension into the left
cheek. No evidence of FDG avid cervical lymphadenopathy or
distant metastatic disease at that time. PET scan did show
increased uptake in the rectal area. Patient has declined a
colonoscopy.
He began cisplatin/XRT on ___, with last dose ___. He had
interval PET ___ that showed interval resolution of FDG avid
uptake in the mass. He was last seen by his oncologist in
___.
At that time there was no clinical evidence of recurrence
although the patient declined a complete exam.
Initial vitals: 97.6 101 189/98 24 95% RA
Exam notable for: Not responding to verbal stimuli
Responds to painful stimuli of RUE, does not respond to painful
stimuli of LUE or bilateral lower extremities
Labs notable for: WBC 16.9, Na 130, BUN/Cr ___, Ca ___, UA
with spec ___ >1.050
Imaging notable for: MRI brain, MRI spine
Consults: Code cord, Neurology, Spine
Patient given: 500cc NS, morphine 4 mg IVx3, magnesium 4 g IV
Per ED resident, HCP states that once it is confirmed to be
cancer they will make patient CMO/transition to hospice, and do
not want chemotherapy/oncologic treatment.
On arrival to the floor, the patient is alert but does not
respond to questions.
ROS: Unable to obtain due to neurological condition.
Past Medical History:
- Squamous cell carcinoma of the oral cavity
-- S/p cisplatin (C1D1 ___ and XRT
- Cognitive delay
- Hyperlipidemia
- Hypertension
- DMII
- Osteoporosis
- Depression
- Hyponatremia
- BPH
- Macular degeneration
- Hearing loss
- S/p tonsillectomy
- S/p cataract surgery
- S/p retinal detachment surgery
Social History:
___
Family History:
- Father: ___ cancer
Physical Exam:
ADMISSION EXAM:
VITALS: 97.2 137/78 94 18 93 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, right pupil nonreactive, left pupil 2 mm and
reactive
ENT: Ears and nose without visible erythema, masses, or trauma.
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation; Foley in
place
MSK: Decreased tone, flaccid, no peripheral edema
SKIN: No rashes or ulcerations noted
NEURO: Alert, does not follow commands, flaccid in bilateral
upper and lower extremities, toes mute
PSYCH: Unable to assess
DISCHARGE EXAM:
___ 0003 Temp: 97.7 Axillary BP: 123/62 HR: 69 RR: 16 O2
sat: 97% O2 delivery: RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, L fixed, R 2-3 mm, with gaze preference to
right.
ENT: Ears and nose without visible erythema, masses, or trauma.
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
anteriorly. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation; Foley in
place
MSK: Decreased tone, flaccid, no peripheral edema
SKIN: No rashes or ulcerations noted
NEURO: Opens eyes to loud voice, does not follow commands,
flaccid in bilateral upper and lower extremities, no withdrawal
to painful stimuli,
toes mute. +clonus.
PSYCH: Unable to assess
Pertinent Results:
ADMISSION LABS
--------------
___ 11:30PM BLOOD WBC-16.9* RBC-3.96* Hgb-13.7 Hct-38.7*
MCV-98 MCH-34.6* MCHC-35.4 RDW-11.9 RDWSD-42.6 Plt ___
___ 11:30PM BLOOD Neuts-87.2* Lymphs-5.7* Monos-5.9
Eos-0.4* Baso-0.2 Im ___ AbsNeut-14.76* AbsLymp-0.96*
AbsMono-0.99* AbsEos-0.07 AbsBaso-0.03
___ 11:30PM BLOOD ___ PTT-25.8 ___
___ 11:30PM BLOOD Glucose-207* UreaN-31* Creat-1.3* Na-130*
K-4.4 Cl-93* HCO3-25 AnGap-12
___ 11:30PM BLOOD CK(CPK)-20*
___ 03:03PM BLOOD Calcium-10.9* Phos-3.9 Mg-1.6
IMAGING
-------
- MRI spine (___):
IMPRESSION:
1. Abnormal marrow replacement worrisome for metastatic disease
involving the of the C3 and C4 vertebrae which are slightly
expanded.
2. Secondary severe canal narrowing with cord compression from
the C3-4 through C4-5 level with associated cord signal
abnormality.
3. Additional metastatic lesion involving the left C4-C5 through
C5-C6 facets with soft tissue extension as well.
4. Multilevel severe left neural foraminal narrowing is seen at
C3-C4, C4-C5, and C5-C6.
5. Multilevel degenerative changes of the lumbar spine are most
pronounced at L4-L5 where there is moderate spinal canal
stenosis
and moderate bilateral neural foraminal narrowing.
- MRI brain (___): Preliminary read:
1. No evidence of hemorrhage, edema, masses, mass effect,
midline
shift or large territorial infarction.
2. Extensive paranasal sinus disease.
3. Final read to be performed by the Neuroradiology service.
- CTA head and neck ___ ___:
1. CT Head: No evidence of large vessel acute territorial
infarction. Aspect Score: 10
2. Extensive osseous metastatic disease with destruction of the
facial bones and skull base. Calvarial osseous metastatic
disease
with associated neoplastic soft tissue is noted. The osseous
metastatic disease involves the cervical spine where there is
severe narrowing of the spinal canal at C3-4 with marked cord
compression.
3. Occlusion of the distal right vertebral artery. This however
appears to have been present on a previous MR angiogram of the
head dated ___.
MICROBIOLOGY
------------
___ 4:50 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS
--------------
___ 06:06AM BLOOD WBC-7.9 RBC-3.79* Hgb-13.1* Hct-37.8*
MCV-100* MCH-34.6* MCHC-34.7 RDW-11.9 RDWSD-43.7 Plt ___
___ 05:49AM BLOOD Glucose-217* UreaN-52* Creat-1.1 Na-139
K-4.9 Cl-101 HCO3-20* AnGap-18
___ 05:49AM BLOOD Calcium-10.6* Phos-3.9 Mg-1.___ man with history of squamous cell carcinoma of the
oral cavity s/p chemoXRT, intellectual disability with change in
mental status, found to have flaccid paralysis in setting of
metastatic disease.
ACUTE/ACTIVE PROBLEMS:
# Squamous cell carcinoma of the oral cavity with metastasis
# Flaccid paralysis
# Cerebellar stroke
# Severe cord compression at C3-4:
Patient with history of squamous cell carcinoma of the oral
cavity s/p chemoXRT now with evidence of recurrence and
metastatic disease in including extensive osseous metastatic
disease involving the cervical spine with narrowing of the
spinal canal at C3-4 with marked cord compression, likely
causing his flaccid paralysis. He was treated with IV
dexamethasone while in house. Neurosurgery is not offering
surgical intervention based on entire clinical picture. Oncology
was consulted and agreed with patient's prognosis and
recommended CMO. Palliative radiation was discussed with health
care proxy and was not within goals of care. He was also found
to have cerebellar stroke, for which neurology was consulted;
further work up was not within goals of care.
Social Work, Legal and Palliative Care were consulted to assist
with goals of care.G iven the aggressive nature of his
malignancy, CPR and intubation would likely be futile. The
various medical teams have recommended ___ care and
hospice. The patient's HCP, ___, feels that the patient would
want to go back to his group
home and receive hospice care there. She, however, wants Mr.
___ to remain full code as she believes that this is his
wish. She stated that he has been neglected and mistreated his
entire life and in this last phase of his life, she wants to
make
sure that his wishes are respected and honored. She would like
to readdress this at hospice after she discusses it with Mr.
___ however we discussed with her that it is unlikely that
she would be able to have a meaningful conversation with Mr.
___.
We have identified a hospice agency that will accept the patient
as full code.
In terms of medications, he will be discharged on morphine 5mg
of oral concentrated solution 20mg/ml q4h scheduled for pain
control, and would consider Ativan 0.25 mg q6H PRN for anxiety
(oral concentrated form). He was receiving IV acetaminophen
while in house for pain, and this will be transitioned to PR
formulation.
With regard to PO, patient is at very high risk for aspiration
given mental status and medical condition, and at present he is
unable to swallow. Given that the overall wish is for patient to
be able to go to hospice at his group home such that patient may
pass away there comfortably, we specifically discussed with HCP
only administering medications for pain and anxiety in oral
concentrated form, and that upon discharge, we would discontinue
his dexamethasone. In the same vein, we also discussed
artificial nutrition and hydration with ___. TPN is not
indicated; we feel that it would not be appropriate to place a
surgical G-tube or that the patient would tolerate a NGT- nor
would these interventions be consistent with patient's stated
goals. While we agreed that while we would continue IVF while he
is in
house, he would not longer be receiving IV hydration as this is
generally not provided when patients are on hospice care. She
understood.
Hence, he will be NPO except for oral morphine and Ativan in
concentrated form; this was discussed with ___ who was in
agreement.
# Hyponatremia: Suspect hypovolemic, resolved with IVF.
# Possible acute kidney injury: Unknown baseline Cr, now 1.3 on
admission. ___ be some degree of pre-renal azotemia. S/p IVF
with improvement.
# Leukocytosis: Patient afebrile, UA bland, CXR without
pneumonia, skin without infection. Suspect due to malignancy.
# Hypercalcemia: Suspect due to malignancy.
CHRONIC/STABLE PROBLEMS:
# Depression:
- Hold citalopram
# GERD:
- Hold omeprazole
# Osteoporosis:
- Hold Vitamin D
# BPH:
- Hold tamsulosin
TRANSITIONS OF CARE
-------------------
[] Patient transitioned to hospice care but remains full code;
please continue to address with HCP as appropriate
[] Pain control: morphine 5mg of oral concentrated solution
20mg/ml q4h, PR tylenol ___ mg q8H PRN, Ativan 0.25 mg q6H PRN
for anxiety (oral concentrated form- confirmed available at
hospice)
[] Hard C collar at all times, maintain log roll precautions
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Vitamin D 1000 UNIT PO DAILY
2. TraZODone 50 mg PO QHS:PRN insomnia
3. Thera-M
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ultivitamin,tx-iron-Ca-FA-min;<br>multivitamin,tx-iron-minerals)
9 mg iron-400 mcg oral DAILY
4. Escitalopram Oxalate 10 mg PO DAILY
5. Tamsulosin 0.4 mg PO QHS
6. Omeprazole 20 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
8. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PR Q8H:PRN Pain - Mild/Fever
2. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
3. LORazepam Oral Solution 0.25 mg PO Q6H:PRN anxiety
4. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 5 mg
PO Q4H
Discharge Disposition:
Expired
Discharge Diagnosis:
C3-C4 cord compression
Cerebellar CVA
Metastatic cancer, likely oral squamous cell carcinoma
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your recent
hospitalization. You came to the hospital with inability to
move your arms and legs. Further testing showed that you had a
cord compression that will leave you paralyzed from the neck
down. This was from metastatic cancer that is likely from your
oral cancer. You also had a small stroke. You are now being
discharged to hospice, which are the wishes of your health care
proxy.
It is important that you continue to take your medications as
prescribed and follow up with the appointments listed below.
Good luck!
Followup Instructions:
___
|
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"E861",
"D72828",
"E8352",
"I6501",
"Z87891",
"F419",
"G4700",
"G893"
] |
Allergies: ether Chief Complaint: Arm and leg paralysis Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] man with history of squamous cell carcinoma of the oral cavity s/p chemoXRT, intellectual disability presenting with change in mental status. Per review of chart, the patient was in his usual state of health prior to today. last seen well around 1600. He was at a nursing facility and developed sudden onset of left-sided weakness and garbled speech, noted around [MASKED]. He was taken by EMS to [MASKED], where a CTA of the head and neck was performed that did not show any large vessel occlusion but did demonstrate osseous metastatic disease of the cervical spine and spinal canal narrowing at C3-C4. He was subsequently transferred to [MASKED] for further care. Of note, per review of records the patient follows at [MASKED] for his oncologic care. He was found by his dentist to have a left facial mass in [MASKED]. He was initially treated with antibiotics for presumed infection, and subsequently referred to ENT and the mass was biopsied, which demonstrated a poorly-differentiated squamous cell carcinoma. He underwent PET CT in [MASKED] that demonstrated FDG avid uptake associated with the mass in the left maxillary sinus, the left pterygoid plate with extension into the left cheek. No evidence of FDG avid cervical lymphadenopathy or distant metastatic disease at that time. PET scan did show increased uptake in the rectal area. Patient has declined a colonoscopy. He began cisplatin/XRT on [MASKED], with last dose [MASKED]. He had interval PET [MASKED] that showed interval resolution of FDG avid uptake in the mass. He was last seen by his oncologist in [MASKED]. At that time there was no clinical evidence of recurrence although the patient declined a complete exam. Initial vitals: 97.6 101 189/98 24 95% RA Exam notable for: Not responding to verbal stimuli Responds to painful stimuli of RUE, does not respond to painful stimuli of LUE or bilateral lower extremities Labs notable for: WBC 16.9, Na 130, BUN/Cr [MASKED], Ca [MASKED], UA with spec [MASKED] >1.050 Imaging notable for: MRI brain, MRI spine Consults: Code cord, Neurology, Spine Patient given: 500cc NS, morphine 4 mg IVx3, magnesium 4 g IV Per ED resident, HCP states that once it is confirmed to be cancer they will make patient CMO/transition to hospice, and do not want chemotherapy/oncologic treatment. On arrival to the floor, the patient is alert but does not respond to questions. ROS: Unable to obtain due to neurological condition. Past Medical History: - Squamous cell carcinoma of the oral cavity -- S/p cisplatin (C1D1 [MASKED] and XRT - Cognitive delay - Hyperlipidemia - Hypertension - DMII - Osteoporosis - Depression - Hyponatremia - BPH - Macular degeneration - Hearing loss - S/p tonsillectomy - S/p cataract surgery - S/p retinal detachment surgery Social History: [MASKED] Family History: - Father: [MASKED] cancer Physical Exam: ADMISSION EXAM: VITALS: 97.2 137/78 94 18 93 RA GENERAL: Alert and in no apparent distress EYES: Anicteric, right pupil nonreactive, left pupil 2 mm and reactive ENT: Ears and nose without visible erythema, masses, or trauma. CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation; Foley in place MSK: Decreased tone, flaccid, no peripheral edema SKIN: No rashes or ulcerations noted NEURO: Alert, does not follow commands, flaccid in bilateral upper and lower extremities, toes mute PSYCH: Unable to assess DISCHARGE EXAM: [MASKED] 0003 Temp: 97.7 Axillary BP: 123/62 HR: 69 RR: 16 O2 sat: 97% O2 delivery: RA GENERAL: Alert and in no apparent distress EYES: Anicteric, L fixed, R 2-3 mm, with gaze preference to right. ENT: Ears and nose without visible erythema, masses, or trauma. CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement anteriorly. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation; Foley in place MSK: Decreased tone, flaccid, no peripheral edema SKIN: No rashes or ulcerations noted NEURO: Opens eyes to loud voice, does not follow commands, flaccid in bilateral upper and lower extremities, no withdrawal to painful stimuli, toes mute. +clonus. PSYCH: Unable to assess Pertinent Results: ADMISSION LABS -------------- [MASKED] 11:30PM BLOOD WBC-16.9* RBC-3.96* Hgb-13.7 Hct-38.7* MCV-98 MCH-34.6* MCHC-35.4 RDW-11.9 RDWSD-42.6 Plt [MASKED] [MASKED] 11:30PM BLOOD Neuts-87.2* Lymphs-5.7* Monos-5.9 Eos-0.4* Baso-0.2 Im [MASKED] AbsNeut-14.76* AbsLymp-0.96* AbsMono-0.99* AbsEos-0.07 AbsBaso-0.03 [MASKED] 11:30PM BLOOD [MASKED] PTT-25.8 [MASKED] [MASKED] 11:30PM BLOOD Glucose-207* UreaN-31* Creat-1.3* Na-130* K-4.4 Cl-93* HCO3-25 AnGap-12 [MASKED] 11:30PM BLOOD CK(CPK)-20* [MASKED] 03:03PM BLOOD Calcium-10.9* Phos-3.9 Mg-1.6 IMAGING ------- - MRI spine ([MASKED]): IMPRESSION: 1. Abnormal marrow replacement worrisome for metastatic disease involving the of the C3 and C4 vertebrae which are slightly expanded. 2. Secondary severe canal narrowing with cord compression from the C3-4 through C4-5 level with associated cord signal abnormality. 3. Additional metastatic lesion involving the left C4-C5 through C5-C6 facets with soft tissue extension as well. 4. Multilevel severe left neural foraminal narrowing is seen at C3-C4, C4-C5, and C5-C6. 5. Multilevel degenerative changes of the lumbar spine are most pronounced at L4-L5 where there is moderate spinal canal stenosis and moderate bilateral neural foraminal narrowing. - MRI brain ([MASKED]): Preliminary read: 1. No evidence of hemorrhage, edema, masses, mass effect, midline shift or large territorial infarction. 2. Extensive paranasal sinus disease. 3. Final read to be performed by the Neuroradiology service. - CTA head and neck [MASKED] [MASKED]: 1. CT Head: No evidence of large vessel acute territorial infarction. Aspect Score: 10 2. Extensive osseous metastatic disease with destruction of the facial bones and skull base. Calvarial osseous metastatic disease with associated neoplastic soft tissue is noted. The osseous metastatic disease involves the cervical spine where there is severe narrowing of the spinal canal at C3-4 with marked cord compression. 3. Occlusion of the distal right vertebral artery. This however appears to have been present on a previous MR angiogram of the head dated [MASKED]. MICROBIOLOGY ------------ [MASKED] 4:50 am URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. DISCHARGE LABS -------------- [MASKED] 06:06AM BLOOD WBC-7.9 RBC-3.79* Hgb-13.1* Hct-37.8* MCV-100* MCH-34.6* MCHC-34.7 RDW-11.9 RDWSD-43.7 Plt [MASKED] [MASKED] 05:49AM BLOOD Glucose-217* UreaN-52* Creat-1.1 Na-139 K-4.9 Cl-101 HCO3-20* AnGap-18 [MASKED] 05:49AM BLOOD Calcium-10.6* Phos-3.9 Mg-1.[MASKED] man with history of squamous cell carcinoma of the oral cavity s/p chemoXRT, intellectual disability with change in mental status, found to have flaccid paralysis in setting of metastatic disease. ACUTE/ACTIVE PROBLEMS: # Squamous cell carcinoma of the oral cavity with metastasis # Flaccid paralysis # Cerebellar stroke # Severe cord compression at C3-4: Patient with history of squamous cell carcinoma of the oral cavity s/p chemoXRT now with evidence of recurrence and metastatic disease in including extensive osseous metastatic disease involving the cervical spine with narrowing of the spinal canal at C3-4 with marked cord compression, likely causing his flaccid paralysis. He was treated with IV dexamethasone while in house. Neurosurgery is not offering surgical intervention based on entire clinical picture. Oncology was consulted and agreed with patient's prognosis and recommended CMO. Palliative radiation was discussed with health care proxy and was not within goals of care. He was also found to have cerebellar stroke, for which neurology was consulted; further work up was not within goals of care. Social Work, Legal and Palliative Care were consulted to assist with goals of care.G iven the aggressive nature of his malignancy, CPR and intubation would likely be futile. The various medical teams have recommended [MASKED] care and hospice. The patient's HCP, [MASKED], feels that the patient would want to go back to his group home and receive hospice care there. She, however, wants Mr. [MASKED] to remain full code as she believes that this is his wish. She stated that he has been neglected and mistreated his entire life and in this last phase of his life, she wants to make sure that his wishes are respected and honored. She would like to readdress this at hospice after she discusses it with Mr. [MASKED] however we discussed with her that it is unlikely that she would be able to have a meaningful conversation with Mr. [MASKED]. We have identified a hospice agency that will accept the patient as full code. In terms of medications, he will be discharged on morphine 5mg of oral concentrated solution 20mg/ml q4h scheduled for pain control, and would consider Ativan 0.25 mg q6H PRN for anxiety (oral concentrated form). He was receiving IV acetaminophen while in house for pain, and this will be transitioned to PR formulation. With regard to PO, patient is at very high risk for aspiration given mental status and medical condition, and at present he is unable to swallow. Given that the overall wish is for patient to be able to go to hospice at his group home such that patient may pass away there comfortably, we specifically discussed with HCP only administering medications for pain and anxiety in oral concentrated form, and that upon discharge, we would discontinue his dexamethasone. In the same vein, we also discussed artificial nutrition and hydration with [MASKED]. TPN is not indicated; we feel that it would not be appropriate to place a surgical G-tube or that the patient would tolerate a NGT- nor would these interventions be consistent with patient's stated goals. While we agreed that while we would continue IVF while he is in house, he would not longer be receiving IV hydration as this is generally not provided when patients are on hospice care. She understood. Hence, he will be NPO except for oral morphine and Ativan in concentrated form; this was discussed with [MASKED] who was in agreement. # Hyponatremia: Suspect hypovolemic, resolved with IVF. # Possible acute kidney injury: Unknown baseline Cr, now 1.3 on admission. [MASKED] be some degree of pre-renal azotemia. S/p IVF with improvement. # Leukocytosis: Patient afebrile, UA bland, CXR without pneumonia, skin without infection. Suspect due to malignancy. # Hypercalcemia: Suspect due to malignancy. CHRONIC/STABLE PROBLEMS: # Depression: - Hold citalopram # GERD: - Hold omeprazole # Osteoporosis: - Hold Vitamin D # BPH: - Hold tamsulosin TRANSITIONS OF CARE ------------------- [] Patient transitioned to hospice care but remains full code; please continue to address with HCP as appropriate [] Pain control: morphine 5mg of oral concentrated solution 20mg/ml q4h, PR tylenol [MASKED] mg q8H PRN, Ativan 0.25 mg q6H PRN for anxiety (oral concentrated form- confirmed available at hospice) [] Hard C collar at all times, maintain log roll precautions Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Vitamin D 1000 UNIT PO DAILY 2. TraZODone 50 mg PO QHS:PRN insomnia 3. Thera-M ( m u l t i v i t - i r o n - F A - c a l c i u m - m i n s ; < b r > m ultivitamin,tx-iron-Ca-FA-min;<br>multivitamin,tx-iron-minerals) 9 mg iron-400 mcg oral DAILY 4. Escitalopram Oxalate 10 mg PO DAILY 5. Tamsulosin 0.4 mg PO QHS 6. Omeprazole 20 mg PO DAILY 7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 8. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PR Q8H:PRN Pain - Mild/Fever 2. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 3. LORazepam Oral Solution 0.25 mg PO Q6H:PRN anxiety 4. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 5 mg PO Q4H Discharge Disposition: Expired Discharge Diagnosis: C3-C4 cord compression Cerebellar CVA Metastatic cancer, likely oral squamous cell carcinoma Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure caring for you during your recent hospitalization. You came to the hospital with inability to move your arms and legs. Further testing showed that you had a cord compression that will leave you paralyzed from the neck down. This was from metastatic cancer that is likely from your oral cancer. You also had a small stroke. You are now being discharged to hospice, which are the wishes of your health care proxy. It is important that you continue to take your medications as prescribed and follow up with the appointments listed below. Good luck! Followup Instructions: [MASKED]
|
[] |
[
"E871",
"N179",
"Z515",
"Z66",
"I10",
"E119",
"F329",
"Z87891",
"F419",
"G4700"
] |
[
"C7949: Secondary malignant neoplasm of other parts of nervous system",
"I63449: Cerebral infarction due to embolism of unspecified cerebellar artery",
"E43: Unspecified severe protein-calorie malnutrition",
"C7951: Secondary malignant neoplasm of bone",
"C7989: Secondary malignant neoplasm of other specified sites",
"G9529: Other cord compression",
"G8194: Hemiplegia, unspecified affecting left nondominant side",
"D688: Other specified coagulation defects",
"E871: Hypo-osmolality and hyponatremia",
"N179: Acute kidney failure, unspecified",
"R063: Periodic breathing",
"Z681: Body mass index [BMI] 19.9 or less, adult",
"C029: Malignant neoplasm of tongue, unspecified",
"G8311: Monoplegia of lower limb affecting right dominant side",
"R4789: Other speech disturbances",
"Z9221: Personal history of antineoplastic chemotherapy",
"Z923: Personal history of irradiation",
"Z515: Encounter for palliative care",
"Z66: Do not resuscitate",
"F79: Unspecified intellectual disabilities",
"E7849: Other hyperlipidemia",
"I10: Essential (primary) hypertension",
"E119: Type 2 diabetes mellitus without complications",
"M810: Age-related osteoporosis without current pathological fracture",
"F329: Major depressive disorder, single episode, unspecified",
"E861: Hypovolemia",
"D72828: Other elevated white blood cell count",
"E8352: Hypercalcemia",
"I6501: Occlusion and stenosis of right vertebral artery",
"Z87891: Personal history of nicotine dependence",
"F419: Anxiety disorder, unspecified",
"G4700: Insomnia, unspecified",
"G893: Neoplasm related pain (acute) (chronic)"
] |
10,027,100
| 21,297,827
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
vancomycin / Thorazine / contact metal agent
Attending: ___.
Chief Complaint:
Inguinal hernia
Major Surgical or Invasive Procedure:
___: right-sided inguinal hernia repair
History of Present Illness:
Per resident: ___ active IVDA, ETOH abuse with Hep C, on
methadone program who presented to the clinic with Rt inguinal
hernia. the patient niticed the hernia ___ m ago and had a few ER
visit for symoptomatic hernia , it was never incarcerated and
was not operated on. Denies trauma, or heavy lifting. He also
denies fevers, chills, nausea, of decreased PO intake. Pt
requesting the hernia to be repaired.
Past Medical History:
HCV,
Bipolar disorder
Active IVDU heroin sometimes sniffs
ETOH active drinker came to the clinic
s/p car accident with Lt tibial Fx and shoulder injuries on ___ for which he had surgery and plating in both sites Per
patient (probably at ___)
Past Surgical History:
Incision, drainage, and packing of left forearm abscess. ___
Lt tibial and Rt shoulder Fixation ___ ___
Social History:
___
Family History:
NC
Physical Exam:
VS:T99.3 P45 (pt states baseline ___ BP 166/82 RR 18 02
100%RA
General: no acute distress, alert and oriented x 3
Cardiac: regular rhythm, bradycardia, NL S1,S2
Resp: clear to auscultation, bilaterally
Abdomen: soft, non-tender, non-distended, no rebound
tenderness/guarding
Wounds: abdominal lap sites with primary dgs, slight
serosanguinous staining x 1; no periwound erythema or ecchymosis
Ext: no lower extremity edema or tenderness
Pertinent Results:
LABS:
___ 05:00AM BLOOD Hct-37.2*
___ 04:39PM BLOOD Hct-36.5*
Brief Hospital Course:
The patient presented to pre-op on ___ . Pt was
evaluated by anaesthesia and was taken to the operating room
where he underwent a laparoscopic right inguinal hernia repair.
There were no adverse events in the operating room; please see
the operative note for details. Pt was extubated, taken to the
PACU until stable, then transferred to the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with the patient's home
methadone dose and prn oxycodone. He was transitioned to oral
oxycodone-acetaminophen upon discharge.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. He was noted
to have bradycardia during the hospitalization, which was
asymptomatic and the baseline heart rate, per patient.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient tolerated a Regular diet
post-operatively; intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Methadone (Concentrated Oral Solution) 10 mg/1 mL 73 mg PO
DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
2. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain
- Mild
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth q
4 hours Disp #*40 Tablet Refills:*0
3. Methadone (Concentrated Oral Solution) 10 mg/1 mL 73 mg PO
AS DIRECTED BY PRESCRIBING PROVIDER
___:
Home
Discharge Diagnosis:
Right-sided inguinal hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You have undergone repair of your right sided inguinal hernia,
recovered in the hospital and are now preparing for discharge
with the following 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, operating heavy machinery or consuming alcohol
while taking pain medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
[
"K4030",
"B1920",
"F1110",
"F1010",
"F17210"
] |
Allergies: vancomycin / Thorazine / contact metal agent Chief Complaint: Inguinal hernia Major Surgical or Invasive Procedure: [MASKED]: right-sided inguinal hernia repair History of Present Illness: Per resident: [MASKED] active IVDA, ETOH abuse with Hep C, on methadone program who presented to the clinic with Rt inguinal hernia. the patient niticed the hernia [MASKED] m ago and had a few ER visit for symoptomatic hernia , it was never incarcerated and was not operated on. Denies trauma, or heavy lifting. He also denies fevers, chills, nausea, of decreased PO intake. Pt requesting the hernia to be repaired. Past Medical History: HCV, Bipolar disorder Active IVDU heroin sometimes sniffs ETOH active drinker came to the clinic s/p car accident with Lt tibial Fx and shoulder injuries on [MASKED] for which he had surgery and plating in both sites Per patient (probably at [MASKED]) Past Surgical History: Incision, drainage, and packing of left forearm abscess. [MASKED] Lt tibial and Rt shoulder Fixation [MASKED] [MASKED] Social History: [MASKED] Family History: NC Physical Exam: VS:T99.3 P45 (pt states baseline [MASKED] BP 166/82 RR 18 02 100%RA General: no acute distress, alert and oriented x 3 Cardiac: regular rhythm, bradycardia, NL S1,S2 Resp: clear to auscultation, bilaterally Abdomen: soft, non-tender, non-distended, no rebound tenderness/guarding Wounds: abdominal lap sites with primary dgs, slight serosanguinous staining x 1; no periwound erythema or ecchymosis Ext: no lower extremity edema or tenderness Pertinent Results: LABS: [MASKED] 05:00AM BLOOD Hct-37.2* [MASKED] 04:39PM BLOOD Hct-36.5* Brief Hospital Course: The patient presented to pre-op on [MASKED] . Pt was evaluated by anaesthesia and was taken to the operating room where he underwent a laparoscopic right inguinal hernia repair. There were no adverse events in the operating room; please see the operative note for details. Pt was extubated, taken to the PACU until stable, then transferred to the ward for observation. Neuro: The patient was alert and oriented throughout hospitalization; pain was managed with the patient's home methadone dose and prn oxycodone. He was transitioned to oral oxycodone-acetaminophen upon discharge. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. He was noted to have bradycardia during the hospitalization, which was asymptomatic and the baseline heart rate, per patient. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient tolerated a Regular diet post-operatively; intake and output were closely monitored ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and [MASKED] dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Methadone (Concentrated Oral Solution) 10 mg/1 mL 73 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 2. OxyCODONE--Acetaminophen (5mg-325mg) [MASKED] TAB PO Q4H:PRN Pain - Mild RX *oxycodone-acetaminophen 5 mg-325 mg [MASKED] tablet(s) by mouth q 4 hours Disp #*40 Tablet Refills:*0 3. Methadone (Concentrated Oral Solution) 10 mg/1 mL 73 mg PO AS DIRECTED BY PRESCRIBING PROVIDER [MASKED]: Home Discharge Diagnosis: Right-sided inguinal hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You have undergone repair of your right sided inguinal hernia, recovered in the hospital and are now preparing for discharge with the following 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, operating heavy machinery or consuming alcohol while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips [MASKED] days after surgery. Followup Instructions: [MASKED]
|
[] |
[
"F17210"
] |
[
"K4030: Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent",
"B1920: Unspecified viral hepatitis C without hepatic coma",
"F1110: Opioid abuse, uncomplicated",
"F1010: Alcohol abuse, uncomplicated",
"F17210: Nicotine dependence, cigarettes, uncomplicated"
] |
10,027,100
| 27,697,220
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
Leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o M w/PMHx tibial fracture s/p ORIF at ___, IVDU and
bipolar disorder who presented to ___ for fever and Left knee
pain. Pt reports acute-onset knee and lower leg pain this
afternoon, up to ___. He notes associated erythema and
swelling. He has never had these symptoms before. No numbness in
Left foot. He denies any fever, malaise, SOB, CP or n/v prior to
presenting to ___.
Of note, pt underwent a Right shoulder and Left tibial ORIF with
screw placement on ___ at ___ in the setting of an MVA. He
also notes that he does use IV drugs and has not done so in ___
years.
In the ED, initial vitals: 102.5; 87; 146/87; 18; 96% RA
There was a report that patient had recently used IV drugs and
was confused in the ED. Pt denied this on the floor.
- Labs notable for:
Cr: 0.7
CRP 4.5
CBC: 9.4>11.7/35.1<151
UA negative
UTox positive for opiates/methadone
STox pending at the time of transfer
3x bcx drawn
- Imaging notable for:
Tib/Fib AP/Lateral showed:
Status post ORIF of the proximal tibia with plate and screw
fixation with hardware in anatomic alignment.
Very focal subtle linear lucency in the cortex of the medial
metadiaphysis of the proximal left tibia, just underlying
hardware plate, is of indeterminate age. Could relate to prior
fracture or a more recent stress fracture.
No prior for comparison.
Bedside U/S without focal abscess in the knee
CXR showed: No focal consolidation
- Pt had a joint aspiration showing WBC 14, RBC ___
- Patient given:
IV Clindamycin (600 mg ordered)
- Vitals prior to transfer:
100.6; 82; 139/80; 15; 94% RA
On arrival to the floor, pt reports continued pain and swelling
in LLE.
Past Medical History:
IV drug use
Hepatitis C
Bipolar
Alcohol abuse
Social History:
___
Family History:
Mother with diabetes and heart problems
Physical Exam:
ADMISSION EXAM
==============
Vitals: 100.3; 143/80; 71; 18; 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: WWP. Large area of warmth, erythema and TTP along anterior
aspect of LLE. 2+ DP pulses, equal bilaterally.
MSK: ROM of Left knee could not be fully assessed due to pain
with movement of Left leg
Skin: Without rashes or lesions. Track marks on bilateral
forearms. Surgical scar on anterior aspect of Right shoulder.
Neuro: A&Ox3. Grossly intact.
DISCHARGE EXAM
==============
Vital Signs: Tmax 100.3, BP 138-154/80-88, HR 55-71, RR 18,
96-97%RA
General: Alert, oriented, sitting up in bed comfortable, eating
breakfast
Lungs: Clear to auscultation bilaterally, good air movement
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: WWP. mild erythema and TTP over large area of skin
overlying the tibia, exquistitely tender near proximal tibia; no
TTP at knee joint area
MSK: ROM of Left knee could not be fully assessed due to pain
with movement of Left leg
Skin: Track marks on bilateral forearms. Surgical scar on
anterior aspect of Right shoulder.
Neuro: A&Ox3. Grossly intact.
Pertinent Results:
ADMISSION LABS
=============
___ 08:35PM BLOOD WBC-9.4# RBC-3.72* Hgb-11.7* Hct-35.1*
MCV-94 MCH-31.5 MCHC-33.3 RDW-14.0 RDWSD-48.4* Plt ___
___ 08:35PM BLOOD Neuts-59.0 ___ Monos-11.8
Eos-0.5* Baso-0.5 Im ___ AbsNeut-5.52# AbsLymp-2.63
AbsMono-1.11* AbsEos-0.05 AbsBaso-0.05
___ 08:35PM BLOOD ___ PTT-34.1 ___
___ 08:35PM BLOOD Plt ___
___ 08:35PM BLOOD Glucose-108* UreaN-7 Creat-0.7 Na-135
K-3.7 Cl-97 HCO3-25 AnGap-17
___ 08:35PM BLOOD CRP-4.5
___ 08:35PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:46PM BLOOD Lactate-1.6
IMAGING
======
X-ray tib/fib
FINDINGS:
Patient is status post ORIF of the proximal tibia with plate and
screw
fixation. Hardware appears in anatomic alignment. No hardware
fracture is
identified. On the AP view, there is very focal subtle linear
lucency in the
cortex of the medial metadiaphysis of the proximal tibia, just
underlying
hardware plate is of indeterminate age. No prior available for
comparison.
Well corticated 8 mm ossific structure just lateral to the
lateral tibial
plateau is chronic. There is likely a suprapatellar joint
effusion. Patellar
spurring is noted.
IMPRESSION:
Status post ORIF of the proximal tibia with plate and screw
fixation with
hardware in anatomic alignment.
Very focal subtle linear lucency in the cortex of the medial
metadiaphysis of
the proximal left tibia, just underlying hardware plate, is of
indeterminate
age. Could relate to prior fracture or a more recent stress
fracture.
CXR ___
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or
pneumothorax.
The cardiac and mediastinal silhouettes are grossly stable. No
overt
pulmonary edema is seen. Chronic deformity of the proximal
right humerus with
hardware is seen, but not well assessed on this study.
IMPRESSION:
No focal consolidation.
Ultrasound lower extremity ___
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
DISCHARGE LABS
=============
___ 06:30AM BLOOD WBC-6.2 RBC-3.86* Hgb-12.0* Hct-36.3*
MCV-94 MCH-31.1 MCHC-33.1 RDW-13.8 RDWSD-47.7* Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-107* UreaN-6 Creat-0.7 Na-136
K-4.1 Cl-98 HCO3-26 AnGap-16
___ 06:30AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.0 Iron-60
___ 06:30AM BLOOD calTIBC-306 VitB12-401 Folate-14
Ferritn-416* TRF-___ y/o M w/PMHx tibial fracture s/p ORIF at ___, IVDU and
bipolar disorder who presented to ___ for fever and Left knee
pain c/w moderate cellulitis.
#Cellulitis: The patient presented with left knee pain after
undergoing a left tibial ORF with screw placement on ___ at
___ in the setting of an MVA. In the afternoon of ___, he
developed acute onset left leg pain and swelling with difficulty
ambulating. He presented to ___, where ortho evaluated in the
OR. Joint was aspirated and fluid not concerning for septic
joint. His CRP and ESR were low pointing away from
osteomyelitis. He was initially treated with IV clindamycin but
was narrowed to cephalexin to complete a 7-day course, with
noticeable improvement in his symptoms while in the hospital. He
was instructed to follow up with his PCP as an outpatient.
#Anemia: The patient's CBC was notable for a hemoglobin around
12g. Iron studies were sent and were consistent with AOCD.
#history of IVDU on methadone: He was given methadone 73 mg
daily with confirmation of this dose by his ___ clinic. He
was given a letter indicating his last dose prior to discharge.
TRANSITIONAL ISSUES
===================
- The ED reported that the patient had taken heroin in the past
month, however on the floor the patient denied this stating it
had been ___ years prior. His urine and blood toxicology were
positive for opiates, methadone, and EtOH at 102 but nothing
else.
FULL CODE
CONTACT: Friend ___ ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Methadone 73 mg PO DAILY
Discharge Medications:
1. Cephalexin 500 mg PO QID
RX *cephalexin 500 mg 1 tablet(s) by mouth four times a day Disp
#*21 Tablet Refills:*0
2. Methadone 73 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
- Cellulitis
Secondary
- history of IV drug use on methadone
- 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 here at ___.
You came to the hospital with leg pain and swelling. This was
due to an infection of the skin, also known as cellulitis. We
treated this infection with antibiotics. The orthopedic surgeons
evaluated you and saw that there was no infection in the knee
joint itself. You were discharged on oral antibiotics to
finishing treating the skin infection.
Again, it was a pleasure taking care of you.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
[
"L03116",
"F1120",
"F319",
"F17210",
"D649",
"S82102D",
"V892XXD",
"Z23"
] |
Allergies: vancomycin Chief Complaint: Leg pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] y/o M w/PMHx tibial fracture s/p ORIF at [MASKED], IVDU and bipolar disorder who presented to [MASKED] for fever and Left knee pain. Pt reports acute-onset knee and lower leg pain this afternoon, up to [MASKED]. He notes associated erythema and swelling. He has never had these symptoms before. No numbness in Left foot. He denies any fever, malaise, SOB, CP or n/v prior to presenting to [MASKED]. Of note, pt underwent a Right shoulder and Left tibial ORIF with screw placement on [MASKED] at [MASKED] in the setting of an MVA. He also notes that he does use IV drugs and has not done so in [MASKED] years. In the ED, initial vitals: 102.5; 87; 146/87; 18; 96% RA There was a report that patient had recently used IV drugs and was confused in the ED. Pt denied this on the floor. - Labs notable for: Cr: 0.7 CRP 4.5 CBC: 9.4>11.7/35.1<151 UA negative UTox positive for opiates/methadone STox pending at the time of transfer 3x bcx drawn - Imaging notable for: Tib/Fib AP/Lateral showed: Status post ORIF of the proximal tibia with plate and screw fixation with hardware in anatomic alignment. Very focal subtle linear lucency in the cortex of the medial metadiaphysis of the proximal left tibia, just underlying hardware plate, is of indeterminate age. Could relate to prior fracture or a more recent stress fracture. No prior for comparison. Bedside U/S without focal abscess in the knee CXR showed: No focal consolidation - Pt had a joint aspiration showing WBC 14, RBC [MASKED] - Patient given: IV Clindamycin (600 mg ordered) - Vitals prior to transfer: 100.6; 82; 139/80; 15; 94% RA On arrival to the floor, pt reports continued pain and swelling in LLE. Past Medical History: IV drug use Hepatitis C Bipolar Alcohol abuse Social History: [MASKED] Family History: Mother with diabetes and heart problems Physical Exam: ADMISSION EXAM ============== Vitals: 100.3; 143/80; 71; 18; 96% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: WWP. Large area of warmth, erythema and TTP along anterior aspect of LLE. 2+ DP pulses, equal bilaterally. MSK: ROM of Left knee could not be fully assessed due to pain with movement of Left leg Skin: Without rashes or lesions. Track marks on bilateral forearms. Surgical scar on anterior aspect of Right shoulder. Neuro: A&Ox3. Grossly intact. DISCHARGE EXAM ============== Vital Signs: Tmax 100.3, BP 138-154/80-88, HR 55-71, RR 18, 96-97%RA General: Alert, oriented, sitting up in bed comfortable, eating breakfast Lungs: Clear to auscultation bilaterally, good air movement gallops Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: WWP. mild erythema and TTP over large area of skin overlying the tibia, exquistitely tender near proximal tibia; no TTP at knee joint area MSK: ROM of Left knee could not be fully assessed due to pain with movement of Left leg Skin: Track marks on bilateral forearms. Surgical scar on anterior aspect of Right shoulder. Neuro: A&Ox3. Grossly intact. Pertinent Results: ADMISSION LABS ============= [MASKED] 08:35PM BLOOD WBC-9.4# RBC-3.72* Hgb-11.7* Hct-35.1* MCV-94 MCH-31.5 MCHC-33.3 RDW-14.0 RDWSD-48.4* Plt [MASKED] [MASKED] 08:35PM BLOOD Neuts-59.0 [MASKED] Monos-11.8 Eos-0.5* Baso-0.5 Im [MASKED] AbsNeut-5.52# AbsLymp-2.63 AbsMono-1.11* AbsEos-0.05 AbsBaso-0.05 [MASKED] 08:35PM BLOOD [MASKED] PTT-34.1 [MASKED] [MASKED] 08:35PM BLOOD Plt [MASKED] [MASKED] 08:35PM BLOOD Glucose-108* UreaN-7 Creat-0.7 Na-135 K-3.7 Cl-97 HCO3-25 AnGap-17 [MASKED] 08:35PM BLOOD CRP-4.5 [MASKED] 08:35PM BLOOD ASA-NEG [MASKED] Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 08:46PM BLOOD Lactate-1.6 IMAGING ====== X-ray tib/fib FINDINGS: Patient is status post ORIF of the proximal tibia with plate and screw fixation. Hardware appears in anatomic alignment. No hardware fracture is identified. On the AP view, there is very focal subtle linear lucency in the cortex of the medial metadiaphysis of the proximal tibia, just underlying hardware plate is of indeterminate age. No prior available for comparison. Well corticated 8 mm ossific structure just lateral to the lateral tibial plateau is chronic. There is likely a suprapatellar joint effusion. Patellar spurring is noted. IMPRESSION: Status post ORIF of the proximal tibia with plate and screw fixation with hardware in anatomic alignment. Very focal subtle linear lucency in the cortex of the medial metadiaphysis of the proximal left tibia, just underlying hardware plate, is of indeterminate age. Could relate to prior fracture or a more recent stress fracture. CXR [MASKED] FINDINGS: No focal consolidation is seen. There is no pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are grossly stable. No overt pulmonary edema is seen. Chronic deformity of the proximal right humerus with hardware is seen, but not well assessed on this study. IMPRESSION: No focal consolidation. Ultrasound lower extremity [MASKED] IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. DISCHARGE LABS ============= [MASKED] 06:30AM BLOOD WBC-6.2 RBC-3.86* Hgb-12.0* Hct-36.3* MCV-94 MCH-31.1 MCHC-33.1 RDW-13.8 RDWSD-47.7* Plt [MASKED] [MASKED] 06:30AM BLOOD Plt [MASKED] [MASKED] 06:30AM BLOOD Glucose-107* UreaN-6 Creat-0.7 Na-136 K-4.1 Cl-98 HCO3-26 AnGap-16 [MASKED] 06:30AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.0 Iron-60 [MASKED] 06:30AM BLOOD calTIBC-306 VitB12-401 Folate-14 Ferritn-416* TRF-[MASKED] y/o M w/PMHx tibial fracture s/p ORIF at [MASKED], IVDU and bipolar disorder who presented to [MASKED] for fever and Left knee pain c/w moderate cellulitis. #Cellulitis: The patient presented with left knee pain after undergoing a left tibial ORF with screw placement on [MASKED] at [MASKED] in the setting of an MVA. In the afternoon of [MASKED], he developed acute onset left leg pain and swelling with difficulty ambulating. He presented to [MASKED], where ortho evaluated in the OR. Joint was aspirated and fluid not concerning for septic joint. His CRP and ESR were low pointing away from osteomyelitis. He was initially treated with IV clindamycin but was narrowed to cephalexin to complete a 7-day course, with noticeable improvement in his symptoms while in the hospital. He was instructed to follow up with his PCP as an outpatient. #Anemia: The patient's CBC was notable for a hemoglobin around 12g. Iron studies were sent and were consistent with AOCD. #history of IVDU on methadone: He was given methadone 73 mg daily with confirmation of this dose by his [MASKED] clinic. He was given a letter indicating his last dose prior to discharge. TRANSITIONAL ISSUES =================== - The ED reported that the patient had taken heroin in the past month, however on the floor the patient denied this stating it had been [MASKED] years prior. His urine and blood toxicology were positive for opiates, methadone, and EtOH at 102 but nothing else. FULL CODE CONTACT: Friend [MASKED] [MASKED] [MASKED] on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Methadone 73 mg PO DAILY Discharge Medications: 1. Cephalexin 500 mg PO QID RX *cephalexin 500 mg 1 tablet(s) by mouth four times a day Disp #*21 Tablet Refills:*0 2. Methadone 73 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary - Cellulitis Secondary - history of IV drug use on methadone - 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 here at [MASKED]. You came to the hospital with leg pain and swelling. This was due to an infection of the skin, also known as cellulitis. We treated this infection with antibiotics. The orthopedic surgeons evaluated you and saw that there was no infection in the knee joint itself. You were discharged on oral antibiotics to finishing treating the skin infection. Again, it was a pleasure taking care of you. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"F17210",
"D649"
] |
[
"L03116: Cellulitis of left lower limb",
"F1120: Opioid dependence, uncomplicated",
"F319: Bipolar disorder, unspecified",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"D649: Anemia, unspecified",
"S82102D: Unspecified fracture of upper end of left tibia, subsequent encounter for closed fracture with routine healing",
"V892XXD: Person injured in unspecified motor-vehicle accident, traffic, subsequent encounter",
"Z23: Encounter for immunization"
] |
10,027,100
| 27,707,627
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
vancomycin / Thorazine / contact metal agent
Attending: ___.
Chief Complaint:
sore throat
Major Surgical or Invasive Procedure:
Colonoscopy on ___
History of Present Illness:
Mr. ___ is a ___ male with a PMH of treatment
native HCV, polysubstance abuse (heroin and benzo), and
homelessness, who is being directly admitted for colonoscopy
prep
for BRBPR. The patient follows with PCP ___ and
Dr.
___ was recently seen in ___ for BRBPR. At the time
he was recommended to proceed with a colonoscopy. However, due
to
his homelessness, he was unable to perform the prep. His PCP and
Dr. ___ was able to coordinate a ___ prep for his
work up.
On presentation, the patient complaints of having a mild sore
throat that started yesterday without radiation, denies
congestion, cough, or sputum production, fever or chills. He
also
has abdominal pain in the RUQ which he says is chronic from his
Hep C. In addition, the patient endorsed having consumed 3x 25oz
beer and half a pint of vodka hours prior to his presentation.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
HCV
Bipolar disorder
Opioid Use Disorder with active IV heroin use (last used a few
hours prior to admission) sometimes sniffs
ETOH active
Surgical history:
Incision, drainage, and packing of left forearm abscess. ___
Lt tibial and Rt shoulder Fixation BWH ___
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION:
GENERAL: Alert and in no distress, disheveled, 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, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs. +2 bilateral pedal edema
up to the knees.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Discharge:
GENERAL: Alert and in no distress, does not appear intoxicated
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Moves all extremities, strength grossly full
and symmetric bilaterally in all limbs. +2 bilateral pedal edema
up to the knees.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission:
___ 09:05PM GLUCOSE-105* UREA N-11 CREAT-0.7 SODIUM-138
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-27 ANION GAP-11
___ 09:05PM estGFR-Using this
___ 09:05PM ALT(SGPT)-51* AST(SGOT)-87* ALK PHOS-113 TOT
BILI-0.3
___ 09:05PM LIPASE-28
___ 09:05PM TOT PROT-7.2 PHOSPHATE-3.7
___ 09:05PM WBC-5.1 RBC-4.05* HGB-13.0* HCT-39.4* MCV-97
MCH-32.1* MCHC-33.0 RDW-13.9 RDWSD-49.8*
___ 09:05PM PLT COUNT-138*
___ 09:05PM ___
Discharge:
___ 07:19AM BLOOD WBC-5.3 RBC-4.02* Hgb-12.9* Hct-38.8*
MCV-97 MCH-32.1* MCHC-33.2 RDW-13.8 RDWSD-49.4* Plt ___
___ 07:19AM BLOOD Glucose-99 UreaN-9 Creat-0.6 Na-140 K-4.2
Cl-104 HCO3-25 AnGap-11
___ 09:05PM BLOOD ALT-51* AST-87* AlkPhos-113 TotBili-0.3
Brief Hospital Course:
THE PATIENT LEFT AGAINST MEDICAL ADVICE. He expressed
understanding of the risk of withdrawal if he left and had
capacity to leave.
Mr. ___ is a ___ male with the
PMH of HCV, PTSD, polysubstance abuse and prediabetes who
presents for ___ prep for BRBPR.
ACUTE/ACTIVE PROBLEMS:
# BRBPR: Presented with new onset of BRBPR. He was admitted to
complete inpatient prep. Colonoscopy normal except for
hemorrhoids on ___.
# Homelessness: SW consult was placed but he left AMA prior to
them seeing him.
# treatment naïve HCV
hx of IVDU and needle sharing. AST/ALT slightly elevated. He
should be treated for HCV, which he can discuss with his PCP.
# Polysubstance abuse
Active ETOH and heroin abuse. Last ETOH use was on the day of
admission where he drank half a pint of vodka and 3x 25 oz
beers. Will need to remain inpatient to ensure no withdrawal. In
addition, he continues to use heroin, last use 6 days prior to
admission. On Methadone at the Addictions Treatment ___
___. We attempted to call them to verify the home dose,
but they never called back. We continued him on the supposed
dose of 73 mg methadone. We wanted to keep him in the hospital
to monitor for EtOH withdrawal but he elected to leave against
medical advice. We requested SW come by to evaluate outpatient
resources for relapse prevention.
# Pedal edema: Bilateral pedal edema could be ___ to nutritional
deficiency and
alcohol abuse.
CHRONIC PROBLEMS:
# PTSD
# Prediabetes
More than 30 minutes were spent preparing this discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Chlorthalidone 25 mg PO DAILY
3. Methadone 73 mg PO DAILY
4. Naloxone Nasal Spray 4 mg IH ONCE MR1
5. fluticasone furoate 27.5 mcg/actuation nasal DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) [Vitamin B-1] 100 mg 1 tablet(s)
by mouth daily Disp #*30 Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
5. Chlorthalidone 25 mg PO DAILY
6. fluticasone furoate 27.5 mcg/actuation nasal DAILY
7. Methadone 73 mg PO DAILY
8. Naloxone Nasal Spray 4 mg IH ONCE MR1
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hemorrhoids, polysubstance abuse
Secondary: HCV
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 blood in your stool.
You also were drinking alcohol. We did a colonoscopy which only
showed hemorrhoids, which you can treat with over the counter
___ Baths and steroid cream, but it does not mean you have any
life threatening diseases.
We wanted to keep you to ensure that you didn't have any
withdrawal symptoms from drinking alcohol, but you elected to
leave against medical advice. We hope that you will seek the
help you need for your alcohol use.
You should follow up with your Primary care physician after
discharge. Call them in the morning to schedule an appointment.
Your care team at ___
Followup Instructions:
___
|
[
"K648",
"K644",
"K209",
"K625",
"K219",
"B1920",
"F1910",
"F1120",
"F319",
"D696",
"F1010",
"F4310",
"D649",
"K760",
"F17210",
"R7303",
"R609",
"R1011",
"Z8679",
"Z590"
] |
Allergies: vancomycin / Thorazine / contact metal agent Chief Complaint: sore throat Major Surgical or Invasive Procedure: Colonoscopy on [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] male with a PMH of treatment native HCV, polysubstance abuse (heroin and benzo), and homelessness, who is being directly admitted for colonoscopy prep for BRBPR. The patient follows with PCP [MASKED] and Dr. [MASKED] was recently seen in [MASKED] for BRBPR. At the time he was recommended to proceed with a colonoscopy. However, due to his homelessness, he was unable to perform the prep. His PCP and Dr. [MASKED] was able to coordinate a [MASKED] prep for his work up. On presentation, the patient complaints of having a mild sore throat that started yesterday without radiation, denies congestion, cough, or sputum production, fever or chills. He also has abdominal pain in the RUQ which he says is chronic from his Hep C. In addition, the patient endorsed having consumed 3x 25oz beer and half a pint of vodka hours prior to his presentation. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: HCV Bipolar disorder Opioid Use Disorder with active IV heroin use (last used a few hours prior to admission) sometimes sniffs ETOH active Surgical history: Incision, drainage, and packing of left forearm abscess. [MASKED] Lt tibial and Rt shoulder Fixation BWH [MASKED] Social History: [MASKED] Family History: Unknown Physical Exam: ADMISSION: GENERAL: Alert and in no distress, disheveled, 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, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs. +2 bilateral pedal edema up to the knees. SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Discharge: GENERAL: Alert and in no distress, does not appear intoxicated EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Moves all extremities, strength grossly full and symmetric bilaterally in all limbs. +2 bilateral pedal edema up to the knees. SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: Admission: [MASKED] 09:05PM GLUCOSE-105* UREA N-11 CREAT-0.7 SODIUM-138 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-27 ANION GAP-11 [MASKED] 09:05PM estGFR-Using this [MASKED] 09:05PM ALT(SGPT)-51* AST(SGOT)-87* ALK PHOS-113 TOT BILI-0.3 [MASKED] 09:05PM LIPASE-28 [MASKED] 09:05PM TOT PROT-7.2 PHOSPHATE-3.7 [MASKED] 09:05PM WBC-5.1 RBC-4.05* HGB-13.0* HCT-39.4* MCV-97 MCH-32.1* MCHC-33.0 RDW-13.9 RDWSD-49.8* [MASKED] 09:05PM PLT COUNT-138* [MASKED] 09:05PM [MASKED] Discharge: [MASKED] 07:19AM BLOOD WBC-5.3 RBC-4.02* Hgb-12.9* Hct-38.8* MCV-97 MCH-32.1* MCHC-33.2 RDW-13.8 RDWSD-49.4* Plt [MASKED] [MASKED] 07:19AM BLOOD Glucose-99 UreaN-9 Creat-0.6 Na-140 K-4.2 Cl-104 HCO3-25 AnGap-11 [MASKED] 09:05PM BLOOD ALT-51* AST-87* AlkPhos-113 TotBili-0.3 Brief Hospital Course: THE PATIENT LEFT AGAINST MEDICAL ADVICE. He expressed understanding of the risk of withdrawal if he left and had capacity to leave. Mr. [MASKED] is a [MASKED] male with the PMH of HCV, PTSD, polysubstance abuse and prediabetes who presents for [MASKED] prep for BRBPR. ACUTE/ACTIVE PROBLEMS: # BRBPR: Presented with new onset of BRBPR. He was admitted to complete inpatient prep. Colonoscopy normal except for hemorrhoids on [MASKED]. # Homelessness: SW consult was placed but he left AMA prior to them seeing him. # treatment naïve HCV hx of IVDU and needle sharing. AST/ALT slightly elevated. He should be treated for HCV, which he can discuss with his PCP. # Polysubstance abuse Active ETOH and heroin abuse. Last ETOH use was on the day of admission where he drank half a pint of vodka and 3x 25 oz beers. Will need to remain inpatient to ensure no withdrawal. In addition, he continues to use heroin, last use 6 days prior to admission. On Methadone at the Addictions Treatment [MASKED] [MASKED]. We attempted to call them to verify the home dose, but they never called back. We continued him on the supposed dose of 73 mg methadone. We wanted to keep him in the hospital to monitor for EtOH withdrawal but he elected to leave against medical advice. We requested SW come by to evaluate outpatient resources for relapse prevention. # Pedal edema: Bilateral pedal edema could be [MASKED] to nutritional deficiency and alcohol abuse. CHRONIC PROBLEMS: # PTSD # Prediabetes More than 30 minutes were spent preparing this discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 2. Chlorthalidone 25 mg PO DAILY 3. Methadone 73 mg PO DAILY 4. Naloxone Nasal Spray 4 mg IH ONCE MR1 5. fluticasone furoate 27.5 mcg/actuation nasal DAILY Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) [Vitamin B-1] 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 5. Chlorthalidone 25 mg PO DAILY 6. fluticasone furoate 27.5 mcg/actuation nasal DAILY 7. Methadone 73 mg PO DAILY 8. Naloxone Nasal Spray 4 mg IH ONCE MR1 Discharge Disposition: Home Discharge Diagnosis: Primary: Hemorrhoids, polysubstance abuse Secondary: HCV Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED] because you had blood in your stool. You also were drinking alcohol. We did a colonoscopy which only showed hemorrhoids, which you can treat with over the counter [MASKED] Baths and steroid cream, but it does not mean you have any life threatening diseases. We wanted to keep you to ensure that you didn't have any withdrawal symptoms from drinking alcohol, but you elected to leave against medical advice. We hope that you will seek the help you need for your alcohol use. You should follow up with your Primary care physician after discharge. Call them in the morning to schedule an appointment. Your care team at [MASKED] Followup Instructions: [MASKED]
|
[] |
[
"K219",
"D696",
"D649",
"F17210"
] |
[
"K648: Other hemorrhoids",
"K644: Residual hemorrhoidal skin tags",
"K209: Esophagitis, unspecified",
"K625: Hemorrhage of anus and rectum",
"K219: Gastro-esophageal reflux disease without esophagitis",
"B1920: Unspecified viral hepatitis C without hepatic coma",
"F1910: Other psychoactive substance abuse, uncomplicated",
"F1120: Opioid dependence, uncomplicated",
"F319: Bipolar disorder, unspecified",
"D696: Thrombocytopenia, unspecified",
"F1010: Alcohol abuse, uncomplicated",
"F4310: Post-traumatic stress disorder, unspecified",
"D649: Anemia, unspecified",
"K760: Fatty (change of) liver, not elsewhere classified",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"R7303: Prediabetes",
"R609: Edema, unspecified",
"R1011: Right upper quadrant pain",
"Z8679: Personal history of other diseases of the circulatory system",
"Z590: Homelessness"
] |
10,027,100
| 28,151,761
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
vancomycin / Thorazine / contact metal agent
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ undomiciled man with a history of hepatitis C,
opioid use disorder, alcohol abuse who presented to the ED with
1 day history of hematemesis. The patient reports one episode 2
days prior of a couple tablespoons of blood which then occurred
again morning of admission. He denies any blood in his stool or
melena. He denies any chest or abdominal pain. He denies any
shortness of breath. He also reports some bilateral leg swelling
without pain, warmth, fevers which has been present for several
weeks for which another hospital prescribed him Bactrim.
In the ED, initial vitals were: 9 98.9 81 129/100 18 98% RA.
Exam was notable for brown stool, guaiac negative, lower
extremities with 2+ pitting edema and excoriations. Minimal
erythema, no warmth. EKG SR, NA, NI, new TWI V4-V6. Labs
without significant anemia and overall stable. While there were
no red flags in the ED, with stable VS, labs and no hematemesis
in the ED given pulmonary vascular congestion on CXR, EKG
changes compared with prior and no documented history of CHF, he
was admitted for further workup.
On the floor, he was initially ornery and requesting to leave
AMA because he needed to use. He arrived in dirty urine and
stool covered clothing and he was cleaned up. He reports feeling
unwell, "like my body is deteriorating"
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 or
abdominal pain. No dysuria. Denies arthralgias or myalgias.
Otherwise ROS is negative.
Past Medical History:
HCV
Bipolar disorder
Opioid Use Disorder with active IV heroin use (last used a few
hours prior to admission) sometimes sniffs
ETOH active
Surgical history:
Incision, drainage, and packing of left forearm abscess. ___
Lt tibial and Rt shoulder Fixation BWH ___
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.2 PO 158 / 84 70 20 98 Ra
Pain Scale: ___
General: Patient appears dishelved, unkempt and foul smelling.
Alert, oriented and in no acute distress
HEENT: Sclera anicteric, poor dentition
Neck: supple, JVP low, no LAD appreciated
Lungs: Clear to auscultation bilaterally, moving air well and
symmetrically, no wheezes, rales or rhonchi appreciated
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality, no murmurs, rubs or gallops appreciated
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds throughout, no rebound or guarding
Ext: Bilateral ___ pitting up to knees
Neuro: CN2-12 grossly in tact, motor and sensory function
grossly intact in bilateral UE and ___, symmetric. Nodding off
during exam
DISCHARGE PHYSICAL EXAM
General: Alert, oriented and in no acute distress
HEENT: Sclera anicteric, poor dentition
Neck: supple, JVP low, no LAD appreciated
Lungs: Clear to auscultation bilaterally, moving air well and
symmetrically, no wheezes, rales or rhonchi appreciated
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality, no murmurs, rubs or gallops appreciated
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds throughout, no rebound or guarding
Ext: Bilateral ___ pitting up to knees R > L. Minimal /
resolving erythema RLE, several scabbed over excoriations
Neuro: CN2-12 grossly intact, motor and sensory function grossly
intact in bilateral UE and ___, symmetric.
Pertinent Results:
Admission Labs:
___ 11:55PM BLOOD WBC-6.0 RBC-3.38* Hgb-11.4* Hct-33.8*
MCV-100* MCH-33.7* MCHC-33.7 RDW-14.8 RDWSD-54.7* Plt ___
___ 11:55PM BLOOD Neuts-45.6 ___ Monos-12.7 Eos-1.7
Baso-0.8 Im ___ AbsNeut-2.73# AbsLymp-2.33 AbsMono-0.76
AbsEos-0.10 AbsBaso-0.05
___ 11:55PM BLOOD ___ PTT-33.9 ___
___ 11:55PM BLOOD Glucose-127* UreaN-11 Creat-0.6 Na-135
K-3.5 Cl-96 HCO3-26 AnGap-17
___ 11:55PM BLOOD Lipase-28
___ 11:55PM BLOOD Albumin-3.6
___ 11:55PM BLOOD proBNP-140*
Imaging:
___ CHEST X-RAY: Low lung volumes, mild cardiomegaly, and
central pulmonary vascular
congestion. Right apical airspace opacity appears modestly more
conspicuous as compared to the prior examination, and could be
further evaluated by apical lordotic views if clinically
indicated.
___ CHEST X-RAY
FINDINGS:
The previously described opacity at the right lung apex appears
less
conspicuous on apical lordotic views. Some of the abnormality
is due to
deformity of the right clavicular head, and there may be
additional bony
deformity of the adjacent manubrium.
IMPRESSION:
No good evidence for clinically significant pulmonary or pleural
abnormality
at the right apex.
Brief Hospital Course:
___ undomiciled man with a history of hepatitis C,
opioid use disorder, alcohol abuse who presented to the ED with
1 day history of hematemesis, one week history of R > L
bilateral lower extremity edema, rib pain after sustaining rib
fractures in assault, and hemoptysis.
# Hematemesis vs Hemoptysis
Patient did not give a clear history - he reported vomiting up
blood, but while inpatient, RN observed hemoptysis. He reports
a history of rib fractures secondary to assault. He denies
fevers, chills, weight loss, night sweats. Because he also had
concomitant R > L lower extremity edema, pulmonary embolism is
possible. Pulmonary infection, trauma, malignancy are also
possibilities. I discussed this with the patient and ordered
lower extremity ultrasound and CTA to evaluate further the
source of bleeding. He left the hospital against medical advice
before this could be obtained.
# Bilateral lower extremity edema, R > L
Unclear etiology as well, while there is pulmonary vascular
congestion on admission CXR his proBNP is normal and he has no
symptoms of CHF. Apparently had recent diagnosis of cellulitis
and started treatment with antibiotics prescribed at ___.
Patient reports negative LENIs. Severe onycomycosis and
excoriations from scratching on bilateral lower extremities
predisposing to cellulitis. As above, ordered LENIs, but
patient left against medical advice before this could be
obtained.
# Opioid Use Disorder
Unable to confirm methadone dose with Addiction ___
___ (___) before he left against medical advice. He
indicates 73mg Po Daily.
Patient reports ongoing daily heroin use, occasionally snorting
heroin, despite being enrolled in methadone program. Social
work was consulted but was unable to see him before he left
against medical advice
I had a frank discussion with the patient regarding his ongoing
drug abuse - he stated he was interested in drug rehabilitation,
and agreed to stay for further workup as outlined above.
Shortly after our discussion, he told his nurse he was leaving
against medical advice, and he walked out of the hospital before
I could re-assess him and have a discussion of risks
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methadone 73 mg PO DAILY
(unable to verify with Addiction Treatment ___
- ___, where he reportedly obtains methadone)
Discharge Medications:
1. Methadone 73 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
OPIOD USE DISORDER
Discharge Condition:
LEFT AGAINST MEDICAL ADVICE
Discharge Instructions:
LEFT AGAINST MEDICAL ADVICE
Followup Instructions:
___
|
[
"K920",
"F1120",
"F1010",
"Z590",
"M7989",
"F17210"
] |
Allergies: vancomycin / Thorazine / contact metal agent Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: NONE History of Present Illness: [MASKED] undomiciled man with a history of hepatitis C, opioid use disorder, alcohol abuse who presented to the ED with 1 day history of hematemesis. The patient reports one episode 2 days prior of a couple tablespoons of blood which then occurred again morning of admission. He denies any blood in his stool or melena. He denies any chest or abdominal pain. He denies any shortness of breath. He also reports some bilateral leg swelling without pain, warmth, fevers which has been present for several weeks for which another hospital prescribed him Bactrim. In the ED, initial vitals were: 9 98.9 81 129/100 18 98% RA. Exam was notable for brown stool, guaiac negative, lower extremities with 2+ pitting edema and excoriations. Minimal erythema, no warmth. EKG SR, NA, NI, new TWI V4-V6. Labs without significant anemia and overall stable. While there were no red flags in the ED, with stable VS, labs and no hematemesis in the ED given pulmonary vascular congestion on CXR, EKG changes compared with prior and no documented history of CHF, he was admitted for further workup. On the floor, he was initially ornery and requesting to leave AMA because he needed to use. He arrived in dirty urine and stool covered clothing and he was cleaned up. He reports feeling unwell, "like my body is deteriorating" 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 or abdominal pain. No dysuria. Denies arthralgias or myalgias. Otherwise ROS is negative. Past Medical History: HCV Bipolar disorder Opioid Use Disorder with active IV heroin use (last used a few hours prior to admission) sometimes sniffs ETOH active Surgical history: Incision, drainage, and packing of left forearm abscess. [MASKED] Lt tibial and Rt shoulder Fixation BWH [MASKED] Social History: [MASKED] Family History: Unknown Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.2 PO 158 / 84 70 20 98 Ra Pain Scale: [MASKED] General: Patient appears dishelved, unkempt and foul smelling. Alert, oriented and in no acute distress HEENT: Sclera anicteric, poor dentition Neck: supple, JVP low, no LAD appreciated Lungs: Clear to auscultation bilaterally, moving air well and symmetrically, no wheezes, rales or rhonchi appreciated CV: Regular rate and rhythm, S1 and S2 clear and of good quality, no murmurs, rubs or gallops appreciated Abdomen: soft, non-tender, non-distended, normoactive bowel sounds throughout, no rebound or guarding Ext: Bilateral [MASKED] pitting up to knees Neuro: CN2-12 grossly in tact, motor and sensory function grossly intact in bilateral UE and [MASKED], symmetric. Nodding off during exam DISCHARGE PHYSICAL EXAM General: Alert, oriented and in no acute distress HEENT: Sclera anicteric, poor dentition Neck: supple, JVP low, no LAD appreciated Lungs: Clear to auscultation bilaterally, moving air well and symmetrically, no wheezes, rales or rhonchi appreciated CV: Regular rate and rhythm, S1 and S2 clear and of good quality, no murmurs, rubs or gallops appreciated Abdomen: soft, non-tender, non-distended, normoactive bowel sounds throughout, no rebound or guarding Ext: Bilateral [MASKED] pitting up to knees R > L. Minimal / resolving erythema RLE, several scabbed over excoriations Neuro: CN2-12 grossly intact, motor and sensory function grossly intact in bilateral UE and [MASKED], symmetric. Pertinent Results: Admission Labs: [MASKED] 11:55PM BLOOD WBC-6.0 RBC-3.38* Hgb-11.4* Hct-33.8* MCV-100* MCH-33.7* MCHC-33.7 RDW-14.8 RDWSD-54.7* Plt [MASKED] [MASKED] 11:55PM BLOOD Neuts-45.6 [MASKED] Monos-12.7 Eos-1.7 Baso-0.8 Im [MASKED] AbsNeut-2.73# AbsLymp-2.33 AbsMono-0.76 AbsEos-0.10 AbsBaso-0.05 [MASKED] 11:55PM BLOOD [MASKED] PTT-33.9 [MASKED] [MASKED] 11:55PM BLOOD Glucose-127* UreaN-11 Creat-0.6 Na-135 K-3.5 Cl-96 HCO3-26 AnGap-17 [MASKED] 11:55PM BLOOD Lipase-28 [MASKED] 11:55PM BLOOD Albumin-3.6 [MASKED] 11:55PM BLOOD proBNP-140* Imaging: [MASKED] CHEST X-RAY: Low lung volumes, mild cardiomegaly, and central pulmonary vascular congestion. Right apical airspace opacity appears modestly more conspicuous as compared to the prior examination, and could be further evaluated by apical lordotic views if clinically indicated. [MASKED] CHEST X-RAY FINDINGS: The previously described opacity at the right lung apex appears less conspicuous on apical lordotic views. Some of the abnormality is due to deformity of the right clavicular head, and there may be additional bony deformity of the adjacent manubrium. IMPRESSION: No good evidence for clinically significant pulmonary or pleural abnormality at the right apex. Brief Hospital Course: [MASKED] undomiciled man with a history of hepatitis C, opioid use disorder, alcohol abuse who presented to the ED with 1 day history of hematemesis, one week history of R > L bilateral lower extremity edema, rib pain after sustaining rib fractures in assault, and hemoptysis. # Hematemesis vs Hemoptysis Patient did not give a clear history - he reported vomiting up blood, but while inpatient, RN observed hemoptysis. He reports a history of rib fractures secondary to assault. He denies fevers, chills, weight loss, night sweats. Because he also had concomitant R > L lower extremity edema, pulmonary embolism is possible. Pulmonary infection, trauma, malignancy are also possibilities. I discussed this with the patient and ordered lower extremity ultrasound and CTA to evaluate further the source of bleeding. He left the hospital against medical advice before this could be obtained. # Bilateral lower extremity edema, R > L Unclear etiology as well, while there is pulmonary vascular congestion on admission CXR his proBNP is normal and he has no symptoms of CHF. Apparently had recent diagnosis of cellulitis and started treatment with antibiotics prescribed at [MASKED]. Patient reports negative LENIs. Severe onycomycosis and excoriations from scratching on bilateral lower extremities predisposing to cellulitis. As above, ordered LENIs, but patient left against medical advice before this could be obtained. # Opioid Use Disorder Unable to confirm methadone dose with Addiction [MASKED] [MASKED] ([MASKED]) before he left against medical advice. He indicates 73mg Po Daily. Patient reports ongoing daily heroin use, occasionally snorting heroin, despite being enrolled in methadone program. Social work was consulted but was unable to see him before he left against medical advice I had a frank discussion with the patient regarding his ongoing drug abuse - he stated he was interested in drug rehabilitation, and agreed to stay for further workup as outlined above. Shortly after our discussion, he told his nurse he was leaving against medical advice, and he walked out of the hospital before I could re-assess him and have a discussion of risks Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Methadone 73 mg PO DAILY (unable to verify with Addiction Treatment [MASKED] - [MASKED], where he reportedly obtains methadone) Discharge Medications: 1. Methadone 73 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: OPIOD USE DISORDER Discharge Condition: LEFT AGAINST MEDICAL ADVICE Discharge Instructions: LEFT AGAINST MEDICAL ADVICE Followup Instructions: [MASKED]
|
[] |
[
"F17210"
] |
[
"K920: Hematemesis",
"F1120: Opioid dependence, uncomplicated",
"F1010: Alcohol abuse, uncomplicated",
"Z590: Homelessness",
"M7989: Other specified soft tissue disorders",
"F17210: Nicotine dependence, cigarettes, uncomplicated"
] |
10,027,100
| 29,368,678
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
Left arm infection
Major Surgical or Invasive Procedure:
Drainage of abscess ___ left arm on ___ and ___
History of Present Illness:
Mr. ___ is a ___ yo M with history of IVDU presenting with
left arm swelling and pain. Patient first noticed pain and
swelling ___ his left arm 5 days ago at night, after injecting
heroin on that day.
He notes that he was with friends who were using, and so he used
with them. ___ terms of his heroin use, he is not sure what type
he uses and describes it as brown/beige rock that he dissolves
___ tap water. He gets his needles from Needle Exchange or from
the pharmacy and usually uses them twice. The needle he used
during his last injection was a second time use. He denies
cleaning his arm before injecting, and reports using the
cigarette filter as a cotton.
He notes chills, episodes of night sweats, some occasional
feeling of being cold but no fevers. He denies any prior history
of infection from IV drug use. He denies use of any other drugs.
He reports daily heroin use for almost ___ years; however, he
reports injecting heroin 1 or 2 times a month for the last few
months after joining ___ where
he is getting daily methadone. He notes he feels that he is well
plugged ___ with the ___ clinic he is a part of and feels
that he has reduced his use substantially. He denies sharing
needles recently. He consents to HIV testing.
___ the ED, initial vital signs were: 99.3 80 141/87 16 97% RA
- Exam notable for extensive track marks on both arms, and
swelling, erythema, and tenderness ___ left arm
- Labs were notable for H/H 12.4/36.6 and absence of
leukocytosis
- Studies performed include Na 135, K 3.8, Cl 28, bicarb 25,
BUN 9, Cr 0.7, and lactate 1.3. Bedside ultrasound that showed
no fluid collection.
- Patient was given clindamycin 600 mg IV ONCE
- Vitals on transfer: 99.3 72 138/67 14 96% RA
Patient was admitted due to substantial infection which should
improve prior to discharge due to poor follow up. On the
medicine floor, patient was hemodynamically stable and ___ no
acute distress. He was continued on IV clindamycin overnight.
Past Medical History:
IV drug use
Hepatitis C
Bipolar
Alcohol abuse
Social History:
___
Family History:
Mother with diabetes and heart problems
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
Vitals- T 99.5 HR 61-64 BP ___ RR 18 SaO2 96% RA
weight 69.2 kg
General: well-appearing, ___ no acute distress
HEENT: EOMI, ___
CV: RRR, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes, rales, or
rhonci
Abdomen: Normal bowel sounds, soft, non-tender to palpation ___
all quadrants
Ext: 2+ peripheral pulses
Skin: Multiple tattoos on upper extremities and chest. Left arm
with notable 3 X 3 cm abscess on forearm, warm to the touch,
with tenderness, and overlying erythema of the skin. Strength,
sensation, and pulse intact ___ the arm. No other notable areas
of injection appreciated
PHYSICAL EXAM ON DISCHARGE:
===========================
Vitals- Tmax 98.7/98.4; 100-112/54-75; 51-74; ___ 96-99% RA
General: Well-appearing, ___ no acute distress
CV: RRR, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes, rales, or
rhonci
Abdomen: Normal bowel sounds, soft, non-tender to palpation ___
all quadrants
Upper extremity: Left arm with dressing on, motor and sensation
grossly intact bilaterally.
Pertinent Results:
ON ADMISSION:
=============
___ 05:30PM BLOOD WBC-8.5 RBC-3.80* Hgb-12.4* Hct-36.6*
MCV-96 MCH-32.6* MCHC-33.9 RDW-13.5 RDWSD-47.9* Plt ___
___ 05:30PM BLOOD Neuts-43.7 ___ Monos-12.6 Eos-1.5
Baso-0.5 Im ___ AbsNeut-3.70# AbsLymp-3.52 AbsMono-1.07*
AbsEos-0.13 AbsBaso-0.04
___ 05:30PM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-135 K-3.8
Cl-98 HCO3-25 AnGap-16
___ 05:49PM BLOOD Lactate-1.3
ON DISCHARGE:
=============
___ 06:36AM BLOOD WBC-7.7 RBC-4.21* Hgb-13.4* Hct-40.9
MCV-97 MCH-31.8 MCHC-32.8 RDW-13.3 RDWSD-47.3* Plt ___
___ 06:36AM BLOOD Glucose-93 UreaN-13 Creat-0.8 Na-137
K-4.6 Cl-99 HCO3-28 AnGap-15
___ 06:36AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.2
PERTINENT TESTS:
================
___ 06:00AM BLOOD ALT-52* AST-78* AlkPhos-80 TotBili-1.0
___ 06:00AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.1 Iron-195*
___ 06:00AM BLOOD calTIBC-348 VitB12-420 Ferritn-399
TRF-268
___ 06:00AM BLOOD CRP-3.2
___ 06:00AM BLOOD HIV Ab-Negative
IMAGING:
========
___ Ultrasound left arm:
Subcutaneous left forearm fluid collection consistent with
abscess, measuring 1.2 x 1.1 x 1.6 cm.
MICRO:
======
___ 6:17 pm ABSCESS Source: arm, L.
Fluid should not be sent ___ swab transport media. Submit
fluids ___ a
capped syringe (no needle), red top tube, or sterile cup.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS, CHAINS, AND
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Preliminary):
STREPTOCOCCUS ANGINOSUS (___) GROUP. MODERATE
GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (___)
GROUP
|
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ 0.25 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
___ yo M with history of IV heroine use and hepatitis C who
presented with left arm abscess/cellulitis infection.
#Cellulitis/Abscess: Patient presented with left arm swelling,
erythema, and tenderness ___ location of IVD injected 5 days ago.
Although bedside US did not show fluid collection ___ the ED, the
notable fluid collection under the skin, tenderness to
palpation, and erythema were concerning for an underlying
abscess. Repeat ultrasound showed fluid collection consistent
with abscess, measuring 1.2 x 1.1 x 1.6 cm s/p I&D x2 (on ___
and ___ by Plastic Surgery. Patient was started on
clindamycin (Day ___ and then cipro (Day ___
was added to cover from gram + and anaerobes. Pain control was
achieved with Tylenol and methadone (see below), and
occasionally oxycodone mainly when pain was severe after I&D.
Speciation of gram positive cocci showed streptococcus
anginosus, which was sensitive to vancomycin and penicillins.
Otherwise, anaerobic cultures did not result by the time of
discharge. The significance of the gram positive rods was
unclear, as they did not speciate and were felt by the
microbiology to have potentially been gram positive diplococci.
Pt was discharged with Augmentin and metronidazole with a
planned 9-day course. He was also scheduled for follow up with
plastic surgery.
#IV Drug use: Patient with IV heroine use is currently receiving
methadone at ___. We continued methadone
68 mg daily. Of note, pt frequently went for what he described
as smoke breaks during this hospitalization, lasting up to 2
hours. UDS was initially positive for opiates ___ the setting of
recent oxycodone use. His UDS became negative for opiates the
day before discharge.
#Hepatitis C: Patient has a known history of hepatitis C
infection. LFT's were notable for transaminitis similar to
prior, with ___ and platelets within normal limits.
#Normocytic Anemia: H/H was 3.80/12.4 on admission, which was
stable compared to prior. Iron studies were within normal limits
except for high iron of 195, vitamin B12 was also within normal
limits.
#Bipolar: Patient is not on any medications.
***TRANSITIONAL ISSUES***:
-Pt should complete a 14 day course of Augmentin and
ciprofloxacin (day ___ end ___ and ensure
resolution of symptoms.
-Pt scheduled to follow up with plastic surgery
-Continue daily packing change.
-Patient has anemia (H/H of 12.8/38.4) with elevated RDW and
normal MCV. Monitor H/H and consider further anemia workup.
-Patient has a known history of hepatitis C infection, please
monitor.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methadone 68 mg PO DAILY
Discharge Medications:
1. Methadone 68 mg PO DAILY
2. Naloxone 0.04 mg IV ONCE MR1 Opiate overdose Duration: 1 Dose
Spray 1mL each nostril. Repeat ___ 3min if no response.
RX *naloxone 1 mg/mL 2 mL intranasal once Disp #*2 Syringe
Refills:*0
3. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth every eight (8) hours Disp #*28 Tablet Refills:*0
4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Left arm abscess and cellulitis
SECONDARY DIAGNOSES:
Hepatitis C virus infection
Anemia
Bipolar
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital because you were experiencing left arm
swelling and pain after injecting drugs ___ the arm. Ultrasound
of the arm showed a deep abscess, so the Plastic surgery team
drained it twice. We treated you with antibiotics which you
should continue as prescribed.
You are being discharged with 2 new antibiotics:
amoxicillin-clavulanate and metronidazole. Please take these 3
times each day for the next 9 days. If you develop any rash or
shortness of breath after taking your antibiotics, please seek
medical attention immediately. Please also do not drink alcohol
while taking antibiotics, as this can make you feel ill.
Because it is so difficult to stop using, its important to know
how to keep yourself as safe as possible until you are ready to
quit. Follow these tips when injecting drugs.
- Wash your hands with soap and water first.
- Do not share needles and syringes.
- Always try to use a new needle/syringe for each injection.
- If you are re-using a needle, it must be cleaned before you
use it. If you use it over and over, clean it every time.
- The safest water is sterile water that you buy at the drug
store. If you ___ have sterile water, use water that youve
boiled for at least 10 minutes. Boil just before using, allowing
a short time to cool.
- Use clean, 100% cotton from a dental pellet, Q-tip, or cotton
ball. If you ___ have these, filter paper or tampons may work.
Do not use cigarette filters.
- Clean skin with alcohol before injection.
- Do not lick skin or needle. This increases the risk of
infection.
We are also discharging you with a medication called naloxone.
If you overdose on heroin, this can save your life. If you are
administered this medication, you will need go immediately to an
emergency room. This medication will only make you better for a
short period of time, and your life can be ___ danger after the
medication wears off.
Make sure to follow up with you primary care doctor. We have
also scheduled you for an appointment with a plastic surgeon,
Dr. ___.
It was a pleasure taking care of you!
-Your ___ team
Followup Instructions:
___
|
[
"L02414",
"I420",
"F319",
"F1010",
"B1920",
"F17210",
"B954",
"D649"
] |
Allergies: vancomycin Chief Complaint: Left arm infection Major Surgical or Invasive Procedure: Drainage of abscess [MASKED] left arm on [MASKED] and [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] yo M with history of IVDU presenting with left arm swelling and pain. Patient first noticed pain and swelling [MASKED] his left arm 5 days ago at night, after injecting heroin on that day. He notes that he was with friends who were using, and so he used with them. [MASKED] terms of his heroin use, he is not sure what type he uses and describes it as brown/beige rock that he dissolves [MASKED] tap water. He gets his needles from Needle Exchange or from the pharmacy and usually uses them twice. The needle he used during his last injection was a second time use. He denies cleaning his arm before injecting, and reports using the cigarette filter as a cotton. He notes chills, episodes of night sweats, some occasional feeling of being cold but no fevers. He denies any prior history of infection from IV drug use. He denies use of any other drugs. He reports daily heroin use for almost [MASKED] years; however, he reports injecting heroin 1 or 2 times a month for the last few months after joining [MASKED] where he is getting daily methadone. He notes he feels that he is well plugged [MASKED] with the [MASKED] clinic he is a part of and feels that he has reduced his use substantially. He denies sharing needles recently. He consents to HIV testing. [MASKED] the ED, initial vital signs were: 99.3 80 141/87 16 97% RA - Exam notable for extensive track marks on both arms, and swelling, erythema, and tenderness [MASKED] left arm - Labs were notable for H/H 12.4/36.6 and absence of leukocytosis - Studies performed include Na 135, K 3.8, Cl 28, bicarb 25, BUN 9, Cr 0.7, and lactate 1.3. Bedside ultrasound that showed no fluid collection. - Patient was given clindamycin 600 mg IV ONCE - Vitals on transfer: 99.3 72 138/67 14 96% RA Patient was admitted due to substantial infection which should improve prior to discharge due to poor follow up. On the medicine floor, patient was hemodynamically stable and [MASKED] no acute distress. He was continued on IV clindamycin overnight. Past Medical History: IV drug use Hepatitis C Bipolar Alcohol abuse Social History: [MASKED] Family History: Mother with diabetes and heart problems Physical Exam: PHYSICAL EXAM ON ADMISSION: =========================== Vitals- T 99.5 HR 61-64 BP [MASKED] RR 18 SaO2 96% RA weight 69.2 kg General: well-appearing, [MASKED] no acute distress HEENT: EOMI, [MASKED] CV: RRR, no murmurs Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonci Abdomen: Normal bowel sounds, soft, non-tender to palpation [MASKED] all quadrants Ext: 2+ peripheral pulses Skin: Multiple tattoos on upper extremities and chest. Left arm with notable 3 X 3 cm abscess on forearm, warm to the touch, with tenderness, and overlying erythema of the skin. Strength, sensation, and pulse intact [MASKED] the arm. No other notable areas of injection appreciated PHYSICAL EXAM ON DISCHARGE: =========================== Vitals- Tmax 98.7/98.4; 100-112/54-75; 51-74; [MASKED] 96-99% RA General: Well-appearing, [MASKED] no acute distress CV: RRR, no murmurs Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonci Abdomen: Normal bowel sounds, soft, non-tender to palpation [MASKED] all quadrants Upper extremity: Left arm with dressing on, motor and sensation grossly intact bilaterally. Pertinent Results: ON ADMISSION: ============= [MASKED] 05:30PM BLOOD WBC-8.5 RBC-3.80* Hgb-12.4* Hct-36.6* MCV-96 MCH-32.6* MCHC-33.9 RDW-13.5 RDWSD-47.9* Plt [MASKED] [MASKED] 05:30PM BLOOD Neuts-43.7 [MASKED] Monos-12.6 Eos-1.5 Baso-0.5 Im [MASKED] AbsNeut-3.70# AbsLymp-3.52 AbsMono-1.07* AbsEos-0.13 AbsBaso-0.04 [MASKED] 05:30PM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-135 K-3.8 Cl-98 HCO3-25 AnGap-16 [MASKED] 05:49PM BLOOD Lactate-1.3 ON DISCHARGE: ============= [MASKED] 06:36AM BLOOD WBC-7.7 RBC-4.21* Hgb-13.4* Hct-40.9 MCV-97 MCH-31.8 MCHC-32.8 RDW-13.3 RDWSD-47.3* Plt [MASKED] [MASKED] 06:36AM BLOOD Glucose-93 UreaN-13 Creat-0.8 Na-137 K-4.6 Cl-99 HCO3-28 AnGap-15 [MASKED] 06:36AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.2 PERTINENT TESTS: ================ [MASKED] 06:00AM BLOOD ALT-52* AST-78* AlkPhos-80 TotBili-1.0 [MASKED] 06:00AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.1 Iron-195* [MASKED] 06:00AM BLOOD calTIBC-348 VitB12-420 Ferritn-399 TRF-268 [MASKED] 06:00AM BLOOD CRP-3.2 [MASKED] 06:00AM BLOOD HIV Ab-Negative IMAGING: ======== [MASKED] Ultrasound left arm: Subcutaneous left forearm fluid collection consistent with abscess, measuring 1.2 x 1.1 x 1.6 cm. MICRO: ====== [MASKED] 6:17 pm ABSCESS Source: arm, L. Fluid should not be sent [MASKED] swab transport media. Submit fluids [MASKED] a capped syringe (no needle), red top tube, or sterile cup. GRAM STAIN (Final [MASKED]: 2+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ [MASKED] per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ [MASKED] per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] PAIRS, CHAINS, AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. FLUID CULTURE (Preliminary): STREPTOCOCCUS ANGINOSUS ([MASKED]) GROUP. MODERATE GROWTH. SENSITIVITIES: MIC expressed [MASKED] MCG/ML [MASKED] STREPTOCOCCUS ANGINOSUS ([MASKED]) GROUP | PENICILLIN G----------<=0.06 S VANCOMYCIN------------ 0.25 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. Brief Hospital Course: [MASKED] yo M with history of IV heroine use and hepatitis C who presented with left arm abscess/cellulitis infection. #Cellulitis/Abscess: Patient presented with left arm swelling, erythema, and tenderness [MASKED] location of IVD injected 5 days ago. Although bedside US did not show fluid collection [MASKED] the ED, the notable fluid collection under the skin, tenderness to palpation, and erythema were concerning for an underlying abscess. Repeat ultrasound showed fluid collection consistent with abscess, measuring 1.2 x 1.1 x 1.6 cm s/p I&D x2 (on [MASKED] and [MASKED] by Plastic Surgery. Patient was started on clindamycin (Day [MASKED] and then cipro (Day [MASKED] was added to cover from gram + and anaerobes. Pain control was achieved with Tylenol and methadone (see below), and occasionally oxycodone mainly when pain was severe after I&D. Speciation of gram positive cocci showed streptococcus anginosus, which was sensitive to vancomycin and penicillins. Otherwise, anaerobic cultures did not result by the time of discharge. The significance of the gram positive rods was unclear, as they did not speciate and were felt by the microbiology to have potentially been gram positive diplococci. Pt was discharged with Augmentin and metronidazole with a planned 9-day course. He was also scheduled for follow up with plastic surgery. #IV Drug use: Patient with IV heroine use is currently receiving methadone at [MASKED]. We continued methadone 68 mg daily. Of note, pt frequently went for what he described as smoke breaks during this hospitalization, lasting up to 2 hours. UDS was initially positive for opiates [MASKED] the setting of recent oxycodone use. His UDS became negative for opiates the day before discharge. #Hepatitis C: Patient has a known history of hepatitis C infection. LFT's were notable for transaminitis similar to prior, with [MASKED] and platelets within normal limits. #Normocytic Anemia: H/H was 3.80/12.4 on admission, which was stable compared to prior. Iron studies were within normal limits except for high iron of 195, vitamin B12 was also within normal limits. #Bipolar: Patient is not on any medications. ***TRANSITIONAL ISSUES***: -Pt should complete a 14 day course of Augmentin and ciprofloxacin (day [MASKED] end [MASKED] and ensure resolution of symptoms. -Pt scheduled to follow up with plastic surgery -Continue daily packing change. -Patient has anemia (H/H of 12.8/38.4) with elevated RDW and normal MCV. Monitor H/H and consider further anemia workup. -Patient has a known history of hepatitis C infection, please monitor. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Methadone 68 mg PO DAILY Discharge Medications: 1. Methadone 68 mg PO DAILY 2. Naloxone 0.04 mg IV ONCE MR1 Opiate overdose Duration: 1 Dose Spray 1mL each nostril. Repeat [MASKED] 3min if no response. RX *naloxone 1 mg/mL 2 mL intranasal once Disp #*2 Syringe Refills:*0 3. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q8H RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by mouth every eight (8) hours Disp #*28 Tablet Refills:*0 4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*28 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Left arm abscess and cellulitis SECONDARY DIAGNOSES: Hepatitis C virus infection Anemia Bipolar 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 because you were experiencing left arm swelling and pain after injecting drugs [MASKED] the arm. Ultrasound of the arm showed a deep abscess, so the Plastic surgery team drained it twice. We treated you with antibiotics which you should continue as prescribed. You are being discharged with 2 new antibiotics: amoxicillin-clavulanate and metronidazole. Please take these 3 times each day for the next 9 days. If you develop any rash or shortness of breath after taking your antibiotics, please seek medical attention immediately. Please also do not drink alcohol while taking antibiotics, as this can make you feel ill. Because it is so difficult to stop using, its important to know how to keep yourself as safe as possible until you are ready to quit. Follow these tips when injecting drugs. - Wash your hands with soap and water first. - Do not share needles and syringes. - Always try to use a new needle/syringe for each injection. - If you are re-using a needle, it must be cleaned before you use it. If you use it over and over, clean it every time. - The safest water is sterile water that you buy at the drug store. If you [MASKED] have sterile water, use water that youve boiled for at least 10 minutes. Boil just before using, allowing a short time to cool. - Use clean, 100% cotton from a dental pellet, Q-tip, or cotton ball. If you [MASKED] have these, filter paper or tampons may work. Do not use cigarette filters. - Clean skin with alcohol before injection. - Do not lick skin or needle. This increases the risk of infection. We are also discharging you with a medication called naloxone. If you overdose on heroin, this can save your life. If you are administered this medication, you will need go immediately to an emergency room. This medication will only make you better for a short period of time, and your life can be [MASKED] danger after the medication wears off. Make sure to follow up with you primary care doctor. We have also scheduled you for an appointment with a plastic surgeon, Dr. [MASKED]. It was a pleasure taking care of you! -Your [MASKED] team Followup Instructions: [MASKED]
|
[] |
[
"F17210",
"D649"
] |
[
"L02414: Cutaneous abscess of left upper limb",
"I420: Dilated cardiomyopathy",
"F319: Bipolar disorder, unspecified",
"F1010: Alcohol abuse, uncomplicated",
"B1920: Unspecified viral hepatitis C without hepatic coma",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"B954: Other streptococcus as the cause of diseases classified elsewhere",
"D649: Anemia, unspecified"
] |
10,027,221
| 20,603,875
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right knee pain/infection
Major Surgical or Invasive Procedure:
___: explant right TKA, placement abx spacer
History of Present Illness:
___ y/o male with probably right knee PJI, here for explant right
TKA and placement antibiotic cement spacer with Dr. ___.
Past Medical History:
dyslipidemia, reflux, BPH
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 a Prevena wound VAC dressing in
place
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 12:00AM BLOOD WBC-7.2 RBC-2.88* Hgb-8.3* Hct-25.7*
MCV-89 MCH-28.8 MCHC-32.3 RDW-13.0 RDWSD-42.5 Plt ___
___ 10:30AM BLOOD WBC-8.5 RBC-3.23* Hgb-9.2* Hct-28.8*
MCV-89 MCH-28.5 MCHC-31.9* RDW-12.9 RDWSD-42.4 Plt ___
___ 06:08AM BLOOD WBC-8.2 RBC-3.04* Hgb-8.9* Hct-27.3*
MCV-90 MCH-29.3 MCHC-32.6 RDW-13.2 RDWSD-43.7 Plt ___
___ 06:30AM BLOOD WBC-8.7 RBC-3.43* Hgb-9.8* Hct-30.9*
MCV-90 MCH-28.6 MCHC-31.7* RDW-13.4 RDWSD-44.1 Plt ___
___ 06:08AM BLOOD Neuts-64.0 Lymphs-16.3* Monos-17.4*
Eos-1.5 Baso-0.1 Im ___ AbsNeut-5.21 AbsLymp-1.33
AbsMono-1.42* AbsEos-0.12 AbsBaso-0.01
___ 12:00AM BLOOD Glucose-92 UreaN-11 Creat-0.9 Na-142
K-3.8 Cl-102 HCO3-26 AnGap-14
___ 10:30AM BLOOD Glucose-126* UreaN-12 Creat-0.9 Na-138
K-4.3 Cl-101 HCO3-27 AnGap-10
___ 06:08AM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-136
K-4.0 Cl-100 HCO3-25 AnGap-11
___ 06:30AM BLOOD Glucose-88 UreaN-14 Creat-1.0 Na-140
K-4.7 Cl-102 HCO3-25 AnGap-13
___ 12:00AM BLOOD ALT-7 AST-15 LD(LDH)-157 AlkPhos-69
TotBili-0.4
___ 06:08AM BLOOD ALT-7 AST-12 AlkPhos-58 TotBili-0.6
___ 12:00AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.0
___ 10:30AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.9
___ 06:08AM BLOOD Calcium-7.6* Phos-2.0* Mg-1.8
___ 06:30AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.7
___ 12:00AM BLOOD CRP-227.9*
___ 06:08AM BLOOD CRP-231.6*
___ 10:30AM BLOOD Vanco-21.1*
___ 02:30AM BLOOD Vanco-17.8
___ 11:08AM BLOOD Vanco-15.7
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. Cultures were taken in the OR and showed coag
negative staph. Per ID recommendations, he was started on IV
Vancomycin and Ancef. Their final recommendations were ***.
Postoperative course was remarkable for the following:
POD#1, he became orthostatic with ___. He was given 500ml bolus
of IV and responded appropriately.
POD#3, the patient reported right calf pain on exam. A RLE
ultrasound was obtained and negative for a DVT. A PICC was
placed and placement was confirmed by x-ray (tip is at the level
of cavoatrial junction).
POD#4, The patient denied any right calf tenderness on exam. The
Prevena wound vac dressing was changed on ___ prior to
discharge. He is due for a VAC change on ___. His systolic
blood pressure was 90's. He was asymptomatic. He was bloused
with 500cc NS. His systolic blood pressure improved to 120's.
His vancomycin dose (1250mg every 8 hours) was confirmed with
pharmacy and infectious disease. He will be due for a Vancomycin
trough on ___. Please fax results to ___ as
his dose may need to be adjusted.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient received Lovenox daily for DVT
prophylaxis starting on the morning of POD#1. Prevena wound VAC
applied to right knee and changed on ___. This will be due
for a change on ___ by the rehab facility (confirmed that
this can be down at the rehab facility by case manager). 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.
The patient's weight-bearing status is touch down weigh bearing
on the operative extremity. NO RANGE OF MOTION OF RIGHT KNEE
with knee immbolizer on at all times. Please use walker or 2
crutches.
Mr. ___ is discharged to rehab in stable condition.
Medications on Admission:
1. Acetaminophen 1000 mg PO Q8H
2. BuPROPion 100 mg PO BID
3. ARIPiprazole 15 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. Sertraline 50 mg PO DAILY
9. TraZODone 200 mg PO QHS:PRN sleep issues
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Enoxaparin Sodium 40 mg SC DAILY Duration: 4 Weeks
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
3. Heparin Flush (10 units/ml) 2 mL IV ONCE MR1 For PICC
insertion Duration: 1 Dose
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
5. Senna 8.6 mg PO BID
6. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
7. Vancomycin 1250 mg IV Q 8H
8. Acetaminophen 1000 mg PO Q8H
9. ARIPiprazole 15 mg PO DAILY
10. Atorvastatin 20 mg PO DAILY
11. BuPROPion 100 mg PO BID
12. Furosemide 20 mg PO DAILY
13. Omeprazole 40 mg PO DAILY
14. Sertraline 50 mg PO DAILY
15. Tamsulosin 0.4 mg PO QHS
16. TraZODone 200 mg PO QHS:PRN sleep issues
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right knee PJI
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.
8. ANTICOAGULATION: Please continue your lovenox daily for four
(4) weeks to help prevent deep vein thrombosis (blood clots). At
the end of the four weeks, you may return to your normal Aspirin
regimen if you were taking Aspirin preoperatively.
9. WOUND CARE: Prevena wound vac in place (changed on ___.
It may remain in place for 7 days and will due to be changed on
___. Check the wound for signs of infection such as redness
or thick yellow drainage and promptly notify your surgeon of any
such findings immediately.
10. ___ (once at home): Home ___, IV antibiotics, PICC care,
wound care
11. ACTIVITY: Touchdown weight bearing on the right lower
extremity. Use two crutches or a walker. Mobilize often. No
range of motion of the right knee. Knee immobilizer on right
lower extremity at all times. No strenuous exercise or heavy
lifting until cleared.
12. PICC CARE: Per protocol
13. WEEKLY LABS: draw on ___ and send result to ID RNs
at: ___ R.N.s at ___.
- CBC/DIFF
- CHEM 7
- LFTS
- ESR/CRP
14. PLEASE DRAW A VANCO TROUGH LEVEL ON ___ AND FAX
RESULT TO ___.
**All questions regarding outpatient parenteral antibiotics
should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.**
Physical Therapy:
Touch Down Weight Bearing RLE
** NO RANGE OF MOTION OF RIGHT KNEE **
Knee immobilizer at all times on RLE
Treatments Frequency:
Right knee Prevena Wound VAC (last changed on ___. Wound
VAC due to be changed on ___. Please continue with Prevena
Wound VAC Dressing until his post op visit on ___ with ___
___, PA-C.
Right PICC line care per protocol.
Followup Instructions:
___
|
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"T8453XA",
"M00061",
"Y832",
"Y929",
"Z96653",
"E785",
"K219",
"I10",
"N400",
"F329",
"M79661",
"B958",
"I951"
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Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: right knee pain/infection Major Surgical or Invasive Procedure: [MASKED]: explant right TKA, placement abx spacer History of Present Illness: [MASKED] y/o male with probably right knee PJI, here for explant right TKA and placement antibiotic cement spacer with Dr. [MASKED]. Past Medical History: dyslipidemia, reflux, BPH 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 a Prevena wound VAC dressing in place * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: [MASKED] 12:00AM BLOOD WBC-7.2 RBC-2.88* Hgb-8.3* Hct-25.7* MCV-89 MCH-28.8 MCHC-32.3 RDW-13.0 RDWSD-42.5 Plt [MASKED] [MASKED] 10:30AM BLOOD WBC-8.5 RBC-3.23* Hgb-9.2* Hct-28.8* MCV-89 MCH-28.5 MCHC-31.9* RDW-12.9 RDWSD-42.4 Plt [MASKED] [MASKED] 06:08AM BLOOD WBC-8.2 RBC-3.04* Hgb-8.9* Hct-27.3* MCV-90 MCH-29.3 MCHC-32.6 RDW-13.2 RDWSD-43.7 Plt [MASKED] [MASKED] 06:30AM BLOOD WBC-8.7 RBC-3.43* Hgb-9.8* Hct-30.9* MCV-90 MCH-28.6 MCHC-31.7* RDW-13.4 RDWSD-44.1 Plt [MASKED] [MASKED] 06:08AM BLOOD Neuts-64.0 Lymphs-16.3* Monos-17.4* Eos-1.5 Baso-0.1 Im [MASKED] AbsNeut-5.21 AbsLymp-1.33 AbsMono-1.42* AbsEos-0.12 AbsBaso-0.01 [MASKED] 12:00AM BLOOD Glucose-92 UreaN-11 Creat-0.9 Na-142 K-3.8 Cl-102 HCO3-26 AnGap-14 [MASKED] 10:30AM BLOOD Glucose-126* UreaN-12 Creat-0.9 Na-138 K-4.3 Cl-101 HCO3-27 AnGap-10 [MASKED] 06:08AM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-136 K-4.0 Cl-100 HCO3-25 AnGap-11 [MASKED] 06:30AM BLOOD Glucose-88 UreaN-14 Creat-1.0 Na-140 K-4.7 Cl-102 HCO3-25 AnGap-13 [MASKED] 12:00AM BLOOD ALT-7 AST-15 LD(LDH)-157 AlkPhos-69 TotBili-0.4 [MASKED] 06:08AM BLOOD ALT-7 AST-12 AlkPhos-58 TotBili-0.6 [MASKED] 12:00AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.0 [MASKED] 10:30AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.9 [MASKED] 06:08AM BLOOD Calcium-7.6* Phos-2.0* Mg-1.8 [MASKED] 06:30AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.7 [MASKED] 12:00AM BLOOD CRP-227.9* [MASKED] 06:08AM BLOOD CRP-231.6* [MASKED] 10:30AM BLOOD Vanco-21.1* [MASKED] 02:30AM BLOOD Vanco-17.8 [MASKED] 11:08AM BLOOD Vanco-15.7 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. Cultures were taken in the OR and showed coag negative staph. Per ID recommendations, he was started on IV Vancomycin and Ancef. Their final recommendations were ***. Postoperative course was remarkable for the following: POD#1, he became orthostatic with [MASKED]. He was given 500ml bolus of IV and responded appropriately. POD#3, the patient reported right calf pain on exam. A RLE ultrasound was obtained and negative for a DVT. A PICC was placed and placement was confirmed by x-ray (tip is at the level of cavoatrial junction). POD#4, The patient denied any right calf tenderness on exam. The Prevena wound vac dressing was changed on [MASKED] prior to discharge. He is due for a VAC change on [MASKED]. His systolic blood pressure was 90's. He was asymptomatic. He was bloused with 500cc NS. His systolic blood pressure improved to 120's. His vancomycin dose (1250mg every 8 hours) was confirmed with pharmacy and infectious disease. He will be due for a Vancomycin trough on [MASKED]. Please fax results to [MASKED] as his dose may need to be adjusted. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Lovenox daily for DVT prophylaxis starting on the morning of POD#1. Prevena wound VAC applied to right knee and changed on [MASKED]. This will be due for a change on [MASKED] by the rehab facility (confirmed that this can be down at the rehab facility by case manager). 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. The patient's weight-bearing status is touch down weigh bearing on the operative extremity. NO RANGE OF MOTION OF RIGHT KNEE with knee immbolizer on at all times. Please use walker or 2 crutches. Mr. [MASKED] is discharged to rehab in stable condition. Medications on Admission: 1. Acetaminophen 1000 mg PO Q8H 2. BuPROPion 100 mg PO BID 3. ARIPiprazole 15 mg PO DAILY 4. Atorvastatin 20 mg PO DAILY 5. Furosemide 20 mg PO DAILY 6. Omeprazole 40 mg PO DAILY 7. Tamsulosin 0.4 mg PO QHS 8. Sertraline 50 mg PO DAILY 9. TraZODone 200 mg PO QHS:PRN sleep issues Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Enoxaparin Sodium 40 mg SC DAILY Duration: 4 Weeks Start: Tomorrow - [MASKED], First Dose: First Routine Administration Time 3. Heparin Flush (10 units/ml) 2 mL IV ONCE MR1 For PICC insertion Duration: 1 Dose 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain 5. Senna 8.6 mg PO BID 6. Sodium Chloride 0.9% Flush [MASKED] mL IV DAILY and PRN, line flush 7. Vancomycin 1250 mg IV Q 8H 8. Acetaminophen 1000 mg PO Q8H 9. ARIPiprazole 15 mg PO DAILY 10. Atorvastatin 20 mg PO DAILY 11. BuPROPion 100 mg PO BID 12. Furosemide 20 mg PO DAILY 13. Omeprazole 40 mg PO DAILY 14. Sertraline 50 mg PO DAILY 15. Tamsulosin 0.4 mg PO QHS 16. TraZODone 200 mg PO QHS:PRN sleep issues Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: right knee PJI 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. 8. ANTICOAGULATION: Please continue your lovenox daily for four (4) weeks to help prevent deep vein thrombosis (blood clots). At the end of the four weeks, you may return to your normal Aspirin regimen if you were taking Aspirin preoperatively. 9. WOUND CARE: Prevena wound vac in place (changed on [MASKED]. It may remain in place for 7 days and will due to be changed on [MASKED]. Check the wound for signs of infection such as redness or thick yellow drainage and promptly notify your surgeon of any such findings immediately. 10. [MASKED] (once at home): Home [MASKED], IV antibiotics, PICC care, wound care 11. ACTIVITY: Touchdown weight bearing on the right lower extremity. Use two crutches or a walker. Mobilize often. No range of motion of the right knee. Knee immobilizer on right lower extremity at all times. No strenuous exercise or heavy lifting until cleared. 12. PICC CARE: Per protocol 13. WEEKLY LABS: draw on [MASKED] and send result to ID RNs at: [MASKED] R.N.s at [MASKED]. - CBC/DIFF - CHEM 7 - LFTS - ESR/CRP 14. PLEASE DRAW A VANCO TROUGH LEVEL ON [MASKED] AND FAX RESULT TO [MASKED]. **All questions regarding outpatient parenteral antibiotics should be directed to the [MASKED] R.N.s at [MASKED] or to the on-call ID fellow when the clinic is closed.** Physical Therapy: Touch Down Weight Bearing RLE ** NO RANGE OF MOTION OF RIGHT KNEE ** Knee immobilizer at all times on RLE Treatments Frequency: Right knee Prevena Wound VAC (last changed on [MASKED]. Wound VAC due to be changed on [MASKED]. Please continue with Prevena Wound VAC Dressing until his post op visit on [MASKED] with [MASKED] [MASKED], PA-C. Right PICC line care per protocol. Followup Instructions: [MASKED]
|
[] |
[
"Y929",
"E785",
"K219",
"I10",
"N400",
"F329"
] |
[
"T8453XA: Infection and inflammatory reaction due to internal right knee prosthesis, initial encounter",
"M00061: Staphylococcal arthritis, right knee",
"Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y929: Unspecified place or not applicable",
"Z96653: Presence of artificial knee joint, bilateral",
"E785: Hyperlipidemia, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"I10: Essential (primary) hypertension",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"F329: Major depressive disorder, single episode, unspecified",
"M79661: Pain in right lower leg",
"B958: Unspecified staphylococcus as the cause of diseases classified elsewhere",
"I951: Orthostatic hypotension"
] |
10,027,221
| 24,525,233
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right knee periprosthetic joint infection
Major Surgical or Invasive Procedure:
Removal of antibiotic spacer, irrigation debridement, revision
total knee arthroplasty on the right ___ ___
History of Present Illness:
___ year old male with known right ___ joint
infection with antibiotic spacer now status post removal of
antibiotic spacer and revision total knee arthroplasty ___
___.
Past Medical History:
dyslipidemia, reflux, BPH
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:
___ 06:22AM BLOOD Hct-26.7*
___ 06:30AM BLOOD Hgb-8.6* Hct-26.9*
___ 05:00PM BLOOD WBC-7.6 RBC-3.40* Hgb-9.6* Hct-29.9*
MCV-88 MCH-28.2 MCHC-32.1 RDW-14.6 RDWSD-47.3* Plt ___
___ 06:00AM BLOOD Hgb-9.6* Hct-30.9*
___ 06:20AM BLOOD Hgb-10.3* Hct-32.5*
___ 06:22AM BLOOD Creat-0.9
___ 05:00PM BLOOD Glucose-110* UreaN-15 Creat-1.1 Na-140
K-4.1 Cl-105 HCO3-24 AnGap-11
___ 06:00AM BLOOD Creat-1.1
___ 06:20AM BLOOD Creat-1.2
___ 05:00PM BLOOD CK(CPK)-226
___ 05:00PM BLOOD Calcium-8.2* Phos-2.2* Mg-1.8
___ 05:00PM BLOOD CRP-239.3*
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ TISSUE GRAM STAIN-FINAL; TISSUE-PRELIMINARY
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC
CULTURE-PRELIMINARY INPATIENT
___ JOINT FLUID GRAM STAIN-FINAL; FLUID
CULTURE-PRELIMINARY INPATIENT
___ TISSUE GRAM STAIN-FINAL; TISSUE-FINAL;
ANAEROBIC CULTURE-PRELIMINARY INPATIENT
___ TISSUE GRAM STAIN-FINAL; TISSUE-FINAL;
ANAEROBIC CULTURE-PRELIMINARY INPATIENT
___ TISSUE GRAM STAIN-FINAL; TISSUE-PRELIMINARY;
ANAEROBIC CULTURE-PRELIMINARY INPATIENT
___ TISSUE GRAM STAIN-FINAL; TISSUE-FINAL;
ANAEROBIC CULTURE-PRELIMINARY INPATIENT
Brief Hospital Course:
The patient was admitted to the Orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
POD#1, the patient was hypotensive while in bed (systolics into
the ___. He was given 500 mL bolus of LR x1. His drains were
discontinued.
POD#2, OR cultures grew staph coag negative 1 colony on 1 plate.
ID consulted. They recommended discontinuing Ancef and starting
Daptomycin. Labs were obtained per ID request. WBC 7.9, Hct
29.9, lytes wnl, CK 226 , CRP 239.3, ESR was 43. Blood cultures
x 2 were also obtained, which revealed no growth to date.
POD#3 & 4, no acute events or changes in antibiotic regimen. OR
cultures pending sensitivities to Daptomycin.
POD#5, Infectious disease recommended 6 weeks of IV Daptomycin.
A PICC was placed for 6 weeks of IV antibiotics. OPAT
recommended continuing Daptomycin from ___ through ___.
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.
Mr. ___ is discharged to home with services in stable
condition.
Medications on Admission:
1. ARIPiprazole 15 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. BuPROPion (Sustained Release) 100 mg PO BID
4. meloxicam 7.5 mg oral DAILY
5. Omeprazole 20 mg PO DAILY
6. Sertraline 50 mg PO DAILY
7. Sildenafil 25 mg PO DAILY:PRN night time
8. Tamsulosin 0.4 mg PO QHS
9. TraZODone 200 mg PO QHS:PRN insomnia
10. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
11. Naproxen 250 mg PO Q12H:PRN Pain - Moderate
Discharge Medications:
1. Aspirin EC 81 mg PO BID
2. Daptomycin 650 mg IV Q24H
Start date: ___
Projected end date: ___
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 300 mg PO TID
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain ___
no drinking alcohol or driving while taking this medication
6. Senna 8.6 mg PO BID
7. Acetaminophen 1000 mg PO Q8H
8. ARIPiprazole 15 mg PO DAILY
9. Atorvastatin 10 mg PO QPM
10. BuPROPion (Sustained Release) 100 mg PO BID
11. Omeprazole 20 mg PO DAILY
Continue while on 4-week course of Aspirin 81 mg twice daily.
12. Sertraline 50 mg PO DAILY
13. Sildenafil 25 mg PO DAILY:PRN night time
14. Tamsulosin 0.4 mg PO QHS
15. TraZODone 200 mg PO QHS:PRN insomnia
16. HELD- meloxicam 7.5 mg oral DAILY This medication was held.
Do not restart meloxicam until 4 weeks post-op
17. HELD- Naproxen 250 mg PO Q12H:PRN Pain - Moderate This
medication was held. Do not restart Naproxen until 4 weeks
post-op
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right knee periprosthetic joint infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. You may wrap the knee with an ace bandage
for added compression. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
8. ANTICOAGULATION: Please continue your Aspirin 81 mg twice
daily with food for four (4) weeks to help prevent deep vein
thrombosis (blood clots). Continue your home Omeprazole to
prevent GI upset. 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.
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.
12. PICC CARE: Per protocol
13. WEEKLY LABS: draw on ___ and send result to ID RNs
at: ___ R.N.s at ___.
- CBC/DIFF
- CHEM 7
- LFTS
- ESR/CRP
- CPK
Physical Therapy:
WBAT RLE
ROMAT
Wean assistive device as able (i.e. 2 crutches or walker)
Mobilize frequently
Treatments Frequency:
Remove aquacel POD#7 after surgery
apply dry sterile dressing daily if needed after aquacel
dressing is removed
wound checks daily after aquacel removed
Followup Instructions:
___
|
[
"T8453XA",
"B957",
"I9581",
"E7849",
"K219",
"N400",
"E669",
"Z6830",
"H905",
"Z87891",
"Z96652",
"F329",
"M174",
"Y831",
"Y92098",
"Z89522"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Right knee periprosthetic joint infection Major Surgical or Invasive Procedure: Removal of antibiotic spacer, irrigation debridement, revision total knee arthroplasty on the right [MASKED] [MASKED] History of Present Illness: [MASKED] year old male with known right [MASKED] joint infection with antibiotic spacer now status post removal of antibiotic spacer and revision total knee arthroplasty [MASKED] [MASKED]. Past Medical History: dyslipidemia, reflux, BPH 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] 06:22AM BLOOD Hct-26.7* [MASKED] 06:30AM BLOOD Hgb-8.6* Hct-26.9* [MASKED] 05:00PM BLOOD WBC-7.6 RBC-3.40* Hgb-9.6* Hct-29.9* MCV-88 MCH-28.2 MCHC-32.1 RDW-14.6 RDWSD-47.3* Plt [MASKED] [MASKED] 06:00AM BLOOD Hgb-9.6* Hct-30.9* [MASKED] 06:20AM BLOOD Hgb-10.3* Hct-32.5* [MASKED] 06:22AM BLOOD Creat-0.9 [MASKED] 05:00PM BLOOD Glucose-110* UreaN-15 Creat-1.1 Na-140 K-4.1 Cl-105 HCO3-24 AnGap-11 [MASKED] 06:00AM BLOOD Creat-1.1 [MASKED] 06:20AM BLOOD Creat-1.2 [MASKED] 05:00PM BLOOD CK(CPK)-226 [MASKED] 05:00PM BLOOD Calcium-8.2* Phos-2.2* Mg-1.8 [MASKED] 05:00PM BLOOD CRP-239.3* [MASKED] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [MASKED] TISSUE GRAM STAIN-FINAL; TISSUE-PRELIMINARY {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC CULTURE-PRELIMINARY INPATIENT [MASKED] JOINT FLUID GRAM STAIN-FINAL; FLUID CULTURE-PRELIMINARY INPATIENT [MASKED] TISSUE GRAM STAIN-FINAL; TISSUE-FINAL; ANAEROBIC CULTURE-PRELIMINARY INPATIENT [MASKED] TISSUE GRAM STAIN-FINAL; TISSUE-FINAL; ANAEROBIC CULTURE-PRELIMINARY INPATIENT [MASKED] TISSUE GRAM STAIN-FINAL; TISSUE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARY INPATIENT [MASKED] TISSUE GRAM STAIN-FINAL; TISSUE-FINAL; ANAEROBIC CULTURE-PRELIMINARY INPATIENT Brief Hospital Course: The patient was admitted to the Orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: POD#1, the patient was hypotensive while in bed (systolics into the [MASKED]. He was given 500 mL bolus of LR x1. His drains were discontinued. POD#2, OR cultures grew staph coag negative 1 colony on 1 plate. ID consulted. They recommended discontinuing Ancef and starting Daptomycin. Labs were obtained per ID request. WBC 7.9, Hct 29.9, lytes wnl, CK 226 , CRP 239.3, ESR was 43. Blood cultures x 2 were also obtained, which revealed no growth to date. POD#3 & 4, no acute events or changes in antibiotic regimen. OR cultures pending sensitivities to Daptomycin. POD#5, Infectious disease recommended 6 weeks of IV Daptomycin. A PICC was placed for 6 weeks of IV antibiotics. OPAT recommended continuing Daptomycin from [MASKED] through [MASKED]. 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. Mr. [MASKED] is discharged to home with services in stable condition. Medications on Admission: 1. ARIPiprazole 15 mg PO DAILY 2. Atorvastatin 10 mg PO QPM 3. BuPROPion (Sustained Release) 100 mg PO BID 4. meloxicam 7.5 mg oral DAILY 5. Omeprazole 20 mg PO DAILY 6. Sertraline 50 mg PO DAILY 7. Sildenafil 25 mg PO DAILY:PRN night time 8. Tamsulosin 0.4 mg PO QHS 9. TraZODone 200 mg PO QHS:PRN insomnia 10. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild/Fever 11. Naproxen 250 mg PO Q12H:PRN Pain - Moderate Discharge Medications: 1. Aspirin EC 81 mg PO BID 2. Daptomycin 650 mg IV Q24H Start date: [MASKED] Projected end date: [MASKED] 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 300 mg PO TID 5. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain [MASKED] no drinking alcohol or driving while taking this medication 6. Senna 8.6 mg PO BID 7. Acetaminophen 1000 mg PO Q8H 8. ARIPiprazole 15 mg PO DAILY 9. Atorvastatin 10 mg PO QPM 10. BuPROPion (Sustained Release) 100 mg PO BID 11. Omeprazole 20 mg PO DAILY Continue while on 4-week course of Aspirin 81 mg twice daily. 12. Sertraline 50 mg PO DAILY 13. Sildenafil 25 mg PO DAILY:PRN night time 14. Tamsulosin 0.4 mg PO QHS 15. TraZODone 200 mg PO QHS:PRN insomnia 16. HELD- meloxicam 7.5 mg oral DAILY This medication was held. Do not restart meloxicam until 4 weeks post-op 17. HELD- Naproxen 250 mg PO Q12H:PRN Pain - Moderate This medication was held. Do not restart Naproxen until 4 weeks post-op Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Right knee periprosthetic joint infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Aspirin 81 mg twice daily with food for four (4) weeks to help prevent deep vein thrombosis (blood clots). Continue your home Omeprazole to prevent GI upset. 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. 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. 12. PICC CARE: Per protocol 13. WEEKLY LABS: draw on [MASKED] and send result to ID RNs at: [MASKED] R.N.s at [MASKED]. - CBC/DIFF - CHEM 7 - LFTS - ESR/CRP - CPK Physical Therapy: WBAT RLE ROMAT Wean assistive device as able (i.e. 2 crutches or walker) Mobilize frequently Treatments Frequency: Remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed Followup Instructions: [MASKED]
|
[] |
[
"K219",
"N400",
"E669",
"Z87891",
"F329"
] |
[
"T8453XA: Infection and inflammatory reaction due to internal right knee prosthesis, initial encounter",
"B957: Other staphylococcus as the cause of diseases classified elsewhere",
"I9581: Postprocedural hypotension",
"E7849: Other hyperlipidemia",
"K219: Gastro-esophageal reflux disease without esophagitis",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"E669: Obesity, unspecified",
"Z6830: Body mass index [BMI]30.0-30.9, adult",
"H905: Unspecified sensorineural hearing loss",
"Z87891: Personal history of nicotine dependence",
"Z96652: Presence of left artificial knee joint",
"F329: Major depressive disorder, single episode, unspecified",
"M174: Other bilateral secondary osteoarthritis of knee",
"Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92098: Other place in other non-institutional residence as the place of occurrence of the external cause",
"Z89522: Acquired absence of left knee"
] |
10,027,653
| 20,672,991
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / cilostazol
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP and stone extraction
History of Present Illness:
Ms. ___ is a ___ woman with history of HTN, HLD,
choledocholithiasis presenting with abdominal pain.
Patient is obtained from patient and her daughter, who is at the
bedside. Patient states that pain started yesterday, located in
epigastum with radiation to the back, was sudden in onset,
associated with nausea and vomiting. No diarrhea, fevers, or
chills. Patient has a history of gallstones for which she
underwent ERCP ___ with stone removal and sphincterotomy. She
initially presented to ___. There, labs notable for AST
415, alk phos 215, T bili 2.5, lipase 37, Hb 11.2, WBC 10.9, UA
positive for bacteria and white blood cells. Received IV fluids
and meropenem in outside hospital. She was then transferred here
for evaluation for ERCP.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
- Choledocholithiasis
- Hypertension
- Hyperlipidemia
- Diverticulosis
Social History:
___
Family History:
Father died age ___, mother died age ___ "Old age"
Physical Exam:
ADMISSION EXAM:
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, minimal tenderness in the
epigastric and RUQ region, Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
VITALS: ___ ___ Temp: 98.0 PO BP: 161/77 HR: 75 RR: 18 O2
sat: 96% O2 delivery: Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
CV: Heart rrr, no ___ edema
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, epigastric and RUQ tenderness mild, no
rebound/rigidity. BS present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No diaphoresis
NEURO: Alert, oriented, face symmetric
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS
--------------
___ 06:53AM BLOOD WBC-6.7 RBC-3.33* Hgb-9.9* Hct-30.7*
MCV-92 MCH-29.7 MCHC-32.2 RDW-13.8 RDWSD-47.3* Plt ___
___ 01:22AM BLOOD ALT-454* AST-1141* AlkPhos-270*
TotBili-2.3*
___ 06:53AM BLOOD ALT-189* AST-78* AlkPhos-190* TotBili-0.4
IMAGING
-------
- CT A/P (BID-P): Increased biliary ductal dilation. Mixed
intermediate density and calcified filling defect in the distal
common bile duct most consistent with a partially calcified
gallstone or group of gallstones. There are additional
intermediate density/noncalcified filling defects resting
dependently within the gallbladder. Correlation with clinical
symptoms and LFTs is suggested. Diffuse colonic diverticulosis
without gross evidence of diverticulitis. Bilateral low-grade
UPJ
obstructions.
ERCP: stone extracted.
MICROBIOLOGY
------------
Urine culture ___: negative
Urine culture ___ (___): E.coli
Blood cultures x ___: no growth to date
DISCHARGE LABS
--------------
___ 06:53AM BLOOD WBC-6.7 RBC-3.33* Hgb-9.9* Hct-30.7*
MCV-92 MCH-29.7 MCHC-32.2 RDW-13.8 RDWSD-47.3* Plt ___
___ 06:53AM BLOOD Glucose-110* UreaN-15 Creat-0.9 Na-141
K-3.8 Cl-107 HCO3-23 AnGap-11
___ 06:53AM BLOOD ALT-189* AST-78* AlkPhos-190* TotBili-0.4
___ 06:53AM BLOOD Mg-1.___ woman with history of hypertension, hyperlipidemia,
choledocholithiasis presenting with choledocholithiasis.
# Sepsis, resolved
# Cholangitis/choledocholithiasis:
Patient with history of choledocholithiasis presenting with
abdominal pain, found to have leukocytosis, tachycardia,
transaminitis/hyperbilirubinemia and imaging evidence CBD
dilatation. Patient started on meropenem at outside hospital,
transitioned to ceftriaxone and metronidazole. Blood cultures
were negative. Urine culture at OSH grew E.coli, <100K
organisms. She was eventually transitioned to ciprofloxacin to
complete a five-day course. ERCP was performed with
sphincteroplasty, stone removal and relief of obstruction. LFTs
downtrended after this procedure. Patient was able to advance
diet without a problem. Lipase was within normal limits. She
will follow up with her PCP within one week of discharge.
# Anemia: Baseline unknown though hemoglobin 11 at ___.
No evidence of active bleeding. Hemoglobin stable here with some
dilutional effect from IV fluids. She may need further work-up
for chronic anemia as an outpatient by her PCP.
# Hypertension: continued home metoprolol and nifedipine.
Lisinopril was initially held, and restarted on discharge.
# Hyperlipidemia: home statin will be held for now given
elevated LFTs
TRANSITIONS OF CARE
-------------------
# Follow-up: She will follow up with her PCP within one week of
discharge. Home statin will be held for now given elevated
LFTs, and should be restarted if these normalize.
# Code status: DNR/DNI
# Contacts/HCP/Surrogate and Communication: ___ -
___ - ___, updated ___ by me.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. NIFEdipine (Extended Release) 30 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Metoprolol Tartrate 50 mg PO BID
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
2. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth q24h Disp #*2
Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Metoprolol Tartrate 50 mg PO BID
6. NIFEdipine (Extended Release) 30 mg PO DAILY
7. HELD- Atorvastatin 20 mg PO QPM This medication was held. Do
not restart Atorvastatin until a doctor tells you to
Discharge Disposition:
Home
Discharge Diagnosis:
Choledocholithiasis
Sepsis
Possible urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your recent
hospitalization. You came to the hospital with abdominal pain.
Further testing showed that your bile duct was obstructed and
you underwent ERCP to relieve the obstruction. You are now
being discharged.
It is important that you continue to take your medications as
prescribed and follow up with the appointments listed below.
Good luck!
Followup Instructions:
___
|
[
"A419",
"N390",
"K8031",
"I10",
"D649",
"E785",
"Z66",
"B9620",
"I4581"
] |
Allergies: Sulfa (Sulfonamide Antibiotics) / cilostazol Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ERCP and stone extraction History of Present Illness: Ms. [MASKED] is a [MASKED] woman with history of HTN, HLD, choledocholithiasis presenting with abdominal pain. Patient is obtained from patient and her daughter, who is at the bedside. Patient states that pain started yesterday, located in epigastum with radiation to the back, was sudden in onset, associated with nausea and vomiting. No diarrhea, fevers, or chills. Patient has a history of gallstones for which she underwent ERCP [MASKED] with stone removal and sphincterotomy. She initially presented to [MASKED]. There, labs notable for AST 415, alk phos 215, T bili 2.5, lipase 37, Hb 11.2, WBC 10.9, UA positive for bacteria and white blood cells. Received IV fluids and meropenem in outside hospital. She was then transferred here for evaluation for ERCP. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: - Choledocholithiasis - Hypertension - Hyperlipidemia - Diverticulosis Social History: [MASKED] Family History: Father died age [MASKED], mother died age [MASKED] "Old age" Physical Exam: ADMISSION EXAM: GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, minimal tenderness in the epigastric and RUQ region, Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect DISCHARGE EXAM: VITALS: [MASKED] [MASKED] Temp: 98.0 PO BP: 161/77 HR: 75 RR: 18 O2 sat: 96% O2 delivery: Ra GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round CV: Heart rrr, no [MASKED] edema RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, epigastric and RUQ tenderness mild, no rebound/rigidity. BS present. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No diaphoresis NEURO: Alert, oriented, face symmetric PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS -------------- [MASKED] 06:53AM BLOOD WBC-6.7 RBC-3.33* Hgb-9.9* Hct-30.7* MCV-92 MCH-29.7 MCHC-32.2 RDW-13.8 RDWSD-47.3* Plt [MASKED] [MASKED] 01:22AM BLOOD ALT-454* AST-1141* AlkPhos-270* TotBili-2.3* [MASKED] 06:53AM BLOOD ALT-189* AST-78* AlkPhos-190* TotBili-0.4 IMAGING ------- - CT A/P (BID-P): Increased biliary ductal dilation. Mixed intermediate density and calcified filling defect in the distal common bile duct most consistent with a partially calcified gallstone or group of gallstones. There are additional intermediate density/noncalcified filling defects resting dependently within the gallbladder. Correlation with clinical symptoms and LFTs is suggested. Diffuse colonic diverticulosis without gross evidence of diverticulitis. Bilateral low-grade UPJ obstructions. ERCP: stone extracted. MICROBIOLOGY ------------ Urine culture [MASKED]: negative Urine culture [MASKED] ([MASKED]): E.coli Blood cultures x [MASKED]: no growth to date DISCHARGE LABS -------------- [MASKED] 06:53AM BLOOD WBC-6.7 RBC-3.33* Hgb-9.9* Hct-30.7* MCV-92 MCH-29.7 MCHC-32.2 RDW-13.8 RDWSD-47.3* Plt [MASKED] [MASKED] 06:53AM BLOOD Glucose-110* UreaN-15 Creat-0.9 Na-141 K-3.8 Cl-107 HCO3-23 AnGap-11 [MASKED] 06:53AM BLOOD ALT-189* AST-78* AlkPhos-190* TotBili-0.4 [MASKED] 06:53AM BLOOD Mg-1.[MASKED] woman with history of hypertension, hyperlipidemia, choledocholithiasis presenting with choledocholithiasis. # Sepsis, resolved # Cholangitis/choledocholithiasis: Patient with history of choledocholithiasis presenting with abdominal pain, found to have leukocytosis, tachycardia, transaminitis/hyperbilirubinemia and imaging evidence CBD dilatation. Patient started on meropenem at outside hospital, transitioned to ceftriaxone and metronidazole. Blood cultures were negative. Urine culture at OSH grew E.coli, <100K organisms. She was eventually transitioned to ciprofloxacin to complete a five-day course. ERCP was performed with sphincteroplasty, stone removal and relief of obstruction. LFTs downtrended after this procedure. Patient was able to advance diet without a problem. Lipase was within normal limits. She will follow up with her PCP within one week of discharge. # Anemia: Baseline unknown though hemoglobin 11 at [MASKED]. No evidence of active bleeding. Hemoglobin stable here with some dilutional effect from IV fluids. She may need further work-up for chronic anemia as an outpatient by her PCP. # Hypertension: continued home metoprolol and nifedipine. Lisinopril was initially held, and restarted on discharge. # Hyperlipidemia: home statin will be held for now given elevated LFTs TRANSITIONS OF CARE ------------------- # Follow-up: She will follow up with her PCP within one week of discharge. Home statin will be held for now given elevated LFTs, and should be restarted if these normalize. # Code status: DNR/DNI # Contacts/HCP/Surrogate and Communication: [MASKED] - [MASKED] - [MASKED], updated [MASKED] by me. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. NIFEdipine (Extended Release) 30 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Metoprolol Tartrate 50 mg PO BID Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 2. Ciprofloxacin HCl 500 mg PO Q24H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth q24h Disp #*2 Tablet Refills:*0 3. Aspirin 81 mg PO DAILY 4. Lisinopril 40 mg PO DAILY 5. Metoprolol Tartrate 50 mg PO BID 6. NIFEdipine (Extended Release) 30 mg PO DAILY 7. HELD- Atorvastatin 20 mg PO QPM This medication was held. Do not restart Atorvastatin until a doctor tells you to Discharge Disposition: Home Discharge Diagnosis: Choledocholithiasis Sepsis Possible urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure caring for you during your recent hospitalization. You came to the hospital with abdominal pain. Further testing showed that your bile duct was obstructed and you underwent ERCP to relieve the obstruction. You are now being discharged. It is important that you continue to take your medications as prescribed and follow up with the appointments listed below. Good luck! Followup Instructions: [MASKED]
|
[] |
[
"N390",
"I10",
"D649",
"E785",
"Z66"
] |
[
"A419: Sepsis, unspecified organism",
"N390: Urinary tract infection, site not specified",
"K8031: Calculus of bile duct with cholangitis, unspecified, with obstruction",
"I10: Essential (primary) hypertension",
"D649: Anemia, unspecified",
"E785: Hyperlipidemia, unspecified",
"Z66: Do not resuscitate",
"B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere",
"I4581: Long QT syndrome"
] |
10,027,722
| 26,276,762
|
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain dyspnea
Major Surgical or Invasive Procedure:
___ Redo off-pump coronary artery bypass graft x1 with
skeletonized in situ right internal mammary artery to left
anterior descending artery.
History of Present Illness:
___ year old male with history of hypertension, hyperlipidemia,
DM, a prior MI in ___ and CAD s/p single vessel CABG in ___ (___ to LAD). In the ___ he underwent stress
testing for recurrent chest pain. This showed a mixed defect
involving the entire apex. Med management did not improve his
symptoms. Cath in ___ revealed a chronic T.O. of the
mid LAD and a total occlusion of the LIMA to LAD distal
anastomosis. His meds were yet again adjusted but have been
limited d/t hypotension/lightheadedness. He has continued to
have ongoing symptoms. He was referred for PCI of the ___ LAD
CTO at ___ in ___. Angioplasty of proximal CTO LAD was
performed but unable to reenter vessel due to severe
calcification, failed attempt at retrograde due to tortuosity.
Presents today for surgical consultation.
From a symptom standpoint he reports chest pressure and dyspnea
with as little as walking 5 minutes/100 steps. At times he is
getting chest discomfort at rest. This feels very reminiscent to
his anginal symptoms prior to his CABG. Additionally he
frequently has lightheadedness when standing up and occasional
palpitations.
Past Medical History:
CAD s/p CABG x 1 in ___: ___ to LAD
Hypertension-pt denies, states he has Low BP
Hyperlipidemia
DM Type 2
___: Left Hip fracture s/p surgical repair, now with chronic
pain
GERD
Left second toe partial amputation after an infection
Syncope about 4 months ago- did not undergo workup
CABG ___, (R) shoulder rotator cuff
repair x 2-last ___ yo, (B) cataracts ___, (L) hip fx repair, (L)
partial toe amp
Social History:
___
Family History:
Mother: pacemaker at age ___, s/p stroke, dying at age ___.
Father: CAD around age ___, died from a massive MI at age ___.
Maternal grandmother died from an MI at age ___
Maternal uncle died from an MI at age ___.
Paternal grandmother died from an MI at age ___.
Physical Exam:
Preoperative examination
Pulse: 93 Resp:WNL O2 sat: 100%RA
B/P ___
Height: 6'1" Weight: 185 lb
General:A&O x3, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [] ___ Edema
Varicosities: None [x]
Neuro: Grossly intact [x]
Sternum: Well healed sternotomy incision. (+) click noted.
Pulses:
Femoral Right: Left:
DP Right: Left:
___ Right: Left:
Radial Right:2+ Left:2+
Carotid Bruit: none appreciated, pulses Right:2+ Left:2+
.
Discharge Exam:
Temp: 98.6 (Tm 99.2), BP: 123/56 (88-153/44-77), HR: 76
(74-90), RR: 18 (___), O2 sat: 96% (94-99), O2 delivery: Ra,
Wt: 169.09 lb/76.7 kg
Fluid Balance (last updated ___ @ 1811)
Last 8 hours Total cumulative 415ml
IN: Total 940ml, PO Amt 640ml, IV Amt Infused 300ml
OUT: Total 525ml, Urine Amt 525ml
Last 24 hours Total cumulative 75ml
IN: Total 1300ml, PO Amt 1000ml, IV Amt Infused 300ml
OUT: Total 1225ml, Urine Amt 1225ml
Physical Examination:
General: NAD [x]
Neurological: A/O x3 [x] non-focal []
HEENT: PEERL [x]
Cardiovascular: RRR [x] Irregular [] Murmur [] Rub []
Respiratory: CTA [x] ___ resp distress []
GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]
Extremities:
Right Upper extremity Warm [x] Edema -
Left Upper extremity Warm [x] Edema -
Right Lower extremity Warm [x] Edema -
Left Lower extremity Warm [x] Edema -
Pulses:
DP Right: present Left: present
___ Right: present Left: present
Radial Right: present Left: present
Skin/Wounds: Dry [x] intact [x]
Sternal: CDI [x] ___ erythema or drainage []
Pertinent Results:
Intra-op TEE ___- preliminary report
Conclusions
Pre-CPB:
___ spontaneous echo contrast is seen in the left atrial
appendage.
The interatrial septum is aneurysmal.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40 - 45%). Basal segments functiuon well, but there is
global mid segment HK and apical AK.
There is mild global free wall hypokinesis.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and ___ aortic stenosis or aortic
regurgitation.
The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
There is ___ pericardial effusion.
Gastric views are limited and reduced quality.
Post-CPB:
The patient is in SR, on ___ inotropes.
Unchanged biventricular systolic fxn.
Trivial MR ___ TR.
___ AI. Aorta intact.
.
___ 05:20AM BLOOD WBC-10.7* RBC-3.44* Hgb-9.4* Hct-28.4*
MCV-83 MCH-27.3 MCHC-33.1 RDW-14.6 RDWSD-42.8 Plt ___
___ 01:47PM BLOOD WBC-14.6* RBC-3.49* Hgb-9.6* Hct-28.2*
MCV-81* MCH-27.5 MCHC-34.0 RDW-14.4 RDWSD-41.9 Plt ___
___ 02:17AM BLOOD ___ PTT-24.3* ___
___ 01:47PM BLOOD ___ PTT-27.0 ___
___ 05:20AM BLOOD UreaN-22* Creat-1.0 K-4.6
___ 01:47PM BLOOD UreaN-16 Creat-1.0 Cl-107 HCO3-21*
AnGap-13
Brief Hospital Course:
___ was a same day admission and was taken to the
operating room for redo sternotomy and coronary artery bypass
graft. See operative report for further details. Post
operatively he was taken to the intensive care unit for
management. Later that evening he was weaned from sedation and
extubated however required bipap which he remained on until post
operative day one, which then he was able to be transitioned to
nasal cannula. He was started on diuretic and beta-blocker.
His chest tubes were removed per protocol. He remained in the
intensive care unit for respiratory monitoring. Post operative
day two he was transitioned to the floor and progressively
became more confused he required Haldol and narcotics were
discontinued. He was able to get sleep and mental status
returned to baseline.
He continued to progress epicardial wires were removed per
protocol. He worked with physical therapy on strength and
mobility with recommendation for rehab. He remained clinically
stable and was ready for discharge to rehab at ___,
___ on post operative day 8.
Medications on Admission:
Atorvastatin 80 mg qhs
Clopidogrel 75 mg daily
Trulicty 0.75mg/0.5Ml SC pen injection Q ___
Gabapentin 300 mg TID
Glipizide ER 2.5 mg daily
Metformin 1000 mg BID
NTG SL 0.4 mg SL q 5 mins PRN for CP
Omeprazole 40 mg HS
Paroxetine HCL 10 mg daily
Ranexa 500 mg BID
ASA 81 mg daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Furosemide 20 mg PO DAILY Duration: 7 Days
3. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using HUM Insulin
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
Duration: 6 Months
5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth q6h prn Disp #*15 Tablet
Refills:*0
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Clopidogrel 75 mg PO DAILY
9. Gabapentin 600 mg PO TID
10. GlipiZIDE XL 2.5 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Omeprazole 40 mg PO DAILY
13. PARoxetine 10 mg PO BID
14. Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous 1X/WEEK
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Coronary artery disease s/p coronary revascularization
Encephalopathy multifactorial
Secondary diagnosis
CAD s/p CABG x 1 in ___: LIMA to LAD
Hypertension-pt denies, states he has Low BP
Hyperlipidemia
DM Type 2
___: Left Hip fracture s/p surgical repair, now with chronic
pain
GERD
Left second toe partial amputation after an infection
Syncope about 4 months ago- did not undergo workup
repair x 2-last ___ yo, (B) cataracts ___, (L) hip fx repair, (L)
partial toe amp
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, deconditioned
Sternal pain managed with Tramadol
Sternal Incision - healing well, ___ erythema or drainage
Edema- none
Discharge Instructions:
Please shower daily -wash incisions gently with mild soap, ___
baths or swimming, look at your incisions daily
Please - ___ 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
___ driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
___ lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
[
"I25810",
"I10",
"E785",
"E119",
"Z794",
"K219",
"F419",
"Z006",
"I252"
] |
Allergies: [MASKED] Known Allergies / Adverse Drug Reactions Chief Complaint: chest pain dyspnea Major Surgical or Invasive Procedure: [MASKED] Redo off-pump coronary artery bypass graft x1 with skeletonized in situ right internal mammary artery to left anterior descending artery. History of Present Illness: [MASKED] year old male with history of hypertension, hyperlipidemia, DM, a prior MI in [MASKED] and CAD s/p single vessel CABG in [MASKED] ([MASKED] to LAD). In the [MASKED] he underwent stress testing for recurrent chest pain. This showed a mixed defect involving the entire apex. Med management did not improve his symptoms. Cath in [MASKED] revealed a chronic T.O. of the mid LAD and a total occlusion of the LIMA to LAD distal anastomosis. His meds were yet again adjusted but have been limited d/t hypotension/lightheadedness. He has continued to have ongoing symptoms. He was referred for PCI of the [MASKED] LAD CTO at [MASKED] in [MASKED]. Angioplasty of proximal CTO LAD was performed but unable to reenter vessel due to severe calcification, failed attempt at retrograde due to tortuosity. Presents today for surgical consultation. From a symptom standpoint he reports chest pressure and dyspnea with as little as walking 5 minutes/100 steps. At times he is getting chest discomfort at rest. This feels very reminiscent to his anginal symptoms prior to his CABG. Additionally he frequently has lightheadedness when standing up and occasional palpitations. Past Medical History: CAD s/p CABG x 1 in [MASKED]: [MASKED] to LAD Hypertension-pt denies, states he has Low BP Hyperlipidemia DM Type 2 [MASKED]: Left Hip fracture s/p surgical repair, now with chronic pain GERD Left second toe partial amputation after an infection Syncope about 4 months ago- did not undergo workup CABG [MASKED], (R) shoulder rotator cuff repair x 2-last [MASKED] yo, (B) cataracts [MASKED], (L) hip fx repair, (L) partial toe amp Social History: [MASKED] Family History: Mother: pacemaker at age [MASKED], s/p stroke, dying at age [MASKED]. Father: CAD around age [MASKED], died from a massive MI at age [MASKED]. Maternal grandmother died from an MI at age [MASKED] Maternal uncle died from an MI at age [MASKED]. Paternal grandmother died from an MI at age [MASKED]. Physical Exam: Preoperative examination Pulse: 93 Resp:WNL O2 sat: 100%RA B/P [MASKED] Height: 6'1" Weight: 185 lb General:A&O x3, NAD Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade [MASKED] Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds +[x] Extremities: Warm [x], well-perfused [] [MASKED] Edema Varicosities: None [x] Neuro: Grossly intact [x] Sternum: Well healed sternotomy incision. (+) click noted. Pulses: Femoral Right: Left: DP Right: Left: [MASKED] Right: Left: Radial Right:2+ Left:2+ Carotid Bruit: none appreciated, pulses Right:2+ Left:2+ . Discharge Exam: Temp: 98.6 (Tm 99.2), BP: 123/56 (88-153/44-77), HR: 76 (74-90), RR: 18 ([MASKED]), O2 sat: 96% (94-99), O2 delivery: Ra, Wt: 169.09 lb/76.7 kg Fluid Balance (last updated [MASKED] @ 1811) Last 8 hours Total cumulative 415ml IN: Total 940ml, PO Amt 640ml, IV Amt Infused 300ml OUT: Total 525ml, Urine Amt 525ml Last 24 hours Total cumulative 75ml IN: Total 1300ml, PO Amt 1000ml, IV Amt Infused 300ml OUT: Total 1225ml, Urine Amt 1225ml Physical Examination: General: NAD [x] Neurological: A/O x3 [x] non-focal [] HEENT: PEERL [x] Cardiovascular: RRR [x] Irregular [] Murmur [] Rub [] Respiratory: CTA [x] [MASKED] resp distress [] GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x] Extremities: Right Upper extremity Warm [x] Edema - Left Upper extremity Warm [x] Edema - Right Lower extremity Warm [x] Edema - Left Lower extremity Warm [x] Edema - Pulses: DP Right: present Left: present [MASKED] Right: present Left: present Radial Right: present Left: present Skin/Wounds: Dry [x] intact [x] Sternal: CDI [x] [MASKED] erythema or drainage [] Pertinent Results: Intra-op TEE [MASKED]- preliminary report Conclusions Pre-CPB: [MASKED] spontaneous echo contrast is seen in the left atrial appendage. The interatrial septum is aneurysmal. Overall left ventricular systolic function is mildly depressed (LVEF= 40 - 45%). Basal segments functiuon well, but there is global mid segment HK and apical AK. There is mild global free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and [MASKED] aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is [MASKED] pericardial effusion. Gastric views are limited and reduced quality. Post-CPB: The patient is in SR, on [MASKED] inotropes. Unchanged biventricular systolic fxn. Trivial MR [MASKED] TR. [MASKED] AI. Aorta intact. . [MASKED] 05:20AM BLOOD WBC-10.7* RBC-3.44* Hgb-9.4* Hct-28.4* MCV-83 MCH-27.3 MCHC-33.1 RDW-14.6 RDWSD-42.8 Plt [MASKED] [MASKED] 01:47PM BLOOD WBC-14.6* RBC-3.49* Hgb-9.6* Hct-28.2* MCV-81* MCH-27.5 MCHC-34.0 RDW-14.4 RDWSD-41.9 Plt [MASKED] [MASKED] 02:17AM BLOOD [MASKED] PTT-24.3* [MASKED] [MASKED] 01:47PM BLOOD [MASKED] PTT-27.0 [MASKED] [MASKED] 05:20AM BLOOD UreaN-22* Creat-1.0 K-4.6 [MASKED] 01:47PM BLOOD UreaN-16 Creat-1.0 Cl-107 HCO3-21* AnGap-13 Brief Hospital Course: [MASKED] was a same day admission and was taken to the operating room for redo sternotomy and coronary artery bypass graft. See operative report for further details. Post operatively he was taken to the intensive care unit for management. Later that evening he was weaned from sedation and extubated however required bipap which he remained on until post operative day one, which then he was able to be transitioned to nasal cannula. He was started on diuretic and beta-blocker. His chest tubes were removed per protocol. He remained in the intensive care unit for respiratory monitoring. Post operative day two he was transitioned to the floor and progressively became more confused he required Haldol and narcotics were discontinued. He was able to get sleep and mental status returned to baseline. He continued to progress epicardial wires were removed per protocol. He worked with physical therapy on strength and mobility with recommendation for rehab. He remained clinically stable and was ready for discharge to rehab at [MASKED], [MASKED] on post operative day 8. Medications on Admission: Atorvastatin 80 mg qhs Clopidogrel 75 mg daily Trulicty 0.75mg/0.5Ml SC pen injection Q [MASKED] Gabapentin 300 mg TID Glipizide ER 2.5 mg daily Metformin 1000 mg BID NTG SL 0.4 mg SL q 5 mins PRN for CP Omeprazole 40 mg HS Paroxetine HCL 10 mg daily Ranexa 500 mg BID ASA 81 mg daily Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Furosemide 20 mg PO DAILY Duration: 7 Days 3. Insulin SC Sliding Scale Fingerstick QACHS, HS Insulin SC Sliding Scale using HUM Insulin 4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY Duration: 6 Months 5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate RX *tramadol 50 mg 1 tablet(s) by mouth q6h prn Disp #*15 Tablet Refills:*0 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Clopidogrel 75 mg PO DAILY 9. Gabapentin 600 mg PO TID 10. GlipiZIDE XL 2.5 mg PO DAILY 11. MetFORMIN (Glucophage) 1000 mg PO BID 12. Omeprazole 40 mg PO DAILY 13. PARoxetine 10 mg PO BID 14. Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous 1X/WEEK Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Coronary artery disease s/p coronary revascularization Encephalopathy multifactorial Secondary diagnosis CAD s/p CABG x 1 in [MASKED]: LIMA to LAD Hypertension-pt denies, states he has Low BP Hyperlipidemia DM Type 2 [MASKED]: Left Hip fracture s/p surgical repair, now with chronic pain GERD Left second toe partial amputation after an infection Syncope about 4 months ago- did not undergo workup repair x 2-last [MASKED] yo, (B) cataracts [MASKED], (L) hip fx repair, (L) partial toe amp Discharge Condition: Alert and oriented x3, non-focal Ambulating, deconditioned Sternal pain managed with Tramadol Sternal Incision - healing well, [MASKED] erythema or drainage Edema- none Discharge Instructions: Please shower daily -wash incisions gently with mild soap, [MASKED] baths or swimming, look at your incisions daily Please - [MASKED] lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart [MASKED] driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon [MASKED] lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours** Followup Instructions: [MASKED]
|
[] |
[
"I10",
"E785",
"E119",
"Z794",
"K219",
"F419",
"I252"
] |
[
"I25810: Atherosclerosis of coronary artery bypass graft(s) without angina pectoris",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"E119: Type 2 diabetes mellitus without complications",
"Z794: Long term (current) use of insulin",
"K219: Gastro-esophageal reflux disease without esophagitis",
"F419: Anxiety disorder, unspecified",
"Z006: Encounter for examination for normal comparison and control in clinical research program",
"I252: Old myocardial infarction"
] |
10,027,957
| 20,471,885
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Pepcid / Sulfasalazine / metronidazole / azathioprine / Remicade
Attending: ___.
Chief Complaint:
weakness, abdominal discomfort, hematochezia, weight loss
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a pleasant ___ with hx htn, hemorrhoids, Crohn's
for which she has been on various regimens but currently was
controlled on methotrexate every other week, no previous bowel
surgeries, last admission ___ for fever, r/o meningitis who
presents with decreasing H/H, mild weakness, generalized ABD
discomfort, occasional bloody stools (most recent 2 days ago and
3 wks ago), and 15lb weight loss in 2 months. Per review of her
records, she was last hospitalized for her Crohns in ___.
At that time it was recommended that she undergo total colectomy
but the pt declined and ultimately was stabilized on
cyclosporine and prednisone. She required TPN for a brief
period at that time. She has since been followed by ___
___ and at the time of her last visit in ___, she was doing
well with only mild anemia at 29.5, however given intolerance of
oral iron IV iron infusions was recommended. At that time her
methotrexate was decreased from weekly to every other week.
Regarding her recent presentation, pt states that she was
initially brought to urgent care on ___ by her son who
thought that she didn't look well and was concerned about her wt
loss. She was found to be anemic with crit of 25.7 and they
recommended that she go to the ED however she didn't present
until today. Pt states that she has been feeling at ___ and abd
pain is no worse than recent ___ consisting of chronic, diffuse
mild pain x ___ m. In regards to the bloody BMs, she had 4 blood
BMs 3 weeks ago which resolved within 24 hrs. She had some
small blood on TP yesterday with wiping but has not otherwise
noticed dark or bloody stools. No v/d or loose stools.
Subjective fever earlier this week has resolved. Finally, pt
endorses L chest and axillary pain occurring in a discrete line
x ___ weeks, often occurs at rest/not exertional, lasts ___
minutes, sharp, reproducible, not present currently. Pain is
typically improved with raising her L arm. No concurrent SOB.
In the ED, initial vitals were: 98.9 91 129/84 18 100%RA.
Vitals remained stable and she remained afebrile while she was
in the ED. Labs were notable for UA with trace Leuks, few
bacteria. She was given oxycodone, HCTZ, folic acid and
amlodipine. Labs were notable for troponin 0.01 x1, lactate
1.2, CRP 32.7 CXR showed
Currently, she feels well, pain stable, + nausea, no v/d/bloody
stools. No recent sick contects, no recent travel. ROS notable
for chronic constipation which is stable on mirilax/suppository,
no dysuria or frequency. Nocturia ___ night. Had black stools
in the past but none recently.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest tightness,
palpitations. Denies vomiting, diarrhea. 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):
CROHN'S DISEASE currently on methotrexate every other week
-h/o Remicade infusion reaction
--hospitalized ___, Rx cyclosporine and steroids
ALLERGIC RHINITIS
Occ bronchitis
HYPERTENSION
diet controlled diabetes
LACTOSE INTOLERANCE on lactate
POSITIVE PPD, treated with INH x 6 months and ? rifaximin for 9
m in ___, no longer on tx
ARTHRITIS knees, ankle and L shoulder, currently receiving ___
hypertension
Hx iron def anemia on folic acid x2-3, has not yet gotten iron
infusion
-HAs on tylenol
Social History:
___
Family History:
(per chart, confirmed with pt and updated):
-No family history of Crohn's.
-HTN
-breast CA
Physical Exam:
ADmission:
Vitals: 98.0 150/82 80 16 100% RA
Constitutional: Alert, oriented, no acute distress, moves
comfortably around the room
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: Soft, mild diffuse TTP, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
RECTAL: small external hemorrhoids, no stool in vault
Ext: Warm, well perfused, no CCE
Neuro: aaox3 CNII-XII and strength grossly intact
Skin: no rashes or lesions
MSK: point TTP on palpation of chest in area where pt c/o CP
Discharge:
Vitals: 97.6, 126/76, 73, 16, 100%RA
Gen: NAD, lying in bed, moving around well
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
CV: RRR, no murmur
PULM: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
Skin: No visible rash. No jaundice.
Neuro: AAOx3. Fluent speech, no facial droop.
Psych: Full range of affect
Pertinent Results:
___ 06:35PM URINE HOURS-RANDOM
___ 06:35PM URINE HOURS-RANDOM
___ 06:35PM URINE UHOLD-HOLD
___ 06:35PM URINE GR HOLD-HOLD
___ 06:35PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
___ 06:35PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-3
___ 06:35PM URINE MUCOUS-MANY
___ 05:07PM LACTATE-1.2
___ 05:00PM GLUCOSE-84 UREA N-10 CREAT-0.9 SODIUM-142
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-28 ANION GAP-15
___ 05:00PM estGFR-Using this
___ 05:00PM ALT(SGPT)-6 AST(SGOT)-15 LD(LDH)-208 ALK
PHOS-80 TOT BILI-0.1 DIR BILI-0.0 INDIR BIL-0.1
___ 05:00PM LIPASE-30
___ 05:00PM cTropnT-<0.01
___ 05:00PM ALBUMIN-3.9 CALCIUM-9.5 PHOSPHATE-3.4
MAGNESIUM-1.8
___ 05:00PM CRP-32.7*
___ 05:00PM WBC-10.3* RBC-3.31* HGB-7.0* HCT-24.1*
MCV-73* MCH-21.1* MCHC-29.0* RDW-17.7* RDWSD-46.2
___ 05:00PM NEUTS-74.2* LYMPHS-17.8* MONOS-5.0 EOS-2.1
BASOS-0.3 IM ___ AbsNeut-7.61* AbsLymp-1.83 AbsMono-0.51
AbsEos-0.22 AbsBaso-0.03
___ 05:00PM PLT COUNT-512*
___ 05:00PM ___ PTT-27.6 ___
___ 05:00PM ___
___ 05:00PM RET AUT-0.7 ABS RET-0.02
CXR ___: no pna or effusion, no acute process (my read)
EKG: no ST-T changes, NSR
SIGMOIDOSCOPY ___
There were a few pseudopolyps in the sigmoid colon. The rest of
the mucosa to the splenic flexure appeared normal except for
some scarring adjacent to the anus. There was a large anal tag.
Otherwise normal sigmoidoscopy to splenic flexure at 70cm
Discharge Labs:
___ 06:45AM BLOOD WBC-18.5* RBC-3.69* Hgb-8.5* Hct-27.3*
MCV-74* MCH-23.0* MCHC-31.1* RDW-19.0* RDWSD-50.1* Plt ___
___ 06:45AM BLOOD Glucose-119* UreaN-12 Creat-0.8 Na-140
K-3.8 Cl-102 HCO3-29 AnGap-13
___ 07:00AM BLOOD Calcium-9.5 Phos-4.0 Mg-1.___ with Crohn's disease presenting with abdominal discomfort,
weakness, weight loss and occasional hematochezia as well as
atypical chest pain, worsening anemia concerning for slow GI
bleed and possible Crohn's flare.
# C. diff colitis causing:
#Abdominal pain, weight loss, hematochezia
# Subjective fevers: Initial concern for flare of
Crohn's/uncontrolled Crohn's disease but sxs have been stable
for the last 2 months despite decrease in methotrexate dosing,
abd pain is mild, no clear recent bloody stools as episode 2
days ago sounds more like hemorrhoidal bleed than true GI bleed.
She was found to be c. diff positive and was started on PO vanco
125mg Q6 for 14 days. She had improvement in her symptoms. Prior
to the c. diff result coming back she had been placed on IV
solumedrol for possible flair that was stopped once the c. diff
came back positive. GI felt all symptoms consistent with c.
diff and no need for colonoscopy.
#Microcytic Anemia/acute blood loss anemia: H/H 5.9/20.4,
baseline Hct ___. Likely blood loss anemia given report of
knife injury with significant bleeding and no GI bleeding while
in the hospital. She received 2 units of PRBC in the hospital
with stable H/H following. She was given a dose of IV iron as
her iron studies were consistent with iron defiency anemia.
#Chest pain: EKG with no concerning changes for ischemia, neg
trop, atypical and reproducible on exam suggestive of MSK in
etiology. Improved with monitoring.
# Hypertension: elevated in the ED, s/p amlodipine and HCTZ with
improvement in sxs.
-continued home meds
# HA: continued PRN Tylenol
# GERD: continued prn tums
# Allergies: continued cetirizine, fluticasone
# Chronic arthritis pain: continued Percocet, will hold off on
lidocaine patch as pt is unable to get as an outpt.
# CONTACT: ___ ___, daughter)
Greater than 30 minutes was spent in care coordination and
counseling on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen Dose is Unknown PO Q8H:PRN ha
2. Calcium Carbonate Dose is Unknown PO TID:PRN dyspepsia
3. Methotrexate 0.6 ml IV EVERY 2 WEEKS (MO)
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Lactaid (lactase) unknown oral unknown
7. amLODIPine 10 mg PO DAILY
8. lactobacillus combination no.4 unknown oral DAILY
9. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN pain
10. Cetirizine 10 mg PO DAILY
11. Hydrochlorothiazide 25 mg PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Lidocaine 5% Ointment 1 Appl TP AS NEEDED
14. Lidocaine 5% Patch 1 PTCH TD QAM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. amLODIPine 10 mg PO DAILY
3. Calcium Carbonate 500 mg PO TID:PRN dyspepsia
4. Cetirizine 10 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN pain
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Lactaid (lactase) 1 tab ORAL Frequency is Unknown
11. lactobacillus combination ___ tab ORAL DAILY
12. Lidocaine 5% Ointment 1 Appl TP AS NEEDED
13. Methotrexate 0.6 ml IV EVERY 2 WEEKS (MO)
14. vancomycin 125 mg oral Q6H Duration: 13 Days
RX *vancomycin 125 mg 1 capsule(s) by mouth Every 6 hours Disp
#*52 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
C. Diff Colitis
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___,
It was a pleasure taking care of you in the hospital. You were
admitted for evaluation. You were found to be anemic and
received blood with good response. You were found to have c.
diff colitis and were started on antibiotics and you improved.
You will need to complete a 14 day course of antibiotics.
Please take your medications as directed and follow up with your
PCP and gastroenterologist.
Followup Instructions:
___
|
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Allergies: Pepcid / Sulfasalazine / metronidazole / azathioprine / Remicade Chief Complaint: weakness, abdominal discomfort, hematochezia, weight loss Major Surgical or Invasive Procedure: None History of Present Illness: Ms [MASKED] is a pleasant [MASKED] with hx htn, hemorrhoids, Crohn's for which she has been on various regimens but currently was controlled on methotrexate every other week, no previous bowel surgeries, last admission [MASKED] for fever, r/o meningitis who presents with decreasing H/H, mild weakness, generalized ABD discomfort, occasional bloody stools (most recent 2 days ago and 3 wks ago), and 15lb weight loss in 2 months. Per review of her records, she was last hospitalized for her Crohns in [MASKED]. At that time it was recommended that she undergo total colectomy but the pt declined and ultimately was stabilized on cyclosporine and prednisone. She required TPN for a brief period at that time. She has since been followed by [MASKED] [MASKED] and at the time of her last visit in [MASKED], she was doing well with only mild anemia at 29.5, however given intolerance of oral iron IV iron infusions was recommended. At that time her methotrexate was decreased from weekly to every other week. Regarding her recent presentation, pt states that she was initially brought to urgent care on [MASKED] by her son who thought that she didn't look well and was concerned about her wt loss. She was found to be anemic with crit of 25.7 and they recommended that she go to the ED however she didn't present until today. Pt states that she has been feeling at [MASKED] and abd pain is no worse than recent [MASKED] consisting of chronic, diffuse mild pain x [MASKED] m. In regards to the bloody BMs, she had 4 blood BMs 3 weeks ago which resolved within 24 hrs. She had some small blood on TP yesterday with wiping but has not otherwise noticed dark or bloody stools. No v/d or loose stools. Subjective fever earlier this week has resolved. Finally, pt endorses L chest and axillary pain occurring in a discrete line x [MASKED] weeks, often occurs at rest/not exertional, lasts [MASKED] minutes, sharp, reproducible, not present currently. Pain is typically improved with raising her L arm. No concurrent SOB. In the ED, initial vitals were: 98.9 91 129/84 18 100%RA. Vitals remained stable and she remained afebrile while she was in the ED. Labs were notable for UA with trace Leuks, few bacteria. She was given oxycodone, HCTZ, folic acid and amlodipine. Labs were notable for troponin 0.01 x1, lactate 1.2, CRP 32.7 CXR showed Currently, she feels well, pain stable, + nausea, no v/d/bloody stools. No recent sick contects, no recent travel. ROS notable for chronic constipation which is stable on mirilax/suppository, no dysuria or frequency. Nocturia [MASKED] night. Had black stools in the past but none recently. Review of systems: (+) Per HPI (-) Denies chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest tightness, palpitations. Denies vomiting, diarrhea. 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): CROHN'S DISEASE currently on methotrexate every other week -h/o Remicade infusion reaction --hospitalized [MASKED], Rx cyclosporine and steroids ALLERGIC RHINITIS Occ bronchitis HYPERTENSION diet controlled diabetes LACTOSE INTOLERANCE on lactate POSITIVE PPD, treated with INH x 6 months and ? rifaximin for 9 m in [MASKED], no longer on tx ARTHRITIS knees, ankle and L shoulder, currently receiving [MASKED] hypertension Hx iron def anemia on folic acid x2-3, has not yet gotten iron infusion -HAs on tylenol Social History: [MASKED] Family History: (per chart, confirmed with pt and updated): -No family history of Crohn's. -HTN -breast CA Physical Exam: ADmission: Vitals: 98.0 150/82 80 16 100% RA Constitutional: Alert, oriented, no acute distress, moves comfortably around the room HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales, rhonchi GI: Soft, mild diffuse TTP, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley RECTAL: small external hemorrhoids, no stool in vault Ext: Warm, well perfused, no CCE Neuro: aaox3 CNII-XII and strength grossly intact Skin: no rashes or lesions MSK: point TTP on palpation of chest in area where pt c/o CP Discharge: Vitals: 97.6, 126/76, 73, 16, 100%RA Gen: NAD, lying in bed, moving around well Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear CV: RRR, no murmur PULM: normal effort, no accessory muscle use, lungs CTA [MASKED]. GI: soft, NT, ND, BS+ Skin: No visible rash. No jaundice. Neuro: AAOx3. Fluent speech, no facial droop. Psych: Full range of affect Pertinent Results: [MASKED] 06:35PM URINE HOURS-RANDOM [MASKED] 06:35PM URINE HOURS-RANDOM [MASKED] 06:35PM URINE UHOLD-HOLD [MASKED] 06:35PM URINE GR HOLD-HOLD [MASKED] 06:35PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 06:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR [MASKED] 06:35PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-3 [MASKED] 06:35PM URINE MUCOUS-MANY [MASKED] 05:07PM LACTATE-1.2 [MASKED] 05:00PM GLUCOSE-84 UREA N-10 CREAT-0.9 SODIUM-142 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-28 ANION GAP-15 [MASKED] 05:00PM estGFR-Using this [MASKED] 05:00PM ALT(SGPT)-6 AST(SGOT)-15 LD(LDH)-208 ALK PHOS-80 TOT BILI-0.1 DIR BILI-0.0 INDIR BIL-0.1 [MASKED] 05:00PM LIPASE-30 [MASKED] 05:00PM cTropnT-<0.01 [MASKED] 05:00PM ALBUMIN-3.9 CALCIUM-9.5 PHOSPHATE-3.4 MAGNESIUM-1.8 [MASKED] 05:00PM CRP-32.7* [MASKED] 05:00PM WBC-10.3* RBC-3.31* HGB-7.0* HCT-24.1* MCV-73* MCH-21.1* MCHC-29.0* RDW-17.7* RDWSD-46.2 [MASKED] 05:00PM NEUTS-74.2* LYMPHS-17.8* MONOS-5.0 EOS-2.1 BASOS-0.3 IM [MASKED] AbsNeut-7.61* AbsLymp-1.83 AbsMono-0.51 AbsEos-0.22 AbsBaso-0.03 [MASKED] 05:00PM PLT COUNT-512* [MASKED] 05:00PM [MASKED] PTT-27.6 [MASKED] [MASKED] 05:00PM [MASKED] [MASKED] 05:00PM RET AUT-0.7 ABS RET-0.02 CXR [MASKED]: no pna or effusion, no acute process (my read) EKG: no ST-T changes, NSR SIGMOIDOSCOPY [MASKED] There were a few pseudopolyps in the sigmoid colon. The rest of the mucosa to the splenic flexure appeared normal except for some scarring adjacent to the anus. There was a large anal tag. Otherwise normal sigmoidoscopy to splenic flexure at 70cm Discharge Labs: [MASKED] 06:45AM BLOOD WBC-18.5* RBC-3.69* Hgb-8.5* Hct-27.3* MCV-74* MCH-23.0* MCHC-31.1* RDW-19.0* RDWSD-50.1* Plt [MASKED] [MASKED] 06:45AM BLOOD Glucose-119* UreaN-12 Creat-0.8 Na-140 K-3.8 Cl-102 HCO3-29 AnGap-13 [MASKED] 07:00AM BLOOD Calcium-9.5 Phos-4.0 Mg-1.[MASKED] with Crohn's disease presenting with abdominal discomfort, weakness, weight loss and occasional hematochezia as well as atypical chest pain, worsening anemia concerning for slow GI bleed and possible Crohn's flare. # C. diff colitis causing: #Abdominal pain, weight loss, hematochezia # Subjective fevers: Initial concern for flare of Crohn's/uncontrolled Crohn's disease but sxs have been stable for the last 2 months despite decrease in methotrexate dosing, abd pain is mild, no clear recent bloody stools as episode 2 days ago sounds more like hemorrhoidal bleed than true GI bleed. She was found to be c. diff positive and was started on PO vanco 125mg Q6 for 14 days. She had improvement in her symptoms. Prior to the c. diff result coming back she had been placed on IV solumedrol for possible flair that was stopped once the c. diff came back positive. GI felt all symptoms consistent with c. diff and no need for colonoscopy. #Microcytic Anemia/acute blood loss anemia: H/H 5.9/20.4, baseline Hct [MASKED]. Likely blood loss anemia given report of knife injury with significant bleeding and no GI bleeding while in the hospital. She received 2 units of PRBC in the hospital with stable H/H following. She was given a dose of IV iron as her iron studies were consistent with iron defiency anemia. #Chest pain: EKG with no concerning changes for ischemia, neg trop, atypical and reproducible on exam suggestive of MSK in etiology. Improved with monitoring. # Hypertension: elevated in the ED, s/p amlodipine and HCTZ with improvement in sxs. -continued home meds # HA: continued PRN Tylenol # GERD: continued prn tums # Allergies: continued cetirizine, fluticasone # Chronic arthritis pain: continued Percocet, will hold off on lidocaine patch as pt is unable to get as an outpt. # CONTACT: [MASKED] [MASKED], daughter) Greater than 30 minutes was spent in care coordination and counseling on the day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen Dose is Unknown PO Q8H:PRN ha 2. Calcium Carbonate Dose is Unknown PO TID:PRN dyspepsia 3. Methotrexate 0.6 ml IV EVERY 2 WEEKS (MO) 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY 6. Lactaid (lactase) unknown oral unknown 7. amLODIPine 10 mg PO DAILY 8. lactobacillus combination no.4 unknown oral DAILY 9. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN pain 10. Cetirizine 10 mg PO DAILY 11. Hydrochlorothiazide 25 mg PO DAILY 12. FoLIC Acid 1 mg PO DAILY 13. Lidocaine 5% Ointment 1 Appl TP AS NEEDED 14. Lidocaine 5% Patch 1 PTCH TD QAM Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. amLODIPine 10 mg PO DAILY 3. Calcium Carbonate 500 mg PO TID:PRN dyspepsia 4. Cetirizine 10 mg PO DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Hydrochlorothiazide 25 mg PO DAILY 8. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN pain 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Lactaid (lactase) 1 tab ORAL Frequency is Unknown 11. lactobacillus combination [MASKED] tab ORAL DAILY 12. Lidocaine 5% Ointment 1 Appl TP AS NEEDED 13. Methotrexate 0.6 ml IV EVERY 2 WEEKS (MO) 14. vancomycin 125 mg oral Q6H Duration: 13 Days RX *vancomycin 125 mg 1 capsule(s) by mouth Every 6 hours Disp #*52 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: C. Diff Colitis Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms [MASKED], It was a pleasure taking care of you in the hospital. You were admitted for evaluation. You were found to be anemic and received blood with good response. You were found to have c. diff colitis and were started on antibiotics and you improved. You will need to complete a 14 day course of antibiotics. Please take your medications as directed and follow up with your PCP and gastroenterologist. Followup Instructions: [MASKED]
|
[] |
[
"D62",
"I10",
"D509",
"K219",
"K5900"
] |
[
"A047: Enterocolitis due to Clostridium difficile",
"K5090: Crohn's disease, unspecified, without complications",
"D62: Acute posthemorrhagic anemia",
"I10: Essential (primary) hypertension",
"K921: Melena",
"K644: Residual hemorrhoidal skin tags",
"R634: Abnormal weight loss",
"Z6824: Body mass index [BMI] 24.0-24.9, adult",
"J309: Allergic rhinitis, unspecified",
"E739: Lactose intolerance, unspecified",
"M1990: Unspecified osteoarthritis, unspecified site",
"D509: Iron deficiency anemia, unspecified",
"R0789: Other chest pain",
"R51: Headache",
"K219: Gastro-esophageal reflux disease without esophagitis",
"K5900: Constipation, unspecified"
] |
10,027,957
| 24,589,774
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Pepcid / Sulfasalazine / metronidazole / azathioprine
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
___ h/o crohn's disease and recent hospitalization for treatment
of pan colitis with initiation of cyclosporine and use of
prednisone 40mg daily presented to the ___ ED with fever
(high, unspecified), throbbing headache and neck stiffness.
WHen I interviewed her she was confused and could not further
characterize the details of her illness, such as duration as she
kept repeating that headache was present for months and could
not tell me how high and when her fever started. She denies
abdominal pain or bloody stools currently. She could no
complete a 13pt ROS given confusion and difficulties with
sharing details of her illness, but she denies new rash,
weakness, trouble with movement.
Past Medical History:
reviewed details listed in past clinic notes, confirmed h/o
crohn's and latent TB w patient
-latent TB s/p treatment in ___
-ileocolonic fistulizing Crohn's dx in ___, now on low dose pre
and anti-TNF; previously tx with Methotrexate
-h/o Remicade infusion reaction
--hospitalized ___, Rx cyclosporine and steroids
- hypertension
Social History:
___
Family History:
No family history of Crohn's
Physical Exam:
temp 102.2, 124 150/78 98% RA
awake,
confused, inattentive, often answers questions with odd answer
that does not pertain to question being asked: ie responds to
question about year by saying ___ after I had asked her
questions about orientation to month. incorrectly selects ___
rather than ___. repeats certain phrases such as months ago.
moves facial features symmetrically, no visual field defects,
pupils contrict from 4 to 2mm equally, I think there is some
proptosis of her L eye > R
oral candidiasis w white plaque on tongue
clear breath sounds without wheeze
rapid, loud s1 and s2 across precordium, no audible distinct
murmurs,
no cervical or neck adenopathy.
able to flex neck forward and back without difficulty.
no focal abdominal tenderness, no appreciable hepatomegaly
no joint effusions
no visible rash to face, back, extremities
full motor strength against resistance in all extremities
___
did not test gait
she performed poorly with clock draw task, see attached
well appearing not confused, fluent speech, eating food and
walking independently, 150/90 68
no meningismus
calm and cooperative
clear lungs
soft non tender abd
Pertinent Results:
___ 08:16PM BLOOD WBC-25.2*# RBC-4.58# Hgb-11.8# Hct-37.7
MCV-82 MCH-25.8* MCHC-31.3* RDW-16.0* RDWSD-47.8* Plt ___
___ 02:50AM BLOOD WBC-19.4* RBC-4.06 Hgb-10.5* Hct-33.9*
MCV-84 MCH-25.9* MCHC-31.0* RDW-15.9* RDWSD-48.7* Plt ___
___ 02:50AM BLOOD Glucose-114* UreaN-13 Creat-0.9 Na-135
K-4.1 Cl-99 HCO3-22 AnGap-18
___ 02:50AM BLOOD ALT-13 AST-10 AlkPhos-67 TotBili-0.4
___ 04:22AM BLOOD Cyclspr-81*
___ 02:50AM BLOOD HCG-<5
___ 08:23PM BLOOD Lactate-2.0
CXR no focal infiltrate
___ 07:05AM BLOOD WBC-15.7* RBC-3.09* Hgb-7.9* Hct-26.0*
MCV-84 MCH-25.6* MCHC-30.4* RDW-15.8* RDWSD-48.1* Plt ___
___ 07:05AM BLOOD Glucose-97 UreaN-13 Creat-0.8 Na-141
K-3.5 Cl-105 HCO3-26 AnGap-14
___ 02:50AM BLOOD ALT-13 AST-10 AlkPhos-67 TotBili-0.4
___ 04:22AM BLOOD Cyclspr-81*
___ 08:23PM BLOOD Lactate-2.0
HSV PCR neg
___ 11:20 pm CSF;SPINAL FLUID # 3.
ADD-ON REQUEST FOR VIRAL CULTURE ON ___ @1043.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
Enterovirus Culture (Preliminary): No Enterovirus
isolated.
Hematology
ANALYSIS WBC RBC Polys Lymphs Monos
___ 23:20 21 146* 152 75 10
# 4
___ 23:20 13 868* 67 25 8
# 1
1.CLEAR AND COLORLESS
2.20 CELL DIFFERENTIAL
3.PINK AND HAZY, SUPERNATANT CLEAR
Chemistry
CHEMISTRY TotProt Glucose
___ 23:20 51* ___ with crohn's disease who is immunosuppressed with ongoing
use of cyclosporine and prednisone who was hospitalized for
evaluation of fever and leukocytosis. On admission she appeared
septic as well as encephalopathic. She rapidly improved and had
no ongoing signs of encephalopathy within 16hrs of admission.
Ultimately, no source for her leukocytosis and fevers were found
but it was suspected that it was a viral infection. ID and GI
consulted.
#Fever/Sepsis
She underwent infectious work up including lumbar puncture. Her
CSF profile was unremarkable other than slightly elevated
protein and mildly elevated RBC but was not suggestive of
bacterial meningitis. Her HSV PCR was negative and enterovirus
culture was negative. She received empiric broad spectrum
antibiotics (vanco, ceftriaxone, ampicillin) and acyclovir until
her cultures and HSV returned negative. Her serum crypto
antigen was negative. She did not have diarrhea or abdominal
pain and her cdiff was negative. WBC improved.
She had decrease in all cell lines consistent with dilutional
effect as she received >3liters IVF on her first day of
hospitalization.
#Crohn's
--restarted cyclosporine on discharge
--continued prednisone 40mg and Bactrim ppx
GI consulted and during her admission cyclosporine was held and
it was deemed to be safe to restart this therapy for her crohn's
disease on discharge. She was counseled on its effects and
toxicities during last admission when it was started.
#HTN: elevated BPs during admission. Continued on HCTZ. Gave a
dose of amlodipine on ___ but when pharmacy alert noted that
it interacts with cyclosporine she will not continue amlodipine
on discharge.
I am most concerned by the possibility of an encephalitis
given her seemingly acutely confused state, fever, meningismus
seen in the ED with CSF studies that do not clearly suggest
acute bacterial meningitis. I am keeping a broad differential
for bacterial, viral and even mycobacterial pathogens (h/o
latent TB) as causative pathogens.
I understand cyclosporine can cause CNS toxicity but she has
been on stable dose and her level was <100 and this likely would
not cause fever and leukocytosis.
I have already spoken with ID who will consult urgently. I have
ordered HSV PCR to be performed on her CSF, though there is
insufficient fluid to also perform enterovrius PCR and VZV PCR.
There does not appear to be clinical evidence for pulmonary or
GI infections given lack of respiratory or GI symptoms and the
presence of a clear xray. While influenza is negative, if she
develops cough or other symptoms we can obtain nasal swab for
full resp viral panel.
Management:
Diagnostic
--HSV PCR
--MRI brain with contrast stat
--ID consult
Treatment
--acyclovir 700mg IV q8h
--empiric antibitoics for bacterial meningitis to be continued
until discussed with ID and we observe CSF cultures
--ceftriaxone 2000mg IV q12h, IV vancomycin 1000mg q12h (held
off on addition of ampicillin for now)
--supportive care with additional fever and anti-pyretic agents.
Crohn's disease
--I already spoke with GI team who knows her and will follow.
She does seem to have acute confusion as compared with their
recent clinical exams.
--continue prednisone 40mg daily
--hold cyclosporine now.
HTN:
--hctz 25mg daily
Heparin SC BID
full code presumed
contacted son listed in ___ as contact but no answer.
She will need ongoing hospitalization >48hrs to sort out the
cause and to appropriately treat the above acute illness.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CycloSPORINE (Neoral) MODIFIED 200 mg PO Q12H
2. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN pain
3. Cetirizine 10 mg PO DAILY
4. Nystatin Oral Suspension 10 mL PO QID:PRN thrush
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. PredniSONE 40 mg PO DAILY
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Lactaid (lactase) 3,000 unit oral PRN
Discharge Medications:
1. Cetirizine 10 mg PO DAILY
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*0
5. Hydrochlorothiazide 25 mg PO DAILY
6. CycloSPORINE (Neoral) MODIFIED 200 mg PO Q12H
RX *cyclosporine modified 100 mg 2 capsule(s) by mouth twice a
day Disp #*120 Capsule Refills:*0
7. Lactaid (lactase) 3,000 unit oral PRN
8. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
acute viral illness NOS
encephalopathy-resolved likely infectious
crohn's disease
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
you were hospitalized for evaluation of fever and confusion.
you underwent testing with lumbar puncture, mri and lab work
that did not show evidence of bacterial or viral infection. you
still may have had a viral infection that got better with time.
take cyclosporine as prescribed as well as prednisone and
Bactrim.
f/u with your GI doctor next week
if your blood pressure remains elevated your doctors ___ need to
add on another blood pressure pill
Followup Instructions:
___
|
[
"A419",
"G9349",
"B370",
"K5090",
"I10",
"B007"
] |
Allergies: Pepcid / Sulfasalazine / metronidazole / azathioprine Chief Complaint: fever Major Surgical or Invasive Procedure: lumbar puncture History of Present Illness: [MASKED] h/o crohn's disease and recent hospitalization for treatment of pan colitis with initiation of cyclosporine and use of prednisone 40mg daily presented to the [MASKED] ED with fever (high, unspecified), throbbing headache and neck stiffness. WHen I interviewed her she was confused and could not further characterize the details of her illness, such as duration as she kept repeating that headache was present for months and could not tell me how high and when her fever started. She denies abdominal pain or bloody stools currently. She could no complete a 13pt ROS given confusion and difficulties with sharing details of her illness, but she denies new rash, weakness, trouble with movement. Past Medical History: reviewed details listed in past clinic notes, confirmed h/o crohn's and latent TB w patient -latent TB s/p treatment in [MASKED] -ileocolonic fistulizing Crohn's dx in [MASKED], now on low dose pre and anti-TNF; previously tx with Methotrexate -h/o Remicade infusion reaction --hospitalized [MASKED], Rx cyclosporine and steroids - hypertension Social History: [MASKED] Family History: No family history of Crohn's Physical Exam: temp 102.2, 124 150/78 98% RA awake, confused, inattentive, often answers questions with odd answer that does not pertain to question being asked: ie responds to question about year by saying [MASKED] after I had asked her questions about orientation to month. incorrectly selects [MASKED] rather than [MASKED]. repeats certain phrases such as months ago. moves facial features symmetrically, no visual field defects, pupils contrict from 4 to 2mm equally, I think there is some proptosis of her L eye > R oral candidiasis w white plaque on tongue clear breath sounds without wheeze rapid, loud s1 and s2 across precordium, no audible distinct murmurs, no cervical or neck adenopathy. able to flex neck forward and back without difficulty. no focal abdominal tenderness, no appreciable hepatomegaly no joint effusions no visible rash to face, back, extremities full motor strength against resistance in all extremities [MASKED] did not test gait she performed poorly with clock draw task, see attached well appearing not confused, fluent speech, eating food and walking independently, 150/90 68 no meningismus calm and cooperative clear lungs soft non tender abd Pertinent Results: [MASKED] 08:16PM BLOOD WBC-25.2*# RBC-4.58# Hgb-11.8# Hct-37.7 MCV-82 MCH-25.8* MCHC-31.3* RDW-16.0* RDWSD-47.8* Plt [MASKED] [MASKED] 02:50AM BLOOD WBC-19.4* RBC-4.06 Hgb-10.5* Hct-33.9* MCV-84 MCH-25.9* MCHC-31.0* RDW-15.9* RDWSD-48.7* Plt [MASKED] [MASKED] 02:50AM BLOOD Glucose-114* UreaN-13 Creat-0.9 Na-135 K-4.1 Cl-99 HCO3-22 AnGap-18 [MASKED] 02:50AM BLOOD ALT-13 AST-10 AlkPhos-67 TotBili-0.4 [MASKED] 04:22AM BLOOD Cyclspr-81* [MASKED] 02:50AM BLOOD HCG-<5 [MASKED] 08:23PM BLOOD Lactate-2.0 CXR no focal infiltrate [MASKED] 07:05AM BLOOD WBC-15.7* RBC-3.09* Hgb-7.9* Hct-26.0* MCV-84 MCH-25.6* MCHC-30.4* RDW-15.8* RDWSD-48.1* Plt [MASKED] [MASKED] 07:05AM BLOOD Glucose-97 UreaN-13 Creat-0.8 Na-141 K-3.5 Cl-105 HCO3-26 AnGap-14 [MASKED] 02:50AM BLOOD ALT-13 AST-10 AlkPhos-67 TotBili-0.4 [MASKED] 04:22AM BLOOD Cyclspr-81* [MASKED] 08:23PM BLOOD Lactate-2.0 HSV PCR neg [MASKED] 11:20 pm CSF;SPINAL FLUID # 3. ADD-ON REQUEST FOR VIRAL CULTURE ON [MASKED] @1043. GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH. Enterovirus Culture (Preliminary): No Enterovirus isolated. Hematology ANALYSIS WBC RBC Polys Lymphs Monos [MASKED] 23:20 21 146* 152 75 10 # 4 [MASKED] 23:20 13 868* 67 25 8 # 1 1.CLEAR AND COLORLESS 2.20 CELL DIFFERENTIAL 3.PINK AND HAZY, SUPERNATANT CLEAR Chemistry CHEMISTRY TotProt Glucose [MASKED] 23:20 51* [MASKED] with crohn's disease who is immunosuppressed with ongoing use of cyclosporine and prednisone who was hospitalized for evaluation of fever and leukocytosis. On admission she appeared septic as well as encephalopathic. She rapidly improved and had no ongoing signs of encephalopathy within 16hrs of admission. Ultimately, no source for her leukocytosis and fevers were found but it was suspected that it was a viral infection. ID and GI consulted. #Fever/Sepsis She underwent infectious work up including lumbar puncture. Her CSF profile was unremarkable other than slightly elevated protein and mildly elevated RBC but was not suggestive of bacterial meningitis. Her HSV PCR was negative and enterovirus culture was negative. She received empiric broad spectrum antibiotics (vanco, ceftriaxone, ampicillin) and acyclovir until her cultures and HSV returned negative. Her serum crypto antigen was negative. She did not have diarrhea or abdominal pain and her cdiff was negative. WBC improved. She had decrease in all cell lines consistent with dilutional effect as she received >3liters IVF on her first day of hospitalization. #Crohn's --restarted cyclosporine on discharge --continued prednisone 40mg and Bactrim ppx GI consulted and during her admission cyclosporine was held and it was deemed to be safe to restart this therapy for her crohn's disease on discharge. She was counseled on its effects and toxicities during last admission when it was started. #HTN: elevated BPs during admission. Continued on HCTZ. Gave a dose of amlodipine on [MASKED] but when pharmacy alert noted that it interacts with cyclosporine she will not continue amlodipine on discharge. I am most concerned by the possibility of an encephalitis given her seemingly acutely confused state, fever, meningismus seen in the ED with CSF studies that do not clearly suggest acute bacterial meningitis. I am keeping a broad differential for bacterial, viral and even mycobacterial pathogens (h/o latent TB) as causative pathogens. I understand cyclosporine can cause CNS toxicity but she has been on stable dose and her level was <100 and this likely would not cause fever and leukocytosis. I have already spoken with ID who will consult urgently. I have ordered HSV PCR to be performed on her CSF, though there is insufficient fluid to also perform enterovrius PCR and VZV PCR. There does not appear to be clinical evidence for pulmonary or GI infections given lack of respiratory or GI symptoms and the presence of a clear xray. While influenza is negative, if she develops cough or other symptoms we can obtain nasal swab for full resp viral panel. Management: Diagnostic --HSV PCR --MRI brain with contrast stat --ID consult Treatment --acyclovir 700mg IV q8h --empiric antibitoics for bacterial meningitis to be continued until discussed with ID and we observe CSF cultures --ceftriaxone 2000mg IV q12h, IV vancomycin 1000mg q12h (held off on addition of ampicillin for now) --supportive care with additional fever and anti-pyretic agents. Crohn's disease --I already spoke with GI team who knows her and will follow. She does seem to have acute confusion as compared with their recent clinical exams. --continue prednisone 40mg daily --hold cyclosporine now. HTN: --hctz 25mg daily Heparin SC BID full code presumed contacted son listed in [MASKED] as contact but no answer. She will need ongoing hospitalization >48hrs to sort out the cause and to appropriately treat the above acute illness. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. CycloSPORINE (Neoral) MODIFIED 200 mg PO Q12H 2. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN pain 3. Cetirizine 10 mg PO DAILY 4. Nystatin Oral Suspension 10 mL PO QID:PRN thrush 5. Fluticasone Propionate NASAL 1 SPRY NU BID 6. PredniSONE 40 mg PO DAILY 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 8. Lactaid (lactase) 3,000 unit oral PRN Discharge Medications: 1. Cetirizine 10 mg PO DAILY 2. Fluticasone Propionate NASAL 1 SPRY NU BID 3. PredniSONE 40 mg PO DAILY RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Hydrochlorothiazide 25 mg PO DAILY 6. CycloSPORINE (Neoral) MODIFIED 200 mg PO Q12H RX *cyclosporine modified 100 mg 2 capsule(s) by mouth twice a day Disp #*120 Capsule Refills:*0 7. Lactaid (lactase) 3,000 unit oral PRN 8. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: acute viral illness NOS encephalopathy-resolved likely infectious crohn's disease hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: you were hospitalized for evaluation of fever and confusion. you underwent testing with lumbar puncture, mri and lab work that did not show evidence of bacterial or viral infection. you still may have had a viral infection that got better with time. take cyclosporine as prescribed as well as prednisone and Bactrim. f/u with your GI doctor next week if your blood pressure remains elevated your doctors [MASKED] need to add on another blood pressure pill Followup Instructions: [MASKED]
|
[] |
[
"I10"
] |
[
"A419: Sepsis, unspecified organism",
"G9349: Other encephalopathy",
"B370: Candidal stomatitis",
"K5090: Crohn's disease, unspecified, without complications",
"I10: Essential (primary) hypertension",
"B007: Disseminated herpesviral disease"
] |
10,027,957
| 25,485,223
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Pepcid / Sulfasalazine / metronidazole / azathioprine / Remicade
/ Ceftin
Attending: ___.
Chief Complaint:
vision loss
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with Crohn's on MTX, newly Dx'd seizures with brain masses
of unknown significance and recent ED visit for L orbital
cellulitis presents with sudden onset of monocular vision loss.
2 weeks ag,o the patient was seen in the ED for 1 week of
progressive blurry vision. Her eye exam demonstrated increased
intraocular pressure and mild proptosis. CT orbit showed fat
stranding and she was discharged on clindamycin for orbital
cellulitis.
The patient had been doing well and awoke this AM with left eye
vision loss. Patient states she is able to see some in the
periphery of her left eye. She has pain with extraoccular
movements. She went to see her eye doctor who did a dilated exam
and sent her to ___ for further eval.
The patient had been having occasional subjective fevers, last
fever 3 days ago. No chest pain or dyspnea. No neck pain. No
difficulty swallowing.
She was seen by ophtho in the ED:
"The ophthalmic exam is normal aside from a previously noted
APD in the left eye. The MRI orbits/brain demonstrates what
appears to be a left perineuritis. There are no clinical signs
of orbital cellulitis, aside from mild proptosis of the left
globe.
Optic perineuritis is often associated with inflammatory
conditions (ie orbital pseudotumor, sarcoid) and is treated with
steroids, often times with improvement in vision. The problem is
the prior concern that the previously noted brain lesion is an
indolent infection, such as fungus. Given this concern, I think
the benefit of improved vision with steroids is overruled by the
potentially fatal complication of unmasking the potential fungal
infection in the brain with steroids."
Neurology agreed with ___ evaluation.
Seen by ENT as well to eval for mucor. They did a fiberoptic
exam, which was reassuring.
Also seen by neurosurgery, who felt that benefit from steroids
outweighed risk of infection.
Decision was made to start steroids.
In the ED, initial VS were 0 96.8 83 140/79 18 100% RA .
Exam notable for:
NAD
+left sided proptosis. Pain with EOM of left eye. Pupils
dilated Fundoscopic: blurred disc L eye. No erythema RRR no MRG
CTAB
Visual acuity (patient does not have glasses with her):
OD: ___
OS: N/A
Occular Pressure (per outpatient eye doctor today ___ 16 L 18)
CN III-12 intact
Labs showed: WBC 11.8, Hgb 9.1, Hematuria
Imaging showed:
MRI ORBIT: There is minimal increased signal and enhancement
within the retro bulbar fat on the left (series 11, image 8 and
series 13 image 7), which given differences in modality is
similar compared to the prior CT. In addition, there is
increased enhancement of the left orbital nerve compared to the
right (series 14, image 8). The left orbital nerve may be
slightly expanded compared to the right. Again, these findings
likely represent postseptal orbital cellulitis as suggested on
the prior CT.
No acute abnormalities within the visualized brain parenchyma.
Mild paranasal sinus disease is re-demonstrated. Please refer to
the final report for full details.
Received: Percocet, vanc, levoquin, Benadryl
Transfer VS were 79 134/82 16 100% RA
Neurology, ophthalmology, ENT, and Neurosurgery were consulted
On arrival to the floor, patient confirms the above story. She
clarifies that she was previously having fevers (unmeasured, may
be hot flashes) but none today or yesterday. She also states her
vision improved to baseline after clinda but then when she awoke
on day of presentation suddenly had central vision loss.
She currently denies F/C, N/V, SOB, Cp/dizzy, abd pain (had
some R-sided tenderness earlier), constipation/diarrhea.
Endorses continued central vision loss. She had some itching
earlier with Percocet that resolved with Benadryl.
Vaginal bleeding is minimal.
Past Medical History:
(per chart, confirmed with pt):
CROHN'S DISEASE currently on methotrexate every other week
-h/o Remicade infusion reaction
--hospitalized ___, Rx cyclosporine and steroids
ALLERGIC RHINITIS
Occ bronchitis
HYPERTENSION
diet controlled diabetes
LACTOSE INTOLERANCE on lactate
POSITIVE PPD, treated with INH x 6 months and ? rifaximin for 9
m in ___, no longer on tx
ARTHRITIS knees, ankle and L shoulder, currently receiving ___
hypertension
Hx iron def anemia on folic acid x2-3, has not yet gotten iron
infusion
-HAs on tylenol
Social History:
___
Family History:
(per chart, confirmed with pt and updated):
-No family history of Crohn's.
-HTN
-breast CA
Physical Exam:
Admission Physical Exam:
=======================
VS: 98.2 PO 138 / 81 87 97
GENERAL: NAD, pleasant
HEENT: AT/NC, EOMI w/ tenderness on L, L proptosis, mild
periorbital swelling
NECK: supple, no LAD, no thyroid nodules palpated
HEART: RRR, + murmur
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical Exam:
=======================
Vitals: 98.4 139/83 87 16 99% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated, no LAD
RESP: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABD: soft.
GU: no foley
EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: visual field testing improved almost resolved, proptosis
on left resolving
Pertinent Results:
Admission Labs:
==============
___ 04:00PM BLOOD WBC-11.8* RBC-3.50*# Hgb-9.1*# Hct-29.7*#
MCV-85 MCH-26.0 MCHC-30.6* RDW-16.2* RDWSD-49.8* Plt ___
___ 04:00PM BLOOD Neuts-77.9* Lymphs-16.6* Monos-4.2*
Eos-0.7* Baso-0.3 Im ___ AbsNeut-9.18* AbsLymp-1.95
AbsMono-0.50 AbsEos-0.08 AbsBaso-0.03
___ 04:00PM BLOOD Plt ___
___ 04:00PM BLOOD ___ PTT-27.4 ___
___ 04:00PM BLOOD Glucose-106* UreaN-10 Creat-0.8 Na-141
K-3.8 Cl-105 HCO3-24 AnGap-16
Micro:
=====
Lyme pending
HIV pending
Imaging:
========
MRI brain with orbits:
1. Diffuse enhancement surrounding the left optic nerve with
adjacent
retrobulbar fat stranding. These findings are suggestive of
perineuritis,
with differential considerations including inflammatory process
such as
sarcoid. Postseptal cellulitis is considered less likely.
2. Paranasal sinus disease, as above.
3. Additional chronic findings as described above.
Discharge Labs:
===============
___ 08:45AM BLOOD WBC-13.1* RBC-3.10* Hgb-8.2* Hct-26.2*
MCV-85 MCH-26.5 MCHC-31.3* RDW-16.3* RDWSD-50.5* Plt ___
___ 05:30AM BLOOD Glucose-116* UreaN-16 Creat-0.8 Na-143
K-4.1 Cl-110* HCO3-24 AnGap-13
Brief Hospital Course:
Ms. ___ is a ___ yo woman with Crohn's disease on methotrexate
and recently diagnosed seizure disorder as well abnormal MRI
brain findings who presented with vision loss and MRI findings
of perineuritis. She was seen by the neurology, neurosurgery,
ENT, and ophthalmology in the ED. She was also seen by the
infectious disease doctors. ___, her symptoms were
thought to be due to either perineuritis from an inflammatory
process vs. partially treated post septal cellulitis. She
improved with steroids and antibiotics. Steroid course to be
determined by ophthalmology team.
# Vision loss
# Perineuritis: Most likely etiology is inflammatory process vs.
infectious. Opthomology recommended steroids 60 mg daily with
taper to be determined as outpatient; ID was consulted and felt
comfortable with steroids but also recommend unasyn while in
house and then augmentin x 2 weeks on discharge out of concern
for partially treated pre-septal cellulitis. ID felt there was
lower index of suspicion for fungal disease to explain current
presentation. B-glucan, galactomanan, HIV, and Lyme were ordered
and pending at time of discharge. Patient's vision was much
improved at time of discharge. She will follow with optho
(scheduled prior to discharge) this week and ID will contact her
for a follow-up appointment.
#Nasal mucosa management: ENT was consulted in the ED and
recommended the following, which she received in house. An ENT
appointment was not made at discharge, but the patient was
called and given the number to follow with ENT as an outpatient.
- Saline nasal spray ___
- Flonase 2 sprays each nostril BID
- Afrin 2 sprays TID for 3 days following saline rises
# Crohn's: Patient reported that she had not been taking
methotrexate at home because she was worried about the cancer
risk and equates the methotrexate with her new brain lesions.
Her gastroenterologist asked that her methotrexate be restarted,
which was recommended to the patient. However, there is an
interaction between augmentin and methotrexate so it was
recommended that she hold the methotrexate until she complete
her antibiotic course.
# Anemia
# Vaginal bleeding: Stbale throughout stay. On morning of
discharge had a drop in H/H but on repeat H/H was back to
baseline suggesting a lab error. She was continued on
MEDROXYPROGESTERONE ACETATE 10 TABS BID through ___
Chronic Issues:
===============
#Hx of Cribiform plate mass: F/u imaging with improvement.
- neurosurgery f/u as outpatient
# Leptomeningeal enhancement: New, noted on MRI ___. culture
reported final report on ___, was also negative. Serum
RPR tox antibody were negative. ID discussed with patient the
importance of biopsy for definitive diagnosis but she declined.
# HTN: Well controlled.
- Continued dilt
# Seizure disorder:
- Continued keppra
Transitional Issues:
===================
- abx: augmentin through ___
- steroid course to be determined by optho, if patient is on
steroids > 4 weeks, would initiate her on Bactrim prophylaxis
- Methotrexate was restarted per GI recs, but patient was
unwilling to take it, would recommend discussing with her
outpatient gastroenterologist
- However, should hold methotrexate while on augmentin
- should schedule ID follow-up (pending at time of discharge)
- pending labs: B-glucan, galactomannan, Lyme titer, and HIV
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze
2. azelastine 0.15 % (205.5 mcg) nasal BID
3. Voltaren (diclofenac sodium) 1 % topical Q6H:PRN pain
4. Diltiazem Extended-Release 240 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. FoLIC Acid 1 mg PO DAILY
7. LevETIRAcetam 1000 mg PO BID
8. Lidocaine 5% Ointment 1 Appl TP BID
9. Methotrexate 15 mg SC 1X/WEEK (WE)
10. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain -
Severe
11. Polyethylene Glycol 17 g PO DAILY:PRN contstipation
12. TraMADol 50 mg PO TID:PRN Pain - Severe
13. MedroxyPROGESTERone Acetate 10 mg PO BID
14. Beano (alpha-d-galactosidase) 150 unit oral ASDIR
15. Calcium Carbonate 300 mg PO PRN indigestion
16. Cetirizine 10 mg PO DAILY
17. DiphenhydrAMINE 25 mg PO QHS:PRN allergy
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 13 Days
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
daily by mouth twice a day Disp #*26 Tablet Refills:*0
2. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze
4. azelastine 0.15 % (205.5 mcg) nasal BID
5. Beano (alpha-d-galactosidase) 150 unit oral ASDIR
6. Calcium Carbonate 300 mg PO PRN indigestion
7. Cetirizine 10 mg PO DAILY
8. Diclofenac Sodium ___ ___ sodium) 1 % topical Q6H:PRN
pain
9. Diltiazem Extended-Release 240 mg PO DAILY
10. DiphenhydrAMINE 25 mg PO QHS:PRN allergy
11. Fluticasone Propionate NASAL 1 SPRY NU DAILY
12. FoLIC Acid 1 mg PO DAILY
13. LevETIRAcetam 1000 mg PO BID
14. Lidocaine 5% Ointment 1 Appl TP BID
15. MedroxyPROGESTERone Acetate 10 mg PO BID
16. Methotrexate 15 mg SC 1X/WEEK (WE)
17. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain
- Severe
18. Polyethylene Glycol 17 g PO DAILY:PRN contstipation
19. TraMADol 50 mg PO TID:PRN Pain - Severe
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
perineuritis
post septal cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why was I here?
- You had blurred vision.
- You were seen by many different doctors and ___ got steroids
and antibiotics.
- You got better.
What should I do when I get home?
- It is very important to take all your medicines everyday.
- If you do not want to take your methotrexate, please let Dr.
___.
Followup Instructions:
___
|
[
"G588",
"G9389",
"H0520",
"K5090",
"Q211",
"L03818",
"H547",
"J45909",
"D649",
"N939",
"I10",
"G40909",
"E785",
"E119",
"Z9851",
"E739"
] |
Allergies: Pepcid / Sulfasalazine / metronidazole / azathioprine / Remicade / Ceftin Chief Complaint: vision loss Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] with Crohn's on MTX, newly Dx'd seizures with brain masses of unknown significance and recent ED visit for L orbital cellulitis presents with sudden onset of monocular vision loss. 2 weeks ag,o the patient was seen in the ED for 1 week of progressive blurry vision. Her eye exam demonstrated increased intraocular pressure and mild proptosis. CT orbit showed fat stranding and she was discharged on clindamycin for orbital cellulitis. The patient had been doing well and awoke this AM with left eye vision loss. Patient states she is able to see some in the periphery of her left eye. She has pain with extraoccular movements. She went to see her eye doctor who did a dilated exam and sent her to [MASKED] for further eval. The patient had been having occasional subjective fevers, last fever 3 days ago. No chest pain or dyspnea. No neck pain. No difficulty swallowing. She was seen by ophtho in the ED: "The ophthalmic exam is normal aside from a previously noted APD in the left eye. The MRI orbits/brain demonstrates what appears to be a left perineuritis. There are no clinical signs of orbital cellulitis, aside from mild proptosis of the left globe. Optic perineuritis is often associated with inflammatory conditions (ie orbital pseudotumor, sarcoid) and is treated with steroids, often times with improvement in vision. The problem is the prior concern that the previously noted brain lesion is an indolent infection, such as fungus. Given this concern, I think the benefit of improved vision with steroids is overruled by the potentially fatal complication of unmasking the potential fungal infection in the brain with steroids." Neurology agreed with [MASKED] evaluation. Seen by ENT as well to eval for mucor. They did a fiberoptic exam, which was reassuring. Also seen by neurosurgery, who felt that benefit from steroids outweighed risk of infection. Decision was made to start steroids. In the ED, initial VS were 0 96.8 83 140/79 18 100% RA . Exam notable for: NAD +left sided proptosis. Pain with EOM of left eye. Pupils dilated Fundoscopic: blurred disc L eye. No erythema RRR no MRG CTAB Visual acuity (patient does not have glasses with her): OD: [MASKED] OS: N/A Occular Pressure (per outpatient eye doctor today [MASKED] 16 L 18) CN III-12 intact Labs showed: WBC 11.8, Hgb 9.1, Hematuria Imaging showed: MRI ORBIT: There is minimal increased signal and enhancement within the retro bulbar fat on the left (series 11, image 8 and series 13 image 7), which given differences in modality is similar compared to the prior CT. In addition, there is increased enhancement of the left orbital nerve compared to the right (series 14, image 8). The left orbital nerve may be slightly expanded compared to the right. Again, these findings likely represent postseptal orbital cellulitis as suggested on the prior CT. No acute abnormalities within the visualized brain parenchyma. Mild paranasal sinus disease is re-demonstrated. Please refer to the final report for full details. Received: Percocet, vanc, levoquin, Benadryl Transfer VS were 79 134/82 16 100% RA Neurology, ophthalmology, ENT, and Neurosurgery were consulted On arrival to the floor, patient confirms the above story. She clarifies that she was previously having fevers (unmeasured, may be hot flashes) but none today or yesterday. She also states her vision improved to baseline after clinda but then when she awoke on day of presentation suddenly had central vision loss. She currently denies F/C, N/V, SOB, Cp/dizzy, abd pain (had some R-sided tenderness earlier), constipation/diarrhea. Endorses continued central vision loss. She had some itching earlier with Percocet that resolved with Benadryl. Vaginal bleeding is minimal. Past Medical History: (per chart, confirmed with pt): CROHN'S DISEASE currently on methotrexate every other week -h/o Remicade infusion reaction --hospitalized [MASKED], Rx cyclosporine and steroids ALLERGIC RHINITIS Occ bronchitis HYPERTENSION diet controlled diabetes LACTOSE INTOLERANCE on lactate POSITIVE PPD, treated with INH x 6 months and ? rifaximin for 9 m in [MASKED], no longer on tx ARTHRITIS knees, ankle and L shoulder, currently receiving [MASKED] hypertension Hx iron def anemia on folic acid x2-3, has not yet gotten iron infusion -HAs on tylenol Social History: [MASKED] Family History: (per chart, confirmed with pt and updated): -No family history of Crohn's. -HTN -breast CA Physical Exam: Admission Physical Exam: ======================= VS: 98.2 PO 138 / 81 87 97 GENERAL: NAD, pleasant HEENT: AT/NC, EOMI w/ tenderness on L, L proptosis, mild periorbital swelling NECK: supple, no LAD, no thyroid nodules palpated HEART: RRR, + murmur LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes Discharge Physical Exam: ======================= Vitals: 98.4 139/83 87 16 99% RA GENERAL: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear NECK: Supple, JVP not elevated, no LAD RESP: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops ABD: soft. GU: no foley EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: visual field testing improved almost resolved, proptosis on left resolving Pertinent Results: Admission Labs: ============== [MASKED] 04:00PM BLOOD WBC-11.8* RBC-3.50*# Hgb-9.1*# Hct-29.7*# MCV-85 MCH-26.0 MCHC-30.6* RDW-16.2* RDWSD-49.8* Plt [MASKED] [MASKED] 04:00PM BLOOD Neuts-77.9* Lymphs-16.6* Monos-4.2* Eos-0.7* Baso-0.3 Im [MASKED] AbsNeut-9.18* AbsLymp-1.95 AbsMono-0.50 AbsEos-0.08 AbsBaso-0.03 [MASKED] 04:00PM BLOOD Plt [MASKED] [MASKED] 04:00PM BLOOD [MASKED] PTT-27.4 [MASKED] [MASKED] 04:00PM BLOOD Glucose-106* UreaN-10 Creat-0.8 Na-141 K-3.8 Cl-105 HCO3-24 AnGap-16 Micro: ===== Lyme pending HIV pending Imaging: ======== MRI brain with orbits: 1. Diffuse enhancement surrounding the left optic nerve with adjacent retrobulbar fat stranding. These findings are suggestive of perineuritis, with differential considerations including inflammatory process such as sarcoid. Postseptal cellulitis is considered less likely. 2. Paranasal sinus disease, as above. 3. Additional chronic findings as described above. Discharge Labs: =============== [MASKED] 08:45AM BLOOD WBC-13.1* RBC-3.10* Hgb-8.2* Hct-26.2* MCV-85 MCH-26.5 MCHC-31.3* RDW-16.3* RDWSD-50.5* Plt [MASKED] [MASKED] 05:30AM BLOOD Glucose-116* UreaN-16 Creat-0.8 Na-143 K-4.1 Cl-110* HCO3-24 AnGap-13 Brief Hospital Course: Ms. [MASKED] is a [MASKED] yo woman with Crohn's disease on methotrexate and recently diagnosed seizure disorder as well abnormal MRI brain findings who presented with vision loss and MRI findings of perineuritis. She was seen by the neurology, neurosurgery, ENT, and ophthalmology in the ED. She was also seen by the infectious disease doctors. [MASKED], her symptoms were thought to be due to either perineuritis from an inflammatory process vs. partially treated post septal cellulitis. She improved with steroids and antibiotics. Steroid course to be determined by ophthalmology team. # Vision loss # Perineuritis: Most likely etiology is inflammatory process vs. infectious. Opthomology recommended steroids 60 mg daily with taper to be determined as outpatient; ID was consulted and felt comfortable with steroids but also recommend unasyn while in house and then augmentin x 2 weeks on discharge out of concern for partially treated pre-septal cellulitis. ID felt there was lower index of suspicion for fungal disease to explain current presentation. B-glucan, galactomanan, HIV, and Lyme were ordered and pending at time of discharge. Patient's vision was much improved at time of discharge. She will follow with optho (scheduled prior to discharge) this week and ID will contact her for a follow-up appointment. #Nasal mucosa management: ENT was consulted in the ED and recommended the following, which she received in house. An ENT appointment was not made at discharge, but the patient was called and given the number to follow with ENT as an outpatient. - Saline nasal spray [MASKED] - Flonase 2 sprays each nostril BID - Afrin 2 sprays TID for 3 days following saline rises # Crohn's: Patient reported that she had not been taking methotrexate at home because she was worried about the cancer risk and equates the methotrexate with her new brain lesions. Her gastroenterologist asked that her methotrexate be restarted, which was recommended to the patient. However, there is an interaction between augmentin and methotrexate so it was recommended that she hold the methotrexate until she complete her antibiotic course. # Anemia # Vaginal bleeding: Stbale throughout stay. On morning of discharge had a drop in H/H but on repeat H/H was back to baseline suggesting a lab error. She was continued on MEDROXYPROGESTERONE ACETATE 10 TABS BID through [MASKED] Chronic Issues: =============== #Hx of Cribiform plate mass: F/u imaging with improvement. - neurosurgery f/u as outpatient # Leptomeningeal enhancement: New, noted on MRI [MASKED]. culture reported final report on [MASKED], was also negative. Serum RPR tox antibody were negative. ID discussed with patient the importance of biopsy for definitive diagnosis but she declined. # HTN: Well controlled. - Continued dilt # Seizure disorder: - Continued keppra Transitional Issues: =================== - abx: augmentin through [MASKED] - steroid course to be determined by optho, if patient is on steroids > 4 weeks, would initiate her on Bactrim prophylaxis - Methotrexate was restarted per GI recs, but patient was unwilling to take it, would recommend discussing with her outpatient gastroenterologist - However, should hold methotrexate while on augmentin - should schedule ID follow-up (pending at time of discharge) - pending labs: B-glucan, galactomannan, Lyme titer, and HIV Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze 2. azelastine 0.15 % (205.5 mcg) nasal BID 3. Voltaren (diclofenac sodium) 1 % topical Q6H:PRN pain 4. Diltiazem Extended-Release 240 mg PO DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY 6. FoLIC Acid 1 mg PO DAILY 7. LevETIRAcetam 1000 mg PO BID 8. Lidocaine 5% Ointment 1 Appl TP BID 9. Methotrexate 15 mg SC 1X/WEEK (WE) 10. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain - Severe 11. Polyethylene Glycol 17 g PO DAILY:PRN contstipation 12. TraMADol 50 mg PO TID:PRN Pain - Severe 13. MedroxyPROGESTERone Acetate 10 mg PO BID 14. Beano (alpha-d-galactosidase) 150 unit oral ASDIR 15. Calcium Carbonate 300 mg PO PRN indigestion 16. Cetirizine 10 mg PO DAILY 17. DiphenhydrAMINE 25 mg PO QHS:PRN allergy Discharge Medications: 1. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H Duration: 13 Days RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 daily by mouth twice a day Disp #*26 Tablet Refills:*0 2. PredniSONE 60 mg PO DAILY RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze 4. azelastine 0.15 % (205.5 mcg) nasal BID 5. Beano (alpha-d-galactosidase) 150 unit oral ASDIR 6. Calcium Carbonate 300 mg PO PRN indigestion 7. Cetirizine 10 mg PO DAILY 8. Diclofenac Sodium [MASKED] [MASKED] sodium) 1 % topical Q6H:PRN pain 9. Diltiazem Extended-Release 240 mg PO DAILY 10. DiphenhydrAMINE 25 mg PO QHS:PRN allergy 11. Fluticasone Propionate NASAL 1 SPRY NU DAILY 12. FoLIC Acid 1 mg PO DAILY 13. LevETIRAcetam 1000 mg PO BID 14. Lidocaine 5% Ointment 1 Appl TP BID 15. MedroxyPROGESTERone Acetate 10 mg PO BID 16. Methotrexate 15 mg SC 1X/WEEK (WE) 17. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain - Severe 18. Polyethylene Glycol 17 g PO DAILY:PRN contstipation 19. TraMADol 50 mg PO TID:PRN Pain - Severe Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary diagnosis: perineuritis post septal cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at [MASKED]. Why was I here? - You had blurred vision. - You were seen by many different doctors and [MASKED] got steroids and antibiotics. - You got better. What should I do when I get home? - It is very important to take all your medicines everyday. - If you do not want to take your methotrexate, please let Dr. [MASKED]. Followup Instructions: [MASKED]
|
[] |
[
"J45909",
"D649",
"I10",
"E785",
"E119"
] |
[
"G588: Other specified mononeuropathies",
"G9389: Other specified disorders of brain",
"H0520: Unspecified exophthalmos",
"K5090: Crohn's disease, unspecified, without complications",
"Q211: Atrial septal defect",
"L03818: Cellulitis of other sites",
"H547: Unspecified visual loss",
"J45909: Unspecified asthma, uncomplicated",
"D649: Anemia, unspecified",
"N939: Abnormal uterine and vaginal bleeding, unspecified",
"I10: Essential (primary) hypertension",
"G40909: Epilepsy, unspecified, not intractable, without status epilepticus",
"E785: Hyperlipidemia, unspecified",
"E119: Type 2 diabetes mellitus without complications",
"Z9851: Tubal ligation status",
"E739: Lactose intolerance, unspecified"
] |
10,027,957
| 26,603,380
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Pepcid / Sulfasalazine / metronidazole / azathioprine / Remicade
/ Ceftin / aspirin
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
"Ms. ___ is a ___ female hx seizure disorder,
Crohn's Disease followed by Dr. ___, CVA ___
with
residual arm weakness presents for evaluation of lower gi
bleeding.
Pt states that she has known Crohn's Disease and is followed by
Dr. ___ ___ been with ongoing lower GI bleeding for the
past ___ days.
Pt notes that she has had ___ cups of ___ red blood
per
rectum 2x/day x 3 days and 1 x over the past one day. Pt notes
having some associated lower abdominal cramping but notes no
nausea/vomiting/fevers/chills/chest pain/sob/cough/sore
throat/uti symptoms. No travel. No sick contacts. Pt is not on
anticoagulation. No dizziness or lightheadedness.
Pt notes that a sigmoidoscopy was performed on the day of
presentation (outpatient workup by GI for bleeding) which showed
diverticulosis, an erythematous patch with mild edema without
bleeding. Biopsy taken and pt referred for admission given
evidence of active bleeding.
In the ED, pt was hemodynamically stable. cbc/chemistries/crp
notable for hgb 9.2--> 8.3---> 8.7 (was 12.2 ___, crp 4.2. Pt
w/o any symptoms. Pt admitted for additional evaluation and
treatment."
Past Medical History:
(per chart, confirmed with pt):
CROHN'S DISEASE currently on methotrexate every other week
-h/o Remicade infusion reaction
--hospitalized ___, Rx cyclosporine and steroids
ALLERGIC RHINITIS
Occ bronchitis
HYPERTENSION
diet controlled diabetes
LACTOSE INTOLERANCE on lactate
POSITIVE PPD, treated with INH x 6 months and ? rifaximin for 9
m in ___, no longer on tx
ARTHRITIS knees, ankle and L shoulder, currently receiving ___
hypertension
Hx iron def anemia on folic acid x2-3, has not yet gotten iron
infusion
-HAs on tylenol
Social History:
___
Family History:
(per chart, confirmed with pt and updated):
-No family history of Crohn's.
-HTN
-breast CA
Physical Exam:
Admission exam:
EXAM(8)
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
___ CBC- wbc 8.5, H/H 8.7/28.2, plt 260
BMP - 144, K 4.4, Cl 106, co2 24, BUN/Cr ___
Discharge exam:
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: NC AT. MMM
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, ND. +BS. no tenderness to palpation
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Discharge labs:
Hgb stable at 8.8
BMP unchanged
Pertinent Results:
___ 08:20AM BLOOD WBC-7.9 RBC-2.93* Hgb-8.3* Hct-26.7*
MCV-91 MCH-28.3 MCHC-31.1* RDW-13.6 RDWSD-45.0 Plt ___
___ 09:35AM BLOOD Glucose-119* UreaN-9 Creat-0.9 Na-142
K-4.2 Cl-107 HCO3-24 AnGap-11
___ 09:35AM BLOOD CRP-17.2*
___ 01:15PM BLOOD ___ PTT-22.6* ___
___ 01:15PM BLOOD Lipase-26
___ 01:15PM BLOOD cTropnT-<0.01
___ 01:15PM BLOOD Albumin-3.9 Calcium-9.4 Phos-3.6 Mg-1.7
Iron-26*
___ 01:15PM BLOOD calTIBC-321 Ferritn-22 TRF-247
Discharge labs significant for:
Stable Hemoglobin at 8.5
___ 07:00AM BLOOD WBC-8.9 RBC-3.09* Hgb-8.8* Hct-28.1*
MCV-91 MCH-28.5 MCHC-31.3* RDW-13.5 RDWSD-44.8 Plt ___
Brief Hospital Course:
This is a ___ year old female with a history of Crohn's disease
(followed by Dr. ___, hypertension, seizure disorder and CVA
(___) who comes in from endoscopy suite for evaluation of lower
GI bleeding.
# BRBPR
# Acute blood loss anemia
# Chron's disease
Pt presents for evaluation of a BRBPR of ___ day duration. She
had a sigmoidoscopy outpatient to evaluate for source of
bleeding which showed internal hemorrhoids, diverticulosis and
bleeding throughout colon without source identified. Outpatient
GI doctor referred patient in for inpatient monitoring and
further work up with colonoscopy. On arrival, patient was HDS
and Hgb was 8.3, down from 9.2 on ___. She was started on a PPI
and evaluated by inpatient GI team. Patient reported reluctance
in undergoing a colonoscopy and requested to instead have follow
up with her GI physician ___. GI consult team felt this
was reasonable given stable blood counts. She did have one
additional episode on ___ of blood mixed in with stool and
bright blood on TP that patient felt was smaller in quantity in
comparison to episodes at home. Patient was transitioned to oral
pantoprazole and started on iron on discharge given iron
deficiency on blood work (Fe 26, TIBC 321, ferritin 22). Source
of bleeding remained unclear and is likely ___ chron's flare vs
internal hemorrhoids. She was instructed to call her outpatient
GI physician to set up follow up appointment within the next
___ days and counseled on red flag / return precautions.
# Chronic medical problems
- Seizure disorder: c/h keppra
- HTN: home verapamil held out of c/f GIB. Discharged with
instruction to restart medication given stable Hgb and BPs
Transitional issues:
[ ] Source of BRBPR remained unclear, however, appeared to be
decreased in quantity during hospitalization. Please follow up
sigmoidoscopy biopsies from ___. Patient instructed to call her
outpatient GI physician for follow up within ___ day
[ ] Patient started on pantoprazole 20 mg daily as she felt
symptom relief with this medication
[ ] Found to be iron deficient during hospitalization. Hgb
stable throughout hospitalization. Discharged with prescription
for ferrous sulfate 325 mg po every other day
>30 minutes spent on discharge planning and care coordination
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 1500 mg PO BID
2. Cetirizine 10 mg PO DAILY
3. Diltiazem Extended-Release 360 mg PO DAILY
4. DiphenhydrAMINE 25 mg PO QHS
5. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Severe
6. Fleet Enema (Saline) ___AILY:PRN constipation
Discharge Medications:
1. Pantoprazole 40 mg PO Q24H
2. Cetirizine 10 mg PO DAILY
3. DiphenhydrAMINE 25 mg PO QHS
4. LevETIRAcetam 1500 mg PO BID
5. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Severe
6. Diltiazem Extended-Release 360 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Bright red blood per rectum
# Anemia
# Chron's disease
Discharge Condition:
Stable, independent and ambulatory
Discharge Instructions:
Ms ___,
You were sent into the hospital by your GI doctor with bloody
stool of ___ day duration after having a sigmoidoscopy in their
clinic. During your hospitalization, your blood counts remained
stable and you did have some further stool with blood, but it
seemed to be decreased in comparison to the bleeding you had at
home prior to coming in. We started you on a medication to help
with acid production in your stomach in the case that your
bleeding was caused by an ulcer. You should follow up with your
GI doctor for further work up.
We wish you all the best,
Your ___ care team
Followup Instructions:
___
|
[
"K50111",
"D62",
"K648",
"K5730",
"D509",
"E739",
"G40909",
"I10",
"I69331"
] |
Allergies: Pepcid / Sulfasalazine / metronidazole / azathioprine / Remicade / Ceftin / aspirin Chief Complaint: BRBPR Major Surgical or Invasive Procedure: None History of Present Illness: "Ms. [MASKED] is a [MASKED] female hx seizure disorder, Crohn's Disease followed by Dr. [MASKED], CVA [MASKED] with residual arm weakness presents for evaluation of lower gi bleeding. Pt states that she has known Crohn's Disease and is followed by Dr. [MASKED] [MASKED] been with ongoing lower GI bleeding for the past [MASKED] days. Pt notes that she has had [MASKED] cups of [MASKED] red blood per rectum 2x/day x 3 days and 1 x over the past one day. Pt notes having some associated lower abdominal cramping but notes no nausea/vomiting/fevers/chills/chest pain/sob/cough/sore throat/uti symptoms. No travel. No sick contacts. Pt is not on anticoagulation. No dizziness or lightheadedness. Pt notes that a sigmoidoscopy was performed on the day of presentation (outpatient workup by GI for bleeding) which showed diverticulosis, an erythematous patch with mild edema without bleeding. Biopsy taken and pt referred for admission given evidence of active bleeding. In the ED, pt was hemodynamically stable. cbc/chemistries/crp notable for hgb 9.2--> 8.3---> 8.7 (was 12.2 [MASKED], crp 4.2. Pt w/o any symptoms. Pt admitted for additional evaluation and treatment." Past Medical History: (per chart, confirmed with pt): CROHN'S DISEASE currently on methotrexate every other week -h/o Remicade infusion reaction --hospitalized [MASKED], Rx cyclosporine and steroids ALLERGIC RHINITIS Occ bronchitis HYPERTENSION diet controlled diabetes LACTOSE INTOLERANCE on lactate POSITIVE PPD, treated with INH x 6 months and ? rifaximin for 9 m in [MASKED], no longer on tx ARTHRITIS knees, ankle and L shoulder, currently receiving [MASKED] hypertension Hx iron def anemia on folic acid x2-3, has not yet gotten iron infusion -HAs on tylenol Social History: [MASKED] Family History: (per chart, confirmed with pt and updated): -No family history of Crohn's. -HTN -breast CA Physical Exam: Admission exam: EXAM(8) VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect [MASKED] CBC- wbc 8.5, H/H 8.7/28.2, plt 260 BMP - 144, K 4.4, Cl 106, co2 24, BUN/Cr [MASKED] Discharge exam: GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: NC AT. MMM CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, ND. +BS. no tenderness to palpation GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Discharge labs: Hgb stable at 8.8 BMP unchanged Pertinent Results: [MASKED] 08:20AM BLOOD WBC-7.9 RBC-2.93* Hgb-8.3* Hct-26.7* MCV-91 MCH-28.3 MCHC-31.1* RDW-13.6 RDWSD-45.0 Plt [MASKED] [MASKED] 09:35AM BLOOD Glucose-119* UreaN-9 Creat-0.9 Na-142 K-4.2 Cl-107 HCO3-24 AnGap-11 [MASKED] 09:35AM BLOOD CRP-17.2* [MASKED] 01:15PM BLOOD [MASKED] PTT-22.6* [MASKED] [MASKED] 01:15PM BLOOD Lipase-26 [MASKED] 01:15PM BLOOD cTropnT-<0.01 [MASKED] 01:15PM BLOOD Albumin-3.9 Calcium-9.4 Phos-3.6 Mg-1.7 Iron-26* [MASKED] 01:15PM BLOOD calTIBC-321 Ferritn-22 TRF-247 Discharge labs significant for: Stable Hemoglobin at 8.5 [MASKED] 07:00AM BLOOD WBC-8.9 RBC-3.09* Hgb-8.8* Hct-28.1* MCV-91 MCH-28.5 MCHC-31.3* RDW-13.5 RDWSD-44.8 Plt [MASKED] Brief Hospital Course: This is a [MASKED] year old female with a history of Crohn's disease (followed by Dr. [MASKED], hypertension, seizure disorder and CVA ([MASKED]) who comes in from endoscopy suite for evaluation of lower GI bleeding. # BRBPR # Acute blood loss anemia # Chron's disease Pt presents for evaluation of a BRBPR of [MASKED] day duration. She had a sigmoidoscopy outpatient to evaluate for source of bleeding which showed internal hemorrhoids, diverticulosis and bleeding throughout colon without source identified. Outpatient GI doctor referred patient in for inpatient monitoring and further work up with colonoscopy. On arrival, patient was HDS and Hgb was 8.3, down from 9.2 on [MASKED]. She was started on a PPI and evaluated by inpatient GI team. Patient reported reluctance in undergoing a colonoscopy and requested to instead have follow up with her GI physician [MASKED]. GI consult team felt this was reasonable given stable blood counts. She did have one additional episode on [MASKED] of blood mixed in with stool and bright blood on TP that patient felt was smaller in quantity in comparison to episodes at home. Patient was transitioned to oral pantoprazole and started on iron on discharge given iron deficiency on blood work (Fe 26, TIBC 321, ferritin 22). Source of bleeding remained unclear and is likely [MASKED] chron's flare vs internal hemorrhoids. She was instructed to call her outpatient GI physician to set up follow up appointment within the next [MASKED] days and counseled on red flag / return precautions. # Chronic medical problems - Seizure disorder: c/h keppra - HTN: home verapamil held out of c/f GIB. Discharged with instruction to restart medication given stable Hgb and BPs Transitional issues: [ ] Source of BRBPR remained unclear, however, appeared to be decreased in quantity during hospitalization. Please follow up sigmoidoscopy biopsies from [MASKED]. Patient instructed to call her outpatient GI physician for follow up within [MASKED] day [ ] Patient started on pantoprazole 20 mg daily as she felt symptom relief with this medication [ ] Found to be iron deficient during hospitalization. Hgb stable throughout hospitalization. Discharged with prescription for ferrous sulfate 325 mg po every other day >30 minutes spent on discharge planning and care coordination Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LevETIRAcetam 1500 mg PO BID 2. Cetirizine 10 mg PO DAILY 3. Diltiazem Extended-Release 360 mg PO DAILY 4. DiphenhydrAMINE 25 mg PO QHS 5. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe 6. Fleet Enema (Saline) AILY:PRN constipation Discharge Medications: 1. Pantoprazole 40 mg PO Q24H 2. Cetirizine 10 mg PO DAILY 3. DiphenhydrAMINE 25 mg PO QHS 4. LevETIRAcetam 1500 mg PO BID 5. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe 6. Diltiazem Extended-Release 360 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: # Bright red blood per rectum # Anemia # Chron's disease Discharge Condition: Stable, independent and ambulatory Discharge Instructions: Ms [MASKED], You were sent into the hospital by your GI doctor with bloody stool of [MASKED] day duration after having a sigmoidoscopy in their clinic. During your hospitalization, your blood counts remained stable and you did have some further stool with blood, but it seemed to be decreased in comparison to the bleeding you had at home prior to coming in. We started you on a medication to help with acid production in your stomach in the case that your bleeding was caused by an ulcer. You should follow up with your GI doctor for further work up. We wish you all the best, Your [MASKED] care team Followup Instructions: [MASKED]
|
[] |
[
"D62",
"D509",
"I10"
] |
[
"K50111: Crohn's disease of large intestine with rectal bleeding",
"D62: Acute posthemorrhagic anemia",
"K648: Other hemorrhoids",
"K5730: Diverticulosis of large intestine without perforation or abscess without bleeding",
"D509: Iron deficiency anemia, unspecified",
"E739: Lactose intolerance, unspecified",
"G40909: Epilepsy, unspecified, not intractable, without status epilepticus",
"I10: Essential (primary) hypertension",
"I69331: Monoplegia of upper limb following cerebral infarction affecting right dominant side"
] |
10,027,957
| 28,485,516
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Pepcid / Sulfasalazine / metronidazole / azathioprine / Remicade
/ Ceftin
Attending: ___
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
History of Present Illness:
EU Critical ___ is a ___ woman with Crohn's
Disease and HTN who presents after an event concerning for
seizure.
Two hours prior to admission, she called her significant other
and was mumbling. He says that it sounded like she were drinking
because she kept mumbling and was not making sense. He told her
that he would talk to her later.
She was apparently coming home from school. Very stressed out,
has a paper due tomorrow and if she does not pass an exam, she
will not be able to graduate. She was standing at the kitchen
sink, roommate came in the room and noticed that she was odd and
staring into space and not talking. Roommate came in 3 different
times to check on her, and after the third time, the roommate
heard a thud. She had fallen at the sink and a glass fell from
her hand. Her extremities were extended and shaking, and her
whole body was turning to the left side. Her eyes were open and
"rolled back." Mother thought episode lasted ___ seconds, but
others say less than 1 min. EMS called, and pt had another
episode that lasted 1min when they arrived. All episodes self
resolved and did not require medication. Blood glucose in the
180s. SBP in 110s with HR in ___ and pin point pupils.
She was brought to ___. No tongue biting, unclear if there were
any incontinence. Never had episodes like this before. Of note,
this would be her third Christmas in the hospital per mother. Pt
is not back at baseline.
Past Medical History:
(per chart, confirmed with pt):
CROHN'S DISEASE currently on methotrexate every other week
-h/o Remicade infusion reaction
--hospitalized ___, Rx cyclosporine and steroids
ALLERGIC RHINITIS
Occ bronchitis
HYPERTENSION
diet controlled diabetes
LACTOSE INTOLERANCE on lactate
POSITIVE PPD, treated with INH x 6 months and ? rifaximin for 9
m in ___, no longer on tx
ARTHRITIS knees, ankle and L shoulder, currently receiving ___
hypertension
Hx iron def anemia on folic acid x2-3, has not yet gotten iron
infusion
-HAs on tylenol
Social History:
___
Family History:
(per chart, confirmed with pt and updated):
-No family history of Crohn's.
-HTN
-breast CA
Physical Exam:
Admission Exam:
Vitals: HR: 113 BP: 119/76 RR: 24 SaO2: 97% RA
General: NAD
HEENT: NCAT, cervical collar in place
___: RRR, no m/r/g
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to self, ___ and
Women's and ___ (when asked year, says it is ___.
Unable to relate history, inattentive. Follows simple commands.
Speech is fluent with short sentences, intact repetition. Naming
intact to high frequency objects. No paraphasias. Perseverates.
No dysarthria.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No asterixis. Mild
postural tremor in LUE.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 3+ 3+ 3+ 3+ 2
R 3+ 3+ 3+ 3+ 2
Plantar response flexor bilaterally. Pectoralis jerk and cross
adductors present bilaterally. 2 beats of clonus bilaterally.
- Sensory: No deficits to light touch throughout
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: deferred
Discharge Exam
Pertinent Results:
___ 06:13AM ___ COMMENTS-GREEN TOP
___ 06:13AM LACTATE-2.0
___ 05:45AM GLUCOSE-118* UREA N-13 CREAT-0.9 SODIUM-140
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-27 ANION GAP-16
___ 05:45AM estGFR-Using this
___ 05:45AM CALCIUM-9.2 PHOSPHATE-3.5 MAGNESIUM-1.8
___ 05:45AM WBC-12.6* RBC-3.75* HGB-9.9* HCT-31.1* MCV-83
MCH-26.4 MCHC-31.8* RDW-17.0* RDWSD-51.3*
___ 05:45AM PLT COUNT-350
___ 11:05PM URINE HOURS-RANDOM
___ 11:05PM URINE HOURS-RANDOM
___ 11:05PM URINE UCG-NEGATIVE
___ 11:05PM URINE GR HOLD-HOLD
___ 11:05PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 11:05PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 11:05PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-1
___ 11:05PM URINE HYALINE-1*
___ 11:05PM URINE MUCOUS-RARE
___ 10:20PM LACTATE-14.7*
___ 10:08PM GLUCOSE-184* UREA N-13 CREAT-1.1 SODIUM-138
POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-14* ANION GAP-33*
___ 10:08PM estGFR-Using this
___ 10:08PM ALT(SGPT)-9 AST(SGOT)-19 ALK PHOS-93 TOT
BILI-<0.2
___ 10:08PM ALBUMIN-4.1 CALCIUM-9.7 PHOSPHATE-5.3*
MAGNESIUM-2.0
___ 10:08PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 10:08PM WBC-13.9* RBC-4.10 HGB-10.8* HCT-35.7 MCV-87
MCH-26.3 MCHC-30.3* RDW-17.1* RDWSD-54.0*
___ 10:08PM NEUTS-62.5 ___ MONOS-5.5 EOS-1.5
BASOS-0.4 IM ___ AbsNeut-8.71* AbsLymp-4.08* AbsMono-0.77
AbsEos-0.21 AbsBaso-0.06
___ 10:08PM PLT COUNT-395
EEG ___
IMPRESSION: This is an abnormal EEG as it demonstrates the
presence of a single electrographic seizure (without obvious
clinical correlate) originating from left frontotemporal
regions, consistent with an active focus of cortical
irritability in this region. In addition, there are abundant
left frontally predominant sharp waves presenting as continuous
runs of slow periodic discharges (0.2-0.3Hz) primarily during
sleep, confirming local cortical irritability. There are no
other abnormalities noted in her record during wakefulness or
sleep. There are three accidental pushbutton activations.
MRI/MRV ___
IMPRESSION:
1. Slightly irregular area of dural based enhancement in the
anterior
interhemispheric fissure adjacent to the left straight gyrus
measuring up to 18 x 9 mm with adjacent edema of the left
straight/orbital gyri, as described, favored to represent
infection, particularly given adjacent mild bony irregularity of
the fovea ethmoidalis, possibly fungal in this patient with a
history of Crohn's disease with immunosuppression. Dural
inflammatory pseudotumor would be the next most likely etiology.
Meningioma is considered unlikely, though possible.
2. Minimal areas of white matter signal abnormality in a
configuration most suggestive of chronic small vessel ischemic
disease.
3. No dural venous sinus thrombosis.
4. Mild paranasal sinus opacification, as described.
Brief Hospital Course:
___ is a ___ right-handed woman with past medical
history significant for Crohn's disease who presents after 2
events concerning for seizures. She was started on cvEEG and one
electrographic seizure was captured on EEG overnight. She was
also noted to have a left orbital frontal hypodensity on her CT
scan. She was started on seizure prophylaxis with 1000mg of
Keppra BID. She underwent a MRI/MRV to better characterize the
left sided frontal hypodensity in addition to ruling out other
possible focal pathology including a sinus venous thrombosis
-which she would be at increased risk for given her Crohn's
disease. MRI/MRV showed dural based enhancement and edema of the
left straight/orbital gyri concerning for infectious process.
ENT and neurosurgery were consulted. ENT exam did not reveal any
abnormalities. The decision was made to repeat her imaging in 2
weeks before we proceeding with a biopsy.
Of note, the patient was noted to have a cystic lesion in her
kidney which should be followed up with ultrasound in ___ year.
She was also noted to have a PFO, pulmonary hypertension and 2
pulmonary aneurysms which should be addressed in pulmonary and
cardiology clinic (we were unable to arrange these follow ups do
to the holiday weekend).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. diclofenac sodium 1 % topical BID:PRN
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. FoLIC Acid 1 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. lidocaine 5 % topical BID:PRN
7. Methotrexate 15 mg SC 1X/WEEK (___) (0.6ml SC once weekly by
visiting nurse)
8. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain -
Moderate
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. TraMADol 50 mg PO TID:PRN Pain - Moderate
11. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
12. Calcium Carbonate 500 mg PO DAILY:PRN heartburn
13. Cetirizine 10 mg PO DAILY
14. Glycerin Supps 1 SUPP PR PRN constipation
15. Lactaid (lactase) 3,000 unit oral DAILY:PRN
16. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 15 billion cell
oral DAILY
Discharge Medications:
1. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*3
2. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
3. amLODIPine 10 mg PO DAILY
4. Calcium Carbonate 500 mg PO DAILY:PRN heartburn
5. Cetirizine 10 mg PO DAILY
6. diclofenac sodium 1 apl topical BID:PRN rash
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. FoLIC Acid 1 mg PO DAILY
9. Glycerin Supps 1 SUPP PR PRN constipation
10. Hydrochlorothiazide 25 mg PO DAILY
11. Lactaid (lactase) 3,000 unit oral DAILY:PRN
12. lidocaine 5 % topical BID:PRN
13. Methotrexate 15 mg SC 1X/WEEK (___) (0.6ml SC once weekly by
visiting nurse)
14. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain
- Moderate
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 15 billion cell
oral DAILY
17. TraMADol 50 mg PO TID:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ were admitted to ___ for evaluation of episodes that were
concerning for seizures. ___ were placed on cvEEG overnight and
we captured an electrographic seizure. ___ were started on
keppra 1000 mg twice a day. ___ also underwent MRI/MRV of your
brain and it showed and area of inflammation in an area of your
brain which was likely the cause of your seizures.
Please discuss with your primary care doctor the need to set up
pulmonary and cardiology follow up appointments
Please continue to take your medications as described. ___ have
follow up appointments scheduled as below.
It was a pleasure taking care of ___.
Best,
Your ___ Team!
Followup Instructions:
___
|
[
"G40802",
"I281",
"I272",
"K5090",
"Q211",
"N281",
"I10",
"E119"
] |
Allergies: Pepcid / Sulfasalazine / metronidazole / azathioprine / Remicade / Ceftin Chief Complaint: Seizure Major Surgical or Invasive Procedure: History of Present Illness: EU Critical [MASKED] is a [MASKED] woman with Crohn's Disease and HTN who presents after an event concerning for seizure. Two hours prior to admission, she called her significant other and was mumbling. He says that it sounded like she were drinking because she kept mumbling and was not making sense. He told her that he would talk to her later. She was apparently coming home from school. Very stressed out, has a paper due tomorrow and if she does not pass an exam, she will not be able to graduate. She was standing at the kitchen sink, roommate came in the room and noticed that she was odd and staring into space and not talking. Roommate came in 3 different times to check on her, and after the third time, the roommate heard a thud. She had fallen at the sink and a glass fell from her hand. Her extremities were extended and shaking, and her whole body was turning to the left side. Her eyes were open and "rolled back." Mother thought episode lasted [MASKED] seconds, but others say less than 1 min. EMS called, and pt had another episode that lasted 1min when they arrived. All episodes self resolved and did not require medication. Blood glucose in the 180s. SBP in 110s with HR in [MASKED] and pin point pupils. She was brought to [MASKED]. No tongue biting, unclear if there were any incontinence. Never had episodes like this before. Of note, this would be her third Christmas in the hospital per mother. Pt is not back at baseline. Past Medical History: (per chart, confirmed with pt): CROHN'S DISEASE currently on methotrexate every other week -h/o Remicade infusion reaction --hospitalized [MASKED], Rx cyclosporine and steroids ALLERGIC RHINITIS Occ bronchitis HYPERTENSION diet controlled diabetes LACTOSE INTOLERANCE on lactate POSITIVE PPD, treated with INH x 6 months and ? rifaximin for 9 m in [MASKED], no longer on tx ARTHRITIS knees, ankle and L shoulder, currently receiving [MASKED] hypertension Hx iron def anemia on folic acid x2-3, has not yet gotten iron infusion -HAs on tylenol Social History: [MASKED] Family History: (per chart, confirmed with pt and updated): -No family history of Crohn's. -HTN -breast CA Physical Exam: Admission Exam: Vitals: HR: 113 BP: 119/76 RR: 24 SaO2: 97% RA General: NAD HEENT: NCAT, cervical collar in place [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: - Mental status: Awake, alert, oriented to self, [MASKED] and Women's and [MASKED] (when asked year, says it is [MASKED]. Unable to relate history, inattentive. Follows simple commands. Speech is fluent with short sentences, intact repetition. Naming intact to high frequency objects. No paraphasias. Perseverates. No dysarthria. - Cranial Nerves: PERRL 3->2 brisk. VF full to number counting. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength [MASKED] bilaterally. Tongue midline. - Motor: Normal bulk and tone. No drift. No asterixis. Mild postural tremor in LUE. [Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] L 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 - Reflexes: [Bic] [Tri] [[MASKED]] [Quad] [Gastroc] L 3+ 3+ 3+ 3+ 2 R 3+ 3+ 3+ 3+ 2 Plantar response flexor bilaterally. Pectoralis jerk and cross adductors present bilaterally. 2 beats of clonus bilaterally. - Sensory: No deficits to light touch throughout - Coordination: No dysmetria with finger to nose testing bilaterally. - Gait: deferred Discharge Exam Pertinent Results: [MASKED] 06:13AM [MASKED] COMMENTS-GREEN TOP [MASKED] 06:13AM LACTATE-2.0 [MASKED] 05:45AM GLUCOSE-118* UREA N-13 CREAT-0.9 SODIUM-140 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-27 ANION GAP-16 [MASKED] 05:45AM estGFR-Using this [MASKED] 05:45AM CALCIUM-9.2 PHOSPHATE-3.5 MAGNESIUM-1.8 [MASKED] 05:45AM WBC-12.6* RBC-3.75* HGB-9.9* HCT-31.1* MCV-83 MCH-26.4 MCHC-31.8* RDW-17.0* RDWSD-51.3* [MASKED] 05:45AM PLT COUNT-350 [MASKED] 11:05PM URINE HOURS-RANDOM [MASKED] 11:05PM URINE HOURS-RANDOM [MASKED] 11:05PM URINE UCG-NEGATIVE [MASKED] 11:05PM URINE GR HOLD-HOLD [MASKED] 11:05PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG [MASKED] 11:05PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 11:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [MASKED] 11:05PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-1 [MASKED] 11:05PM URINE HYALINE-1* [MASKED] 11:05PM URINE MUCOUS-RARE [MASKED] 10:20PM LACTATE-14.7* [MASKED] 10:08PM GLUCOSE-184* UREA N-13 CREAT-1.1 SODIUM-138 POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-14* ANION GAP-33* [MASKED] 10:08PM estGFR-Using this [MASKED] 10:08PM ALT(SGPT)-9 AST(SGOT)-19 ALK PHOS-93 TOT BILI-<0.2 [MASKED] 10:08PM ALBUMIN-4.1 CALCIUM-9.7 PHOSPHATE-5.3* MAGNESIUM-2.0 [MASKED] 10:08PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [MASKED] 10:08PM WBC-13.9* RBC-4.10 HGB-10.8* HCT-35.7 MCV-87 MCH-26.3 MCHC-30.3* RDW-17.1* RDWSD-54.0* [MASKED] 10:08PM NEUTS-62.5 [MASKED] MONOS-5.5 EOS-1.5 BASOS-0.4 IM [MASKED] AbsNeut-8.71* AbsLymp-4.08* AbsMono-0.77 AbsEos-0.21 AbsBaso-0.06 [MASKED] 10:08PM PLT COUNT-395 EEG [MASKED] IMPRESSION: This is an abnormal EEG as it demonstrates the presence of a single electrographic seizure (without obvious clinical correlate) originating from left frontotemporal regions, consistent with an active focus of cortical irritability in this region. In addition, there are abundant left frontally predominant sharp waves presenting as continuous runs of slow periodic discharges (0.2-0.3Hz) primarily during sleep, confirming local cortical irritability. There are no other abnormalities noted in her record during wakefulness or sleep. There are three accidental pushbutton activations. MRI/MRV [MASKED] IMPRESSION: 1. Slightly irregular area of dural based enhancement in the anterior interhemispheric fissure adjacent to the left straight gyrus measuring up to 18 x 9 mm with adjacent edema of the left straight/orbital gyri, as described, favored to represent infection, particularly given adjacent mild bony irregularity of the fovea ethmoidalis, possibly fungal in this patient with a history of Crohn's disease with immunosuppression. Dural inflammatory pseudotumor would be the next most likely etiology. Meningioma is considered unlikely, though possible. 2. Minimal areas of white matter signal abnormality in a configuration most suggestive of chronic small vessel ischemic disease. 3. No dural venous sinus thrombosis. 4. Mild paranasal sinus opacification, as described. Brief Hospital Course: [MASKED] is a [MASKED] right-handed woman with past medical history significant for Crohn's disease who presents after 2 events concerning for seizures. She was started on cvEEG and one electrographic seizure was captured on EEG overnight. She was also noted to have a left orbital frontal hypodensity on her CT scan. She was started on seizure prophylaxis with 1000mg of Keppra BID. She underwent a MRI/MRV to better characterize the left sided frontal hypodensity in addition to ruling out other possible focal pathology including a sinus venous thrombosis -which she would be at increased risk for given her Crohn's disease. MRI/MRV showed dural based enhancement and edema of the left straight/orbital gyri concerning for infectious process. ENT and neurosurgery were consulted. ENT exam did not reveal any abnormalities. The decision was made to repeat her imaging in 2 weeks before we proceeding with a biopsy. Of note, the patient was noted to have a cystic lesion in her kidney which should be followed up with ultrasound in [MASKED] year. She was also noted to have a PFO, pulmonary hypertension and 2 pulmonary aneurysms which should be addressed in pulmonary and cardiology clinic (we were unable to arrange these follow ups do to the holiday weekend). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. diclofenac sodium 1 % topical BID:PRN 3. Fluticasone Propionate NASAL 1 SPRY NU BID 4. FoLIC Acid 1 mg PO DAILY 5. Hydrochlorothiazide 25 mg PO DAILY 6. lidocaine 5 % topical BID:PRN 7. Methotrexate 15 mg SC 1X/WEEK ([MASKED]) (0.6ml SC once weekly by visiting nurse) 8. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain - Moderate 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. TraMADol 50 mg PO TID:PRN Pain - Moderate 11. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild 12. Calcium Carbonate 500 mg PO DAILY:PRN heartburn 13. Cetirizine 10 mg PO DAILY 14. Glycerin Supps 1 SUPP PR PRN constipation 15. Lactaid (lactase) 3,000 unit oral DAILY:PRN 16. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.acidophilus-Bif. animalis;<br>L.rhamn [MASKED] acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 15 billion cell oral DAILY Discharge Medications: 1. LevETIRAcetam 1000 mg PO BID RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 2. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild 3. amLODIPine 10 mg PO DAILY 4. Calcium Carbonate 500 mg PO DAILY:PRN heartburn 5. Cetirizine 10 mg PO DAILY 6. diclofenac sodium 1 apl topical BID:PRN rash 7. Fluticasone Propionate NASAL 1 SPRY NU BID 8. FoLIC Acid 1 mg PO DAILY 9. Glycerin Supps 1 SUPP PR PRN constipation 10. Hydrochlorothiazide 25 mg PO DAILY 11. Lactaid (lactase) 3,000 unit oral DAILY:PRN 12. lidocaine 5 % topical BID:PRN 13. Methotrexate 15 mg SC 1X/WEEK ([MASKED]) (0.6ml SC once weekly by visiting nurse) 14. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain - Moderate 15. Polyethylene Glycol 17 g PO DAILY:PRN constipation 16. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.acidophilus-Bif. animalis;<br>L.rhamn [MASKED] acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 15 billion cell oral DAILY 17. TraMADol 50 mg PO TID:PRN Pain - Moderate Discharge Disposition: Home Discharge Diagnosis: Seizures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED] were admitted to [MASKED] for evaluation of episodes that were concerning for seizures. [MASKED] were placed on cvEEG overnight and we captured an electrographic seizure. [MASKED] were started on keppra 1000 mg twice a day. [MASKED] also underwent MRI/MRV of your brain and it showed and area of inflammation in an area of your brain which was likely the cause of your seizures. Please discuss with your primary care doctor the need to set up pulmonary and cardiology follow up appointments Please continue to take your medications as described. [MASKED] have follow up appointments scheduled as below. It was a pleasure taking care of [MASKED]. Best, Your [MASKED] Team! Followup Instructions: [MASKED]
|
[] |
[
"I10",
"E119"
] |
[
"G40802: Other epilepsy, not intractable, without status epilepticus",
"I281: Aneurysm of pulmonary artery",
"I272: Other secondary pulmonary hypertension",
"K5090: Crohn's disease, unspecified, without complications",
"Q211: Atrial septal defect",
"N281: Cyst of kidney, acquired",
"I10: Essential (primary) hypertension",
"E119: Type 2 diabetes mellitus without complications"
] |
10,027,957
| 29,592,503
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Pepcid / Sulfasalazine / metronidazole / azathioprine / Remicade
/ Ceftin
Attending: ___.
Chief Complaint:
Positive IgM serum lyme
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old woman with a history of Crohn's
disease on methotrexate, with recent admission to BI acute onset
left eye vision loss found to have an abnormal MRI consistent
with left perioptic neuritis which has improved and she now
returns with a positive lyme IgM.
Ms. ___ reports a history of blurred vision and pain in her
left eye which was present for the past month. She presented to
the ED three weeks ago with left eye pain and was found to have
left eye proptosis on exam. CT showed fat stranding around the
eye and she was given a diagnosis of orbital cellulitis and
started on Clindamycin which improved the blurry vision.
On ___, she awoke with vision loss in the left eye and
presented to ___ ED. Initial neurologic exam showed L eye
proptosis and APD with a loss of vision in the right hemifield
of
the left eye. She then underwent MRI brain and orbits which
showed diffuse enhancement of the optic nerve sheath on the left
consistent with left perioptic neuritis. Neurology was consulted
who recommended ID involvement. She was treated initially with
Vancomycin and Cipro and then narrowed to Augmentin. She also
began Prednisone 60mg daily on ___. She reports improvement
in her vision since starting Prednisone.
She followed up with Dr. ___ in neuro-ophthalmology most
recently in clinic on ___. Visual acuity was documented
initially as only to hand movements in the left eye and then
___ after steroids. Etiology was thought to be secondary an
underlying autoimmune etiology, though work-up thus far has been
negative.
She had routine follow-up with her PCP, who sent off lyme which
turned out to be positive on ___. She was referred back to the
ED to be worked up for possible CNS lyme.
On my visit, in the past week since she has been discharged, she
states that her vision is now back to baseline. Her pain with
extraocular movements has resolved. She denies headache. She
did note that 2 days prior she had blurry vision for about 1
hour
but then improved to baseline. She states her plan for
prednisone and antibiotics were extended for an additional 3
weeks. She is very concerned about how she may have obtained
lying. She denies exposure to wounds or tick bites. She denies
rashes. She is wondering whether her cat was the reason for her
exposure but her cat is a house cat. Since discharge her only
complaint is her chronic knee and ankle pain which she has
previously attributed to Crohn's.
Of note, she was admitted to the neurology service in ___ with events concerning for seizure and was found to have:
left frontal seizures with secondary generalization, left
frontal
FLAIR hyperintensity, anterior skullbase dural enhancement,
discontinuity of the ethmoid plate on the left, no clear sinus
mass, all new from ___ MRI. LP was notable for 6 wbc,
protein 50, normal glucose. Etiology was unknown and given her
clinical stability, patient deferred biopsy. She was treated
with
Keppra 1g BID for her seizures and they have been well
controlled
since then.
ROS notable for chronic joint pains, but no tick bites or
rashes.
She does note indigestion that improved with baking soda as well
as initial nausea when taking prednisone.
Past Medical History:
(per chart, confirmed with pt):
CROHN'S DISEASE currently on methotrexate every other week
-h/o Remicade infusion reaction
--hospitalized ___, Rx cyclosporine and steroids
ALLERGIC RHINITIS
Occ bronchitis
HYPERTENSION
diet controlled diabetes
LACTOSE INTOLERANCE on lactate
POSITIVE PPD, treated with INH x 6 months and ? rifaximin for 9
m in ___, no longer on tx
ARTHRITIS knees, ankle and L shoulder, currently receiving ___
hypertension
Hx iron def anemia on folic acid x2-3, has not yet gotten iron
infusion
-HAs on tylenol
Social History:
___
Family History:
(per chart, confirmed with pt and updated):
-No family history of Crohn's.
-HTN
-breast CA
Physical Exam:
Admission Physical Exam:
Vitals: T: 99.1 P: 87 R: 16 BP: 137/80 SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits.
Pulmonary: CTABL. No R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, +BS, no masses or organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Able to follow both midline and
appendicular commands. Pt was able to register 3 objects and
recall ___ at 5 minutes. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: Left eye proptosis. PERRL 3 to 2mm and brisk.
EOMI without nystagmus. VFF to confrontation. No red
desaturation. Unable to visualize fundi bilaterally.
V: Facial sensation intact to light touch.
VII: L eye proptosis. No facial droop, facial musculature
symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
Discharge Physical Exam:
Vitals: T: 97.9 P: 82 R: ___ BP: 147-161/83 SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits.
Pulmonary: CTABL. No R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, +BS, no masses or organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Able to follow both midline and
appendicular commands. Pt was able to register 3 objects and
recall ___ at 5 minutes. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: Left eye proptosis. PERRL 3 to 2mm and brisk.
EOMI without nystagmus. VFF to confrontation. No red
desaturation. Unable to visualize fundi bilaterally.
V: Facial sensation intact to light touch.
VII: L eye proptosis. No facial droop, facial musculature
symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
Pertinent Results:
___ 12:35PM BLOOD WBC-14.5* RBC-3.38* Hgb-8.7* Hct-28.2*
MCV-83 MCH-25.7* MCHC-30.9* RDW-17.4* RDWSD-52.9* Plt ___
___ 08:00AM BLOOD WBC-19.3* RBC-3.29* Hgb-8.3* Hct-27.4*
MCV-83 MCH-25.2* MCHC-30.3* RDW-17.3* RDWSD-52.1* Plt ___
___ 12:35PM BLOOD Neuts-91.7* Lymphs-6.4* Monos-1.0*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-13.31* AbsLymp-0.93*
AbsMono-0.14* AbsEos-0.00* AbsBaso-0.01
___ 12:35PM BLOOD ___ PTT-23.6* ___
___ 05:25AM BLOOD ___ PTT-22.0* ___
___ 12:35PM BLOOD Glucose-160* UreaN-17 Creat-0.8 Na-142
K-4.2 Cl-106 HCO3-23 AnGap-17
___ 08:00AM BLOOD Glucose-82 UreaN-12 Creat-0.8 Na-145
K-3.8 Cl-107 HCO3-19* AnGap-23*
___ 12:35PM BLOOD ALT-16 AST-13 AlkPhos-78 TotBili-0.2
___ 12:35PM BLOOD Albumin-4.2 Calcium-8.8 Phos-3.5 Mg-2.0
___ 08:00AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.9
___ 12:15PM URINE Color-Straw Appear-Clear Sp ___
___ 12:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 09:08AM CEREBROSPINAL FLUID (CSF) TNC-3 RBC-5 Polys-4
___ ___ 09:08AM CEREBROSPINAL FLUID (CSF) TotProt-33 Glucose-71
___ 09:08AM CEREBROSPINAL FLUID (CSF) BORRELIA BURGDORFERI
ANTIBODY INDEX FOR CNS INFECTION-PND
___ 09:08AM CEREBROSPINAL FLUID (CSF) ANGIOTENSIN 1
CONVERTING ENZYME-PND
___ 09:08AM CEREBROSPINAL FLUID (CSF) CSF HOLD-Test
___ 9:08 am CSF;SPINAL FLUID Source: LP #3.
CSF cytology: pending
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
___ 5:25 am Blood (LYME)
Lyme IgG (Pending):
Lyme IgM (Pending):
___ 12:35 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 12:15 pm URINE Site: CLEAN CATCH
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL
MRI brain and orbits:
1. Interval decrease in left perioptic enhancement and
retro-orbital fat
stranding suggestive of perineuritis.
2. Stable to decreased enhancement along the interhemispheric
fissure and the
inferior left orbital gyrus.
3. No evidence of infarction or new abnormal enhancement.
CXR: neg
Brief Hospital Course:
Ms. ___ is a ___ year-old woman with a history of Crohn's
disease on methotrexate, with left perioptic neuritis and
leptomeningial enhcancement seen on prior neuroimaging that
responded to steroids/Augmentin (she had refused biopsy in past
admissions). Symptomatically, she is much improved since
starting the steroids and her visual acuity is ___ bilaterally
with residual left eye proptosis only.
She was admitted to Neurology as her serum IgM came back
positive for Lyme. Unclear if perioptic neuritis related to lyme
or due to other pathology such as inflammatory vs neoplastic.
Completed LP on ___ and sent csf for further testing such as
csf Lyme/cytology/ACE. CSF studies notable for notable for 3
whites, 5 rbc, normal protein and glucose. Cytology pending
serum and CSF/repeat Serum lyme pending at time of discharge.
An MRI brain/orbits showed no interval change. We also
recommended biopsy to further evaluate and assess her underlying
brain lesions, however patient declined. Patient wanted to be
discharged and stated she will return if she requires IV
antibiotics.
# Neurology:
1) Perioptic neuritis
- Lumbar Puncture performed ___: Cell Count wbc 3 rbc 3,
Protein nl, Glucose nl, ___, Lyme, cytology
- Continued current antibiotics (Augmentin)
- continued Prednisone 60mg daily x 3 weeks
2) Lyme IgM positive
- if csf lyme positive then start IV ceft (will need
desensitization, and PICC line)
- if repeat serum lyme positive then start doxycycline
- ID Consulted, f/u outpatient
3) Seizures:
- continued Keppra
# CV: HTN
- continued Diltiazam
# Pulm:
- continued albuterol prn
# GI: Crohns
- held Methotrexate as there is an interaction with
Augmentin
# Heme: anemia ___ menorrhagia
- H/H trended
- continued Medroxyprogesterone
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze
2. Diltiazem Extended-Release 240 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. LevETIRAcetam 1000 mg PO BID
5. Lidocaine 5% Ointment 1 Appl TP BID
6. MedroxyPROGESTERone Acetate 10 mg PO BID
7. Methotrexate 15 mg SC 1X/WEEK (WE)
8. Polyethylene Glycol 17 g PO DAILY:PRN contstipation
9. PredniSONE 60 mg PO DAILY
10. azelastine 0.15 % (205.5 mcg) nasal BID
11. Beano (alpha-d-galactosidase) 150 unit oral ASDIR
12. Calcium Carbonate 300 mg PO PRN indigestion
13. Cetirizine 10 mg PO DAILY
14. DiphenhydrAMINE 25 mg PO QHS:PRN allergy
15. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain -
Severe
16. TraMADol 50 mg PO TID:PRN Pain - Severe
17. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
18. Diclofenac Sodium ___ ___ sodium) 1 % topical Q6H:PRN
pain
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 21 Days
3. Atovaquone Suspension 1500 mg PO DAILY
4. azelastine 0.15 % (205.5 mcg) nasal BID
5. Beano (alpha-d-galactosidase) 150 unit oral ASDIR
6. Calcium Carbonate 300 mg PO PRN indigestion
7. Cetirizine 10 mg PO DAILY
8. Diclofenac Sodium ___ ___ sodium) 1 % topical Q6H:PRN
pain
9. Diltiazem Extended-Release 240 mg PO DAILY
10. DiphenhydrAMINE 25 mg PO QHS:PRN allergy
11. FoLIC Acid 1 mg PO DAILY
12. LevETIRAcetam 1000 mg PO BID
13. Lidocaine 5% Ointment 1 Appl TP BID
14. MedroxyPROGESTERone Acetate 10 mg PO BID
15. Methotrexate 15 mg SC 1X/WEEK (WE)
16. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain
- Severe
17. Polyethylene Glycol 17 g PO DAILY:PRN contstipation
18. PredniSONE 60 mg PO DAILY
19. TraMADol 50 mg PO TID:PRN Pain - Severe
Discharge Disposition:
Home
Discharge Diagnosis:
Inflammatory process
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with a positive lyme blood test.
Given concern that this may be related to you underlying unknown
neurologic diagnosis, a lumbar puncture was recommended to
evaluate for lyme in the nervous system. Additionally, a lumbar
puncture was recommended to further work-up the lesions in your
brain, specifically to look for evidence of cancer cells,
results of which are pending, but so far the preliminary tests
are benign.
You were seen by the ID doctors, and your lyme testing in the
blood was repeated and lyme was tested in your spinal fluid and
the results are pending. If the spinal fluid returns positive,
we will have you come back to the hospital to start IV
antibiotics.
You should continue on Prednisone and Augmentin to treat the
inflammation around the optic nerve and follow-up with ophtho
and neurology. Please be sure to return to the hospital should
we find positive test results.
It was a pleasure taking care of you,
Your ___ Neurologists
Followup Instructions:
___
|
[
"R7889",
"H0520",
"K5090",
"I10",
"E119",
"D500",
"H468",
"D509",
"J309",
"E739",
"M170",
"M19072",
"M19012",
"G40909",
"N920"
] |
Allergies: Pepcid / Sulfasalazine / metronidazole / azathioprine / Remicade / Ceftin Chief Complaint: Positive IgM serum lyme Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year-old woman with a history of Crohn's disease on methotrexate, with recent admission to BI acute onset left eye vision loss found to have an abnormal MRI consistent with left perioptic neuritis which has improved and she now returns with a positive lyme IgM. Ms. [MASKED] reports a history of blurred vision and pain in her left eye which was present for the past month. She presented to the ED three weeks ago with left eye pain and was found to have left eye proptosis on exam. CT showed fat stranding around the eye and she was given a diagnosis of orbital cellulitis and started on Clindamycin which improved the blurry vision. On [MASKED], she awoke with vision loss in the left eye and presented to [MASKED] ED. Initial neurologic exam showed L eye proptosis and APD with a loss of vision in the right hemifield of the left eye. She then underwent MRI brain and orbits which showed diffuse enhancement of the optic nerve sheath on the left consistent with left perioptic neuritis. Neurology was consulted who recommended ID involvement. She was treated initially with Vancomycin and Cipro and then narrowed to Augmentin. She also began Prednisone 60mg daily on [MASKED]. She reports improvement in her vision since starting Prednisone. She followed up with Dr. [MASKED] in neuro-ophthalmology most recently in clinic on [MASKED]. Visual acuity was documented initially as only to hand movements in the left eye and then [MASKED] after steroids. Etiology was thought to be secondary an underlying autoimmune etiology, though work-up thus far has been negative. She had routine follow-up with her PCP, who sent off lyme which turned out to be positive on [MASKED]. She was referred back to the ED to be worked up for possible CNS lyme. On my visit, in the past week since she has been discharged, she states that her vision is now back to baseline. Her pain with extraocular movements has resolved. She denies headache. She did note that 2 days prior she had blurry vision for about 1 hour but then improved to baseline. She states her plan for prednisone and antibiotics were extended for an additional 3 weeks. She is very concerned about how she may have obtained lying. She denies exposure to wounds or tick bites. She denies rashes. She is wondering whether her cat was the reason for her exposure but her cat is a house cat. Since discharge her only complaint is her chronic knee and ankle pain which she has previously attributed to Crohn's. Of note, she was admitted to the neurology service in [MASKED] with events concerning for seizure and was found to have: left frontal seizures with secondary generalization, left frontal FLAIR hyperintensity, anterior skullbase dural enhancement, discontinuity of the ethmoid plate on the left, no clear sinus mass, all new from [MASKED] MRI. LP was notable for 6 wbc, protein 50, normal glucose. Etiology was unknown and given her clinical stability, patient deferred biopsy. She was treated with Keppra 1g BID for her seizures and they have been well controlled since then. ROS notable for chronic joint pains, but no tick bites or rashes. She does note indigestion that improved with baking soda as well as initial nausea when taking prednisone. Past Medical History: (per chart, confirmed with pt): CROHN'S DISEASE currently on methotrexate every other week -h/o Remicade infusion reaction --hospitalized [MASKED], Rx cyclosporine and steroids ALLERGIC RHINITIS Occ bronchitis HYPERTENSION diet controlled diabetes LACTOSE INTOLERANCE on lactate POSITIVE PPD, treated with INH x 6 months and ? rifaximin for 9 m in [MASKED], no longer on tx ARTHRITIS knees, ankle and L shoulder, currently receiving [MASKED] hypertension Hx iron def anemia on folic acid x2-3, has not yet gotten iron infusion -HAs on tylenol Social History: [MASKED] Family History: (per chart, confirmed with pt and updated): -No family history of Crohn's. -HTN -breast CA Physical Exam: Admission Physical Exam: Vitals: T: 99.1 P: 87 R: 16 BP: 137/80 SaO2: 100% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits. Pulmonary: CTABL. No R/R/W Cardiac: RRR, nl. S1S2, no M/R/G Abdomen: soft, NT/ND, +BS, no masses or organomegaly noted. Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall [MASKED] at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: Left eye proptosis. PERRL 3 to 2mm and brisk. EOMI without nystagmus. VFF to confrontation. No red desaturation. Unable to visualize fundi bilaterally. V: Facial sensation intact to light touch. VII: L eye proptosis. No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [MASKED] L 5 [MASKED] [MASKED] 5 5 5 5 5 5 5 R 5 [MASKED] [MASKED] 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri [MASKED] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Romberg absent. Discharge Physical Exam: Vitals: T: 97.9 P: 82 R: [MASKED] BP: 147-161/83 SaO2: 100% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits. Pulmonary: CTABL. No R/R/W Cardiac: RRR, nl. S1S2, no M/R/G Abdomen: soft, NT/ND, +BS, no masses or organomegaly noted. Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall [MASKED] at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: Left eye proptosis. PERRL 3 to 2mm and brisk. EOMI without nystagmus. VFF to confrontation. No red desaturation. Unable to visualize fundi bilaterally. V: Facial sensation intact to light touch. VII: L eye proptosis. No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [MASKED] L 5 [MASKED] [MASKED] 5 5 5 5 5 5 5 R 5 [MASKED] [MASKED] 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri [MASKED] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: deferred Pertinent Results: [MASKED] 12:35PM BLOOD WBC-14.5* RBC-3.38* Hgb-8.7* Hct-28.2* MCV-83 MCH-25.7* MCHC-30.9* RDW-17.4* RDWSD-52.9* Plt [MASKED] [MASKED] 08:00AM BLOOD WBC-19.3* RBC-3.29* Hgb-8.3* Hct-27.4* MCV-83 MCH-25.2* MCHC-30.3* RDW-17.3* RDWSD-52.1* Plt [MASKED] [MASKED] 12:35PM BLOOD Neuts-91.7* Lymphs-6.4* Monos-1.0* Eos-0.0* Baso-0.1 Im [MASKED] AbsNeut-13.31* AbsLymp-0.93* AbsMono-0.14* AbsEos-0.00* AbsBaso-0.01 [MASKED] 12:35PM BLOOD [MASKED] PTT-23.6* [MASKED] [MASKED] 05:25AM BLOOD [MASKED] PTT-22.0* [MASKED] [MASKED] 12:35PM BLOOD Glucose-160* UreaN-17 Creat-0.8 Na-142 K-4.2 Cl-106 HCO3-23 AnGap-17 [MASKED] 08:00AM BLOOD Glucose-82 UreaN-12 Creat-0.8 Na-145 K-3.8 Cl-107 HCO3-19* AnGap-23* [MASKED] 12:35PM BLOOD ALT-16 AST-13 AlkPhos-78 TotBili-0.2 [MASKED] 12:35PM BLOOD Albumin-4.2 Calcium-8.8 Phos-3.5 Mg-2.0 [MASKED] 08:00AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.9 [MASKED] 12:15PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 12:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] 09:08AM CEREBROSPINAL FLUID (CSF) TNC-3 RBC-5 Polys-4 [MASKED] [MASKED] 09:08AM CEREBROSPINAL FLUID (CSF) TotProt-33 Glucose-71 [MASKED] 09:08AM CEREBROSPINAL FLUID (CSF) BORRELIA BURGDORFERI ANTIBODY INDEX FOR CNS INFECTION-PND [MASKED] 09:08AM CEREBROSPINAL FLUID (CSF) ANGIOTENSIN 1 CONVERTING ENZYME-PND [MASKED] 09:08AM CEREBROSPINAL FLUID (CSF) CSF HOLD-Test [MASKED] 9:08 am CSF;SPINAL FLUID Source: LP #3. CSF cytology: pending GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH. [MASKED] 5:25 am Blood (LYME) Lyme IgG (Pending): Lyme IgM (Pending): [MASKED] 12:35 pm BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] 12:15 pm URINE Site: CLEAN CATCH **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL MRI brain and orbits: 1. Interval decrease in left perioptic enhancement and retro-orbital fat stranding suggestive of perineuritis. 2. Stable to decreased enhancement along the interhemispheric fissure and the inferior left orbital gyrus. 3. No evidence of infarction or new abnormal enhancement. CXR: neg Brief Hospital Course: Ms. [MASKED] is a [MASKED] year-old woman with a history of Crohn's disease on methotrexate, with left perioptic neuritis and leptomeningial enhcancement seen on prior neuroimaging that responded to steroids/Augmentin (she had refused biopsy in past admissions). Symptomatically, she is much improved since starting the steroids and her visual acuity is [MASKED] bilaterally with residual left eye proptosis only. She was admitted to Neurology as her serum IgM came back positive for Lyme. Unclear if perioptic neuritis related to lyme or due to other pathology such as inflammatory vs neoplastic. Completed LP on [MASKED] and sent csf for further testing such as csf Lyme/cytology/ACE. CSF studies notable for notable for 3 whites, 5 rbc, normal protein and glucose. Cytology pending serum and CSF/repeat Serum lyme pending at time of discharge. An MRI brain/orbits showed no interval change. We also recommended biopsy to further evaluate and assess her underlying brain lesions, however patient declined. Patient wanted to be discharged and stated she will return if she requires IV antibiotics. # Neurology: 1) Perioptic neuritis - Lumbar Puncture performed [MASKED]: Cell Count wbc 3 rbc 3, Protein nl, Glucose nl, [MASKED], Lyme, cytology - Continued current antibiotics (Augmentin) - continued Prednisone 60mg daily x 3 weeks 2) Lyme IgM positive - if csf lyme positive then start IV ceft (will need desensitization, and PICC line) - if repeat serum lyme positive then start doxycycline - ID Consulted, f/u outpatient 3) Seizures: - continued Keppra # CV: HTN - continued Diltiazam # Pulm: - continued albuterol prn # GI: Crohns - held Methotrexate as there is an interaction with Augmentin # Heme: anemia [MASKED] menorrhagia - H/H trended - continued Medroxyprogesterone Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze 2. Diltiazem Extended-Release 240 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. LevETIRAcetam 1000 mg PO BID 5. Lidocaine 5% Ointment 1 Appl TP BID 6. MedroxyPROGESTERone Acetate 10 mg PO BID 7. Methotrexate 15 mg SC 1X/WEEK (WE) 8. Polyethylene Glycol 17 g PO DAILY:PRN contstipation 9. PredniSONE 60 mg PO DAILY 10. azelastine 0.15 % (205.5 mcg) nasal BID 11. Beano (alpha-d-galactosidase) 150 unit oral ASDIR 12. Calcium Carbonate 300 mg PO PRN indigestion 13. Cetirizine 10 mg PO DAILY 14. DiphenhydrAMINE 25 mg PO QHS:PRN allergy 15. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain - Severe 16. TraMADol 50 mg PO TID:PRN Pain - Severe 17. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H 18. Diclofenac Sodium [MASKED] [MASKED] sodium) 1 % topical Q6H:PRN pain Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze 2. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H Duration: 21 Days 3. Atovaquone Suspension 1500 mg PO DAILY 4. azelastine 0.15 % (205.5 mcg) nasal BID 5. Beano (alpha-d-galactosidase) 150 unit oral ASDIR 6. Calcium Carbonate 300 mg PO PRN indigestion 7. Cetirizine 10 mg PO DAILY 8. Diclofenac Sodium [MASKED] [MASKED] sodium) 1 % topical Q6H:PRN pain 9. Diltiazem Extended-Release 240 mg PO DAILY 10. DiphenhydrAMINE 25 mg PO QHS:PRN allergy 11. FoLIC Acid 1 mg PO DAILY 12. LevETIRAcetam 1000 mg PO BID 13. Lidocaine 5% Ointment 1 Appl TP BID 14. MedroxyPROGESTERone Acetate 10 mg PO BID 15. Methotrexate 15 mg SC 1X/WEEK (WE) 16. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain - Severe 17. Polyethylene Glycol 17 g PO DAILY:PRN contstipation 18. PredniSONE 60 mg PO DAILY 19. TraMADol 50 mg PO TID:PRN Pain - Severe Discharge Disposition: Home Discharge Diagnosis: Inflammatory process Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] with a positive lyme blood test. Given concern that this may be related to you underlying unknown neurologic diagnosis, a lumbar puncture was recommended to evaluate for lyme in the nervous system. Additionally, a lumbar puncture was recommended to further work-up the lesions in your brain, specifically to look for evidence of cancer cells, results of which are pending, but so far the preliminary tests are benign. You were seen by the ID doctors, and your lyme testing in the blood was repeated and lyme was tested in your spinal fluid and the results are pending. If the spinal fluid returns positive, we will have you come back to the hospital to start IV antibiotics. You should continue on Prednisone and Augmentin to treat the inflammation around the optic nerve and follow-up with ophtho and neurology. Please be sure to return to the hospital should we find positive test results. It was a pleasure taking care of you, Your [MASKED] Neurologists Followup Instructions: [MASKED]
|
[] |
[
"I10",
"E119",
"D509"
] |
[
"R7889: Finding of other specified substances, not normally found in blood",
"H0520: Unspecified exophthalmos",
"K5090: Crohn's disease, unspecified, without complications",
"I10: Essential (primary) hypertension",
"E119: Type 2 diabetes mellitus without complications",
"D500: Iron deficiency anemia secondary to blood loss (chronic)",
"H468: Other optic neuritis",
"D509: Iron deficiency anemia, unspecified",
"J309: Allergic rhinitis, unspecified",
"E739: Lactose intolerance, unspecified",
"M170: Bilateral primary osteoarthritis of knee",
"M19072: Primary osteoarthritis, left ankle and foot",
"M19012: Primary osteoarthritis, left shoulder",
"G40909: Epilepsy, unspecified, not intractable, without status epilepticus",
"N920: Excessive and frequent menstruation with regular cycle"
] |
10,028,125
| 29,060,034
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
adhesive tape / Namenda
Attending: ___.
Chief Complaint:
right knee pain
Major Surgical or Invasive Procedure:
___: right total knee replacement by ___, MD
History of Present Illness:
___ year old female with right knee JRA/osteoarthritis which has
failed conservative management and has elected to proceed with a
left total knee replacement on ___.
Past Medical History:
PMH: anxiety, dementia, hx of BCCA, hx of c.diff s/p stool
transplant, hypothyroid, juvenile rheumatoid arthritis,
diverticulosis, panic disorder, hx of DVT, interstitial
cystitis
Pshx: L THA (___) hysterectomy, cataract surgery, excision of
BCCA on nose, cholectomy
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:
___ 03:00PM BLOOD WBC-10.0 RBC-2.52* Hgb-8.0* Hct-23.6*
MCV-94 MCH-31.7 MCHC-33.9 RDW-13.1 RDWSD-45.1 Plt ___
___ 06:40AM BLOOD WBC-10.4* RBC-2.14* Hgb-6.7* Hct-20.3*
MCV-95 MCH-31.3 MCHC-33.0 RDW-12.7 RDWSD-43.7 Plt ___
___ 06:30AM BLOOD WBC-9.3 RBC-2.45* Hgb-7.6* Hct-23.2*
MCV-95 MCH-31.0 MCHC-32.8 RDW-12.6 RDWSD-43.8 Plt ___
___ 06:20AM BLOOD WBC-8.9 RBC-3.06* Hgb-9.4* Hct-29.7*
MCV-97 MCH-30.7 MCHC-31.6* RDW-12.3 RDWSD-43.8 Plt ___
___ 03:00PM BLOOD Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-108* UreaN-12 Creat-0.9 Na-138
K-3.9 Cl-103 HCO3-23 AnGap-12
___ 06:30AM BLOOD Glucose-102* UreaN-14 Creat-1.1 Na-137
K-4.2 Cl-100 HCO3-24 AnGap-13
___ 06:20AM BLOOD Glucose-128* UreaN-16 Creat-1.0 Na-137
K-4.7 Cl-101 HCO3-25 AnGap-11
___ 06:30AM BLOOD Mg-2.4
___ 06:20AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.6
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:
POD #1, patient was triggered for hypotension with SBP 120s down
to ___ while working with ___. Patient reported some dizziness
with nausea and emesis. She was administered IV Zofran for
nausea with improved relief. Patient's BP improved to 140s/60s
when reclined back in chair. She was also administered 500ml
bolus of IV fluids and her magnesium (1.6) was repleted.
Geriatrics was also consulted for co-management of care, which
they recommended switching Cholestyramine to prn dosing, given
that patient is on Colace/Senna bowel regimen to prevent
constipation while on narcotics.
POD #2, magnesium level improved to 2.4.
POD#3, patient's hematocrit was 20.3. She was given a unit of
blood. Her post-transfusion hematocrit was stable and she was
cleared for discharge home.
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:
1. Atenolol 50 mg PO DAILY
2. Cholestyramine 4 gm PO DAILY
3. Donepezil 5 mg PO DAILY
4. econazole 1 % topical apply to top and bottom of feet, and
between toes 2x a day
5. Finasteride 1 mg PO DAILY
6. Halobetasol Propionate 0.05 % topical apply to rash twice a
day, 2 weeks per month
7. Hydroxychloroquine Sulfate 200 mg PO DAILY
8. LORazepam 0.5 mg PO Q6H:PRN anxiety
9. Losartan Potassium 100 mg PO DAILY
10. Sertraline 50 mg PO TAKE 1.5 TABLETS BY MOUTH EVERY MORNING
11. Acetaminophen 650 mg PO ___ X A DAY AS NEEDED pain
12. Vitamin D Dose is Unknown PO DAILY
13. Advil ___ (ibuprofen-diphenhydramine cit) 200-38 mg oral 1
tablet by mouth as needed
14. Lactobacillus acidophilus 0.5 mg (100 million cell) oral
DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Enoxaparin Sodium 40 mg SC DAILY
3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
do not drink alcohol or drive while taking med
4. Senna 8.6 mg PO BID
5. Acetaminophen 1000 mg PO Q8H
6. Cholestyramine 4 gm PO DAILY:PRN diarrhea
7. Atenolol 50 mg PO DAILY
8. Donepezil 5 mg PO DAILY
9. econazole 1 % topical apply to top and bottom of feet, and
between toes 2x a day
10. Finasteride 1 mg PO DAILY
11. Halobetasol Propionate 0.05 % topical apply to rash twice a
day, 2 weeks per month
12. Lactobacillus acidophilus 0.5 mg (100 million cell) oral
DAILY
13. LORazepam 0.5 mg PO Q6H:PRN anxiety
14. Losartan Potassium 100 mg PO DAILY
15. Sertraline 50 mg PO TAKE 1.5 TABLETS BY MOUTH EVERY MORNING
16. HELD- Advil ___ (ibuprofen-diphenhydramine cit) 200-38 mg
oral 1 tablet by mouth as needed This medication was held. Do
not restart Advil ___ until you complete your course of Lovenox
injections
17. HELD- Hydroxychloroquine Sulfate 200 mg PO DAILY This
medication was held. Do not restart Hydroxychloroquine Sulfate
until at least 2 weeks post-op and requires clearance by your
surgeon
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
right knee juvenile rheumatoid arthritis/osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. You may wrap the knee with an ace bandage
for added compression. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc).
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 RLE
ROMAT
Mobilize frequently
wean from assistive devices when appropriate
Treatments Frequency:
daily dressing changes as needed for drainage
inspect incision daily for erythema/drainage
ice and elevation of operative limb
remove staples and replace with steri-strips at follow up visit
in clinic.
Followup Instructions:
___
|
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Allergies: adhesive tape / Namenda Chief Complaint: right knee pain Major Surgical or Invasive Procedure: [MASKED]: right total knee replacement by [MASKED], MD History of Present Illness: [MASKED] year old female with right knee JRA/osteoarthritis which has failed conservative management and has elected to proceed with a left total knee replacement on [MASKED]. Past Medical History: PMH: anxiety, dementia, hx of BCCA, hx of c.diff s/p stool transplant, hypothyroid, juvenile rheumatoid arthritis, diverticulosis, panic disorder, hx of DVT, interstitial cystitis Pshx: L THA ([MASKED]) hysterectomy, cataract surgery, excision of BCCA on nose, cholectomy 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] 03:00PM BLOOD WBC-10.0 RBC-2.52* Hgb-8.0* Hct-23.6* MCV-94 MCH-31.7 MCHC-33.9 RDW-13.1 RDWSD-45.1 Plt [MASKED] [MASKED] 06:40AM BLOOD WBC-10.4* RBC-2.14* Hgb-6.7* Hct-20.3* MCV-95 MCH-31.3 MCHC-33.0 RDW-12.7 RDWSD-43.7 Plt [MASKED] [MASKED] 06:30AM BLOOD WBC-9.3 RBC-2.45* Hgb-7.6* Hct-23.2* MCV-95 MCH-31.0 MCHC-32.8 RDW-12.6 RDWSD-43.8 Plt [MASKED] [MASKED] 06:20AM BLOOD WBC-8.9 RBC-3.06* Hgb-9.4* Hct-29.7* MCV-97 MCH-30.7 MCHC-31.6* RDW-12.3 RDWSD-43.8 Plt [MASKED] [MASKED] 03:00PM BLOOD Plt [MASKED] [MASKED] 06:40AM BLOOD Plt [MASKED] [MASKED] 06:30AM BLOOD Plt [MASKED] [MASKED] 06:20AM BLOOD Plt [MASKED] [MASKED] 06:40AM BLOOD Glucose-108* UreaN-12 Creat-0.9 Na-138 K-3.9 Cl-103 HCO3-23 AnGap-12 [MASKED] 06:30AM BLOOD Glucose-102* UreaN-14 Creat-1.1 Na-137 K-4.2 Cl-100 HCO3-24 AnGap-13 [MASKED] 06:20AM BLOOD Glucose-128* UreaN-16 Creat-1.0 Na-137 K-4.7 Cl-101 HCO3-25 AnGap-11 [MASKED] 06:30AM BLOOD Mg-2.4 [MASKED] 06:20AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.6 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: POD #1, patient was triggered for hypotension with SBP 120s down to [MASKED] while working with [MASKED]. Patient reported some dizziness with nausea and emesis. She was administered IV Zofran for nausea with improved relief. Patient's BP improved to 140s/60s when reclined back in chair. She was also administered 500ml bolus of IV fluids and her magnesium (1.6) was repleted. Geriatrics was also consulted for co-management of care, which they recommended switching Cholestyramine to prn dosing, given that patient is on Colace/Senna bowel regimen to prevent constipation while on narcotics. POD #2, magnesium level improved to 2.4. POD#3, patient's hematocrit was 20.3. She was given a unit of blood. Her post-transfusion hematocrit was stable and she was cleared for discharge home. 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: 1. Atenolol 50 mg PO DAILY 2. Cholestyramine 4 gm PO DAILY 3. Donepezil 5 mg PO DAILY 4. econazole 1 % topical apply to top and bottom of feet, and between toes 2x a day 5. Finasteride 1 mg PO DAILY 6. Halobetasol Propionate 0.05 % topical apply to rash twice a day, 2 weeks per month 7. Hydroxychloroquine Sulfate 200 mg PO DAILY 8. LORazepam 0.5 mg PO Q6H:PRN anxiety 9. Losartan Potassium 100 mg PO DAILY 10. Sertraline 50 mg PO TAKE 1.5 TABLETS BY MOUTH EVERY MORNING 11. Acetaminophen 650 mg PO [MASKED] X A DAY AS NEEDED pain 12. Vitamin D Dose is Unknown PO DAILY 13. Advil [MASKED] (ibuprofen-diphenhydramine cit) 200-38 mg oral 1 tablet by mouth as needed 14. Lactobacillus acidophilus 0.5 mg (100 million cell) oral DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Enoxaparin Sodium 40 mg SC DAILY 3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate do not drink alcohol or drive while taking med 4. Senna 8.6 mg PO BID 5. Acetaminophen 1000 mg PO Q8H 6. Cholestyramine 4 gm PO DAILY:PRN diarrhea 7. Atenolol 50 mg PO DAILY 8. Donepezil 5 mg PO DAILY 9. econazole 1 % topical apply to top and bottom of feet, and between toes 2x a day 10. Finasteride 1 mg PO DAILY 11. Halobetasol Propionate 0.05 % topical apply to rash twice a day, 2 weeks per month 12. Lactobacillus acidophilus 0.5 mg (100 million cell) oral DAILY 13. LORazepam 0.5 mg PO Q6H:PRN anxiety 14. Losartan Potassium 100 mg PO DAILY 15. Sertraline 50 mg PO TAKE 1.5 TABLETS BY MOUTH EVERY MORNING 16. HELD- Advil [MASKED] (ibuprofen-diphenhydramine cit) 200-38 mg oral 1 tablet by mouth as needed This medication was held. Do not restart Advil [MASKED] until you complete your course of Lovenox injections 17. HELD- Hydroxychloroquine Sulfate 200 mg PO DAILY This medication was held. Do not restart Hydroxychloroquine Sulfate until at least 2 weeks post-op and requires clearance by your surgeon Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: right knee juvenile rheumatoid arthritis/osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc). 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 RLE ROMAT Mobilize frequently wean from assistive devices when appropriate Treatments Frequency: daily dressing changes as needed for drainage inspect incision daily for erythema/drainage ice and elevation of operative limb remove staples and replace with steri-strips at follow up visit in clinic. Followup Instructions: [MASKED]
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"I10: Essential (primary) hypertension",
"F329: Major depressive disorder, single episode, unspecified"
] |
10,028,480
| 21,427,885
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Indocin / Nafcillin
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old woman with a PMH of CAD, Afib, sleep
apnea, who is presenting with chest pain.
She has a history of angina for which she takes isosorbide. She
describes sudden onset sharp left chest pain without radiation,
consistent with her prior anginal symptoms, which happened at
approximately 9 ___. She took no additional medications for this.
She also experienced shortness of breath in the context of this
chest pain. She was feeling well this morning without fever,
chills, sweats, abdominal pain, or chest pain. Denies vomiting.
Chest pain is sharp, over her anterior left chest, without
radiation, and without associated diaphoresis. No exacerbating
or alleviating factors. No exercise intolerance. Per her husband
she is walking around the house comfortably.
Of note, patient was hospitalized from ___ with
chest pain and heart failure exacerbation. After an ACS rule
out, her chest pain was eventually attributed to her heart
failure. She was treated with IV Lasix. She was discharged on an
increased dose of torsemide (from 40mg QAM, 20mg QPM to 40mg
BID), and was started on Imdur 30 mg daily, Hydralazine 25 mg
TID, in addition to her home metoprolol and spironolactone.
After discharge, her Cr increased from 1.7 on discharge to 2.1.
At that time, her dose of torsemide was again decreased to 40mg
QAM, 20mg QPM.
In the ED, initial vitals were: 96.6, 68, 111/98, 18, 97% RA
- Exam notable for:
No leg swelling, mild tenderness over his soft tissue of
lateral right calf and distal thigh
- Labs notable for:
CBC: WBC 7.7, Hgb 12.9, Hct 38.3, Plt 104
Lytes:
132 / 93 / 84
--------------- 244
4.1 \ 25 \ 2.7
___: 16.2 PTT: 28.1 INR: 1.5
Trop-T: <0.01
- No imaging was done.
- Cardiology was consulted and recommended admission to ___
service.
- Patient was given:
___ 01:04 PO Aspirin 243 mg
___ 01:53 IVF NS ( 500 mL ordered)
- Vitals prior to transfer: 97.8, 62, 103/70, 18, 99% RA
Upon arrival to the floor, patient reports that she continues
to have chest pain, saying it is her typical chest pain that
comes and goes. Otherwise states that she feels tired.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
Infarct-related Systolic CHF (EF 25% ___
DM
HTN
CAD (cath at ___ in ___ showing "small vessel disease",
cardiac cath in ___ showing two vessel disease without any
intervention)
Atrial fibrillation
Gout
Non-Hodgkin's lymphoma
Multinodular Goiter
Chronic Low Back Pain
s/p hysterectomy
s/p bilateral knee replacements
s/p bilateral eye surgery
OSA on CPAP
Social History:
___
Family History:
Diabetes; Grandmother died of MI at ___. Father: MI in ___,
Mother: died before her ___ of "heart condition that was
undiagnosed"
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 97.4, HR 72, BP 95/58, RR 16, 98% RA
General: Tired appearing elderly woman, sleeping in bed lying
flat
Neck: Supple. JVP at clavicle at 30 degrees. no LAD
CV: Irregularly irregular with no murmurs appreciated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
========================
VITALS: Afebrile 100s-110s/70s ___ 18 94% room air
WEIGHT: 82.5 kg
TELEMETRY: AF/AFL ___ IVCD
General: Sitting upright and eating in NAD
Neck: mild R trapezius tension; No carotid bruit; JVP not
elevated
CV: Irregularly irregular with no murmurs appreciated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
===============
___ 12:34AM BLOOD WBC-7.7 RBC-4.43 Hgb-12.9 Hct-38.3 MCV-87
MCH-29.1 MCHC-33.7 RDW-13.4 RDWSD-42.4 Plt ___
___ 12:34AM BLOOD Neuts-65.7 ___ Monos-9.5 Eos-0.4*
Baso-0.3 Im ___ AbsNeut-5.03 AbsLymp-1.81 AbsMono-0.73
AbsEos-0.03* AbsBaso-0.02
___ 12:34AM BLOOD ___ PTT-28.1 ___
___ 07:46AM BLOOD Ret Aut-1.9 Abs Ret-0.08
___ 12:34AM BLOOD Glucose-244* UreaN-84* Creat-2.7* Na-132*
K-4.1 Cl-93* HCO3-25 AnGap-18
___ 07:46AM BLOOD TotBili-0.7
___ 12:34AM BLOOD proBNP-1437*
___ 12:34AM BLOOD cTropnT-<0.01
___ 07:46AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:46AM BLOOD Calcium-9.1 Phos-5.8* Mg-2.2
___ 07:46AM BLOOD Hapto-191
___ 03:05PM BLOOD Osmolal-313*
___ 07:46AM BLOOD Digoxin-<0.4*
___ 03:08PM URINE Color-Yellow Appear-Hazy Sp ___
___ 03:08PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 03:08PM URINE RBC-2 WBC-51* Bacteri-MANY Yeast-NONE
Epi-8
___ 03:08PM URINE CastHy-46*
___ 01:14AM URINE Hours-RANDOM Creat-81 Na-21
___ 01:14AM URINE Osmolal-336
MICRO LABS:
===========
___ BLOOD CULTURE Blood Culture, Routine-FINAL
NEGATIVE
___ BLOOD CULTURE Blood Culture, Routine-FINAL
NEGATIVE
IMAGES:
=======
CXR (___): Compared with ___, the left heart border is
less well defined, but the cardiomediastinal silhouette is
enlarged and not significantly changed. There is patchy opacity
at the left lung base, which may account for indistinctness of
the left heart border. Left hemidiaphragm remains visible.
There is minimal atelectasis at the right lung base. No overt
CHF. No gross effusion. No pneumothorax detected.
Renal US (___): Normal renal ultrasound. Specifically, no
hydronephrosis.
DISCHARGE LABS:
===============
___ 06:20AM BLOOD WBC-6.4 RBC-4.20 Hgb-12.2 Hct-37.6 MCV-90
MCH-29.0 MCHC-32.4 RDW-14.3 RDWSD-46.0 Plt ___
___ 06:35AM BLOOD ___ PTT-64.0* ___
___ 06:35AM BLOOD Glucose-194* UreaN-64* Creat-1.9* Na-135
K-4.1 Cl-98 HCO3-23 AnGap-18
___ 06:35AM BLOOD Calcium-8.9 Phos-5.2* Mg-2.2
Brief Hospital Course:
Ms. ___ is an ___ year old woman with a PMH of CAD, Afib, sleep
apnea, who is presenting with chest pain.
Her weight on admission was 2 kg less than previously and she
had a new ___ thought to be due to overdiuresis. Her troponins
were negative and EKG was reassuring. No further ischemic
work-up was performed given her age and comorbidities. Her
diuresis was held initially and restarted to torsemide 40 mg
with goal euvolemia. Her ___ improved (thought to be secondary
to overdiuresis as an outpatient). Her BP medications were
adjusted (decreased metop XL, increased hydral, held losartan
and spironolactone given ___. Given her ___, apixaban was
discontinued and she was bridged to warfarin with heparin gtt
for her atrial fibrillation. Her digoxin was discontinued given
her tenuous renal function. She was treated for an uncomplicated
UTI w/ cefpodoxime (culture was not sent).
#Chronic systolic and diastolic CHF:
TTE on ___ with LVEF 25%, mild biventricular dilation, severe
LV hypokinesis of the septum and inferior walls and mild
hypokinesis of the remaining segments, 3+ MR, mild pulmonary
HTN. BNP 1437 (less than last admission). As above, during
recent hospitalization was felt to be volume up, and torsemide
dose was increased, then subsequently decreased due to ___. She
does not appear volume overloaded on exam. CXR (___) w/
questionable LLL opacity. Discharge weight was 82.1 kg that
hospitalization and ~80 kg on admission. She was transitioned to
torsemide 40 mg PO for net even euvolemia. Her home losartan and
spironolactone were held given her ___. Her home imdur was
continued, her hydralazine was increased from 25 mg daily to 20
mg TID, her metoprolol was decreased from XL 75 mg to 50 mg
daily.
#Acute kidney injury:
Cr has increased since discharge of 1.7, was 2.7 on admission.
Thought to be related to overdiuresis. It was stable at 1.9 upon
discharge. Her home losartan, digoxin, apixaban, and
spironolactone were held.
#Urinary tract infection:
UA (___) w/ leuk positive, WBC 51, many bacteria. Did not
receive UCx. s/p CTX and transition to cefpo. She completed a 7d
course on ___.
#Resolved Chest pain:
EKG and trop reassuring, and patient appearing generally
comfortable. Previously has had chest pain in the setting of
heart failure exacerbations. After previous admission was
discharged on increased dose of torsemide (from 40mg QAM, 20mg
QPM to 40mg BID) though this was subsequently reduced again
given findings ___ as outpatient. Trop 2X negative. CXR with
left sided opacity. BNP 1400 around baseline. Discontinued
doxycycline as low concern for PNA on CXR. Deferring stress test
given age and comorbidities. Continued on aspirin 81 gm daily
and atorvastatin 80 mg daily.
#Thrombocytopenia:
Unclear cause, with no history of liver failure, and no signs of
infection or hemolysis. Unlikely to be from heparin or CTX as
she was TCP on admission prior to receiving these medications.
#Coronary artery disease:
History of 2 vessel CAD (Left main proximal 20% and LAD proximal
30% w diffuse dz) confirmed on cath ___ at ___. Had previous
cath ___ (___) with "small vessel disease." Last nuclear stress
test ___ with moderate fixed inferior wall defect. Continued
aspirin and atorvastatin.
#Insulin-dependent diabetes mellitus: glargine 34U qAM, 10U QPM
with insulin sliding scale.
#Atrial fibrillation:
switched eliquis to warfarin with heparin gtt bridge given ___.
Her digoxin was discontinued.
#Hyperlipidemia: Continued atorvastatin 40mg qHS
#Obstructive sleep apnea: continued home CPAP machine
TRANSITIONAL ISSUES:
====================
-Discharge weight: 82.5 kg
-New medications: Warfarin 7.5 mg and 5 mg on alternating days
-Changed medications: Hydralazine decreased from 25 mg daily to
20 mg TID, metop XL decreased from 75 mg daily to 50 mg daily,
torsemide was changed from 40 mg qam and 20 mg qpm to 40 mg
daily
-Held medications: Losartan 50 daily, spironolactone 25 mg daily
(given CKD and ___, apixiban 2.5 mg BID, digoxin 0.625 mg qd
(given tenuous renal function).
-Anticoagulation: Will determine anticoagulation management with
either ___ or ___ on ___. In the interim, the primary team
at ___ will determine Coumadin dosing.
-INR check: Discharge was 2.5. She will need another IRN draw on
___. ___ will check this and fax to in-patient resident team.
___ clinic will be arranged on ___ (closed
over the weekend)
-Labs: Her last hgb was 12.2, platelets 112, and creatinine was
1.9. Please recheck at her next outpatient appointment.
-CODE: full (confirmed)
-CONTACT: Daughter/HCP: ___, Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Cyanocobalamin 1000 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Metoprolol Succinate XL 75 mg PO BID
7. Senna 17.2 mg PO BID
8. Torsemide 40 mg PO QAM
9. Vitamin D 1000 UNIT PO DAILY
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Spironolactone 25 mg PO DAILY
12. oxyCODONE-acetaminophen 7.5-325 mg oral TID
13. Torsemide 20 mg PO QPM
14. HydrALAZINE 25 mg PO DAILY
15. Losartan Potassium 50 mg PO BID
16. Digoxin 0.0625 mg PO DAILY
17. Gabapentin 100 mg PO TID
18. Pantoprazole 40 mg PO Q24H
19. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL)
subcutaneous 44 units qam 14 units qpm
20. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous
per sliding scale
Discharge Medications:
1. Warfarin 7.5 mg PO DAILY16
RX *warfarin 2.5 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
2. HydrALAZINE 20 mg PO Q8H
RX *hydralazine 10 mg 2 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
3. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Cyanocobalamin 1000 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Gabapentin 100 mg PO TID
9. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous
per sliding scale
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL)
subcutaneous 44 units qam 14 units qpm
12. oxyCODONE-acetaminophen 7.5-325 mg oral TID
13. Pantoprazole 40 mg PO Q24H
14. Senna 17.2 mg PO BID
15. Torsemide 40 mg PO QAM
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
==================
Acute on chronic kidney injury
Heart failure with systolic dysfunction
Hypertension
Atrial fibrillation
Secondary diagnosis:
====================
Obstructive sleep apnea
Hyperlipidemia
Coronary artery 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:
Ms. ___,
You were admitted for kidney injury and chest pain. Your chest
pain resolved on it's own and you had no heart damage. Because
of your kidney impairment, you required a blood thinner through
the IV and you were started on an oral blood thinner called
Coumadin (warfarin). Please stop taking your eliquis, as the
warfarin will replace that. You will need frequent blood draws
to monitor the INR, which is a level of how thin your blood is.
Your blood pressure medication was adjusted (see below) and you
will take torsemide 40 mg daily to start. Weigh yourself as soon
as you get home and every morning, call MD if weight goes up or
down by more than 3 lbs. Please follow-up with your cardiologist
as an outpatient.
It was a pleasure caring for you,
-___ medical care team
Followup Instructions:
___
|
[
"N179",
"I5042",
"E1122",
"I4891",
"D696",
"I130",
"N390",
"G4733",
"E785",
"Z7901",
"Z794",
"N189",
"R079",
"I25119",
"T500X5A",
"Y929",
"K5900"
] |
Allergies: Morphine / Indocin / Nafcillin Chief Complaint: chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is an [MASKED] year old woman with a PMH of CAD, Afib, sleep apnea, who is presenting with chest pain. She has a history of angina for which she takes isosorbide. She describes sudden onset sharp left chest pain without radiation, consistent with her prior anginal symptoms, which happened at approximately 9 [MASKED]. She took no additional medications for this. She also experienced shortness of breath in the context of this chest pain. She was feeling well this morning without fever, chills, sweats, abdominal pain, or chest pain. Denies vomiting. Chest pain is sharp, over her anterior left chest, without radiation, and without associated diaphoresis. No exacerbating or alleviating factors. No exercise intolerance. Per her husband she is walking around the house comfortably. Of note, patient was hospitalized from [MASKED] with chest pain and heart failure exacerbation. After an ACS rule out, her chest pain was eventually attributed to her heart failure. She was treated with IV Lasix. She was discharged on an increased dose of torsemide (from 40mg QAM, 20mg QPM to 40mg BID), and was started on Imdur 30 mg daily, Hydralazine 25 mg TID, in addition to her home metoprolol and spironolactone. After discharge, her Cr increased from 1.7 on discharge to 2.1. At that time, her dose of torsemide was again decreased to 40mg QAM, 20mg QPM. In the ED, initial vitals were: 96.6, 68, 111/98, 18, 97% RA - Exam notable for: No leg swelling, mild tenderness over his soft tissue of lateral right calf and distal thigh - Labs notable for: CBC: WBC 7.7, Hgb 12.9, Hct 38.3, Plt 104 Lytes: 132 / 93 / 84 --------------- 244 4.1 \ 25 \ 2.7 [MASKED]: 16.2 PTT: 28.1 INR: 1.5 Trop-T: <0.01 - No imaging was done. - Cardiology was consulted and recommended admission to [MASKED] service. - Patient was given: [MASKED] 01:04 PO Aspirin 243 mg [MASKED] 01:53 IVF NS ( 500 mL ordered) - Vitals prior to transfer: 97.8, 62, 103/70, 18, 99% RA Upon arrival to the floor, patient reports that she continues to have chest pain, saying it is her typical chest pain that comes and goes. Otherwise states that she feels tired. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: Infarct-related Systolic CHF (EF 25% [MASKED] DM HTN CAD (cath at [MASKED] in [MASKED] showing "small vessel disease", cardiac cath in [MASKED] showing two vessel disease without any intervention) Atrial fibrillation Gout Non-Hodgkin's lymphoma Multinodular Goiter Chronic Low Back Pain s/p hysterectomy s/p bilateral knee replacements s/p bilateral eye surgery OSA on CPAP Social History: [MASKED] Family History: Diabetes; Grandmother died of MI at [MASKED]. Father: MI in [MASKED], Mother: died before her [MASKED] of "heart condition that was undiagnosed" Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vital Signs: 97.4, HR 72, BP 95/58, RR 16, 98% RA General: Tired appearing elderly woman, sleeping in bed lying flat Neck: Supple. JVP at clavicle at 30 degrees. no LAD CV: Irregularly irregular with no murmurs appreciated Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE PHYSICAL EXAM: ======================== VITALS: Afebrile 100s-110s/70s [MASKED] 18 94% room air WEIGHT: 82.5 kg TELEMETRY: AF/AFL [MASKED] IVCD General: Sitting upright and eating in NAD Neck: mild R trapezius tension; No carotid bruit; JVP not elevated CV: Irregularly irregular with no murmurs appreciated Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: =============== [MASKED] 12:34AM BLOOD WBC-7.7 RBC-4.43 Hgb-12.9 Hct-38.3 MCV-87 MCH-29.1 MCHC-33.7 RDW-13.4 RDWSD-42.4 Plt [MASKED] [MASKED] 12:34AM BLOOD Neuts-65.7 [MASKED] Monos-9.5 Eos-0.4* Baso-0.3 Im [MASKED] AbsNeut-5.03 AbsLymp-1.81 AbsMono-0.73 AbsEos-0.03* AbsBaso-0.02 [MASKED] 12:34AM BLOOD [MASKED] PTT-28.1 [MASKED] [MASKED] 07:46AM BLOOD Ret Aut-1.9 Abs Ret-0.08 [MASKED] 12:34AM BLOOD Glucose-244* UreaN-84* Creat-2.7* Na-132* K-4.1 Cl-93* HCO3-25 AnGap-18 [MASKED] 07:46AM BLOOD TotBili-0.7 [MASKED] 12:34AM BLOOD proBNP-1437* [MASKED] 12:34AM BLOOD cTropnT-<0.01 [MASKED] 07:46AM BLOOD CK-MB-2 cTropnT-<0.01 [MASKED] 07:46AM BLOOD Calcium-9.1 Phos-5.8* Mg-2.2 [MASKED] 07:46AM BLOOD Hapto-191 [MASKED] 03:05PM BLOOD Osmolal-313* [MASKED] 07:46AM BLOOD Digoxin-<0.4* [MASKED] 03:08PM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 03:08PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [MASKED] 03:08PM URINE RBC-2 WBC-51* Bacteri-MANY Yeast-NONE Epi-8 [MASKED] 03:08PM URINE CastHy-46* [MASKED] 01:14AM URINE Hours-RANDOM Creat-81 Na-21 [MASKED] 01:14AM URINE Osmolal-336 MICRO LABS: =========== [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE IMAGES: ======= CXR ([MASKED]): Compared with [MASKED], the left heart border is less well defined, but the cardiomediastinal silhouette is enlarged and not significantly changed. There is patchy opacity at the left lung base, which may account for indistinctness of the left heart border. Left hemidiaphragm remains visible. There is minimal atelectasis at the right lung base. No overt CHF. No gross effusion. No pneumothorax detected. Renal US ([MASKED]): Normal renal ultrasound. Specifically, no hydronephrosis. DISCHARGE LABS: =============== [MASKED] 06:20AM BLOOD WBC-6.4 RBC-4.20 Hgb-12.2 Hct-37.6 MCV-90 MCH-29.0 MCHC-32.4 RDW-14.3 RDWSD-46.0 Plt [MASKED] [MASKED] 06:35AM BLOOD [MASKED] PTT-64.0* [MASKED] [MASKED] 06:35AM BLOOD Glucose-194* UreaN-64* Creat-1.9* Na-135 K-4.1 Cl-98 HCO3-23 AnGap-18 [MASKED] 06:35AM BLOOD Calcium-8.9 Phos-5.2* Mg-2.2 Brief Hospital Course: Ms. [MASKED] is an [MASKED] year old woman with a PMH of CAD, Afib, sleep apnea, who is presenting with chest pain. Her weight on admission was 2 kg less than previously and she had a new [MASKED] thought to be due to overdiuresis. Her troponins were negative and EKG was reassuring. No further ischemic work-up was performed given her age and comorbidities. Her diuresis was held initially and restarted to torsemide 40 mg with goal euvolemia. Her [MASKED] improved (thought to be secondary to overdiuresis as an outpatient). Her BP medications were adjusted (decreased metop XL, increased hydral, held losartan and spironolactone given [MASKED]. Given her [MASKED], apixaban was discontinued and she was bridged to warfarin with heparin gtt for her atrial fibrillation. Her digoxin was discontinued given her tenuous renal function. She was treated for an uncomplicated UTI w/ cefpodoxime (culture was not sent). #Chronic systolic and diastolic CHF: TTE on [MASKED] with LVEF 25%, mild biventricular dilation, severe LV hypokinesis of the septum and inferior walls and mild hypokinesis of the remaining segments, 3+ MR, mild pulmonary HTN. BNP 1437 (less than last admission). As above, during recent hospitalization was felt to be volume up, and torsemide dose was increased, then subsequently decreased due to [MASKED]. She does not appear volume overloaded on exam. CXR ([MASKED]) w/ questionable LLL opacity. Discharge weight was 82.1 kg that hospitalization and ~80 kg on admission. She was transitioned to torsemide 40 mg PO for net even euvolemia. Her home losartan and spironolactone were held given her [MASKED]. Her home imdur was continued, her hydralazine was increased from 25 mg daily to 20 mg TID, her metoprolol was decreased from XL 75 mg to 50 mg daily. #Acute kidney injury: Cr has increased since discharge of 1.7, was 2.7 on admission. Thought to be related to overdiuresis. It was stable at 1.9 upon discharge. Her home losartan, digoxin, apixaban, and spironolactone were held. #Urinary tract infection: UA ([MASKED]) w/ leuk positive, WBC 51, many bacteria. Did not receive UCx. s/p CTX and transition to cefpo. She completed a 7d course on [MASKED]. #Resolved Chest pain: EKG and trop reassuring, and patient appearing generally comfortable. Previously has had chest pain in the setting of heart failure exacerbations. After previous admission was discharged on increased dose of torsemide (from 40mg QAM, 20mg QPM to 40mg BID) though this was subsequently reduced again given findings [MASKED] as outpatient. Trop 2X negative. CXR with left sided opacity. BNP 1400 around baseline. Discontinued doxycycline as low concern for PNA on CXR. Deferring stress test given age and comorbidities. Continued on aspirin 81 gm daily and atorvastatin 80 mg daily. #Thrombocytopenia: Unclear cause, with no history of liver failure, and no signs of infection or hemolysis. Unlikely to be from heparin or CTX as she was TCP on admission prior to receiving these medications. #Coronary artery disease: History of 2 vessel CAD (Left main proximal 20% and LAD proximal 30% w diffuse dz) confirmed on cath [MASKED] at [MASKED]. Had previous cath [MASKED] ([MASKED]) with "small vessel disease." Last nuclear stress test [MASKED] with moderate fixed inferior wall defect. Continued aspirin and atorvastatin. #Insulin-dependent diabetes mellitus: glargine 34U qAM, 10U QPM with insulin sliding scale. #Atrial fibrillation: switched eliquis to warfarin with heparin gtt bridge given [MASKED]. Her digoxin was discontinued. #Hyperlipidemia: Continued atorvastatin 40mg qHS #Obstructive sleep apnea: continued home CPAP machine TRANSITIONAL ISSUES: ==================== -Discharge weight: 82.5 kg -New medications: Warfarin 7.5 mg and 5 mg on alternating days -Changed medications: Hydralazine decreased from 25 mg daily to 20 mg TID, metop XL decreased from 75 mg daily to 50 mg daily, torsemide was changed from 40 mg qam and 20 mg qpm to 40 mg daily -Held medications: Losartan 50 daily, spironolactone 25 mg daily (given CKD and [MASKED], apixiban 2.5 mg BID, digoxin 0.625 mg qd (given tenuous renal function). -Anticoagulation: Will determine anticoagulation management with either [MASKED] or [MASKED] on [MASKED]. In the interim, the primary team at [MASKED] will determine Coumadin dosing. -INR check: Discharge was 2.5. She will need another IRN draw on [MASKED]. [MASKED] will check this and fax to in-patient resident team. [MASKED] clinic will be arranged on [MASKED] (closed over the weekend) -Labs: Her last hgb was 12.2, platelets 112, and creatinine was 1.9. Please recheck at her next outpatient appointment. -CODE: full (confirmed) -CONTACT: Daughter/HCP: [MASKED], Cell phone: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 2.5 mg PO BID 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Cyanocobalamin 1000 mcg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Metoprolol Succinate XL 75 mg PO BID 7. Senna 17.2 mg PO BID 8. Torsemide 40 mg PO QAM 9. Vitamin D 1000 UNIT PO DAILY 10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 11. Spironolactone 25 mg PO DAILY 12. oxyCODONE-acetaminophen 7.5-325 mg oral TID 13. Torsemide 20 mg PO QPM 14. HydrALAZINE 25 mg PO DAILY 15. Losartan Potassium 50 mg PO BID 16. Digoxin 0.0625 mg PO DAILY 17. Gabapentin 100 mg PO TID 18. Pantoprazole 40 mg PO Q24H 19. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL) subcutaneous 44 units qam 14 units qpm 20. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous per sliding scale Discharge Medications: 1. Warfarin 7.5 mg PO DAILY16 RX *warfarin 2.5 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 2. HydrALAZINE 20 mg PO Q8H RX *hydralazine 10 mg 2 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 3. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Cyanocobalamin 1000 mcg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Gabapentin 100 mg PO TID 9. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous per sliding scale 10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 11. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL) subcutaneous 44 units qam 14 units qpm 12. oxyCODONE-acetaminophen 7.5-325 mg oral TID 13. Pantoprazole 40 mg PO Q24H 14. Senna 17.2 mg PO BID 15. Torsemide 40 mg PO QAM 16. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary diagnosis: ================== Acute on chronic kidney injury Heart failure with systolic dysfunction Hypertension Atrial fibrillation Secondary diagnosis: ==================== Obstructive sleep apnea Hyperlipidemia Coronary artery 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: Ms. [MASKED], You were admitted for kidney injury and chest pain. Your chest pain resolved on it's own and you had no heart damage. Because of your kidney impairment, you required a blood thinner through the IV and you were started on an oral blood thinner called Coumadin (warfarin). Please stop taking your eliquis, as the warfarin will replace that. You will need frequent blood draws to monitor the INR, which is a level of how thin your blood is. Your blood pressure medication was adjusted (see below) and you will take torsemide 40 mg daily to start. Weigh yourself as soon as you get home and every morning, call MD if weight goes up or down by more than 3 lbs. Please follow-up with your cardiologist as an outpatient. It was a pleasure caring for you, -[MASKED] medical care team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"E1122",
"I4891",
"D696",
"I130",
"N390",
"G4733",
"E785",
"Z7901",
"Z794",
"N189",
"Y929",
"K5900"
] |
[
"N179: Acute kidney failure, unspecified",
"I5042: Chronic combined systolic (congestive) and diastolic (congestive) heart failure",
"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"I4891: Unspecified atrial fibrillation",
"D696: Thrombocytopenia, 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",
"N390: Urinary tract infection, site not specified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"E785: Hyperlipidemia, unspecified",
"Z7901: Long term (current) use of anticoagulants",
"Z794: Long term (current) use of insulin",
"N189: Chronic kidney disease, unspecified",
"R079: Chest pain, unspecified",
"I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris",
"T500X5A: Adverse effect of mineralocorticoids and their antagonists, initial encounter",
"Y929: Unspecified place or not applicable",
"K5900: Constipation, unspecified"
] |
10,028,480
| 24,169,188
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Indocin / Nafcillin
Attending: ___.
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms ___ is a ___ woman with a history of HFrEF (EF ___ in
___, atrial fibrillation, T2DM, HTN, and possibly a recent
TIA, who presents with 4 days of progressive shortness of
breath, fatigue, and altered mental status.
She was admitted to ___ from for a possible TIA. At
that time, MRI and other diagnostic tests were negative, so she
was discharged to ___ on ___. Her Dig was held and
___ was decreased at that hospitalization, but per reports, she
was taking both at rehab.
On ___, her daughter visited her at rehab, and noticed
that she was confused and somnolent. A urine culture was
collected, which eventually grew >100,000 E Coli. The nursing
staff encouraged Ms ___ to drink lots of fluid, and her mental
status improved by ___.
However, for the past 2 days, she has become increasingly short
of breath and she developed a 2L O2 requirement. She has also
had more confusion. Per her daughter, she has had increased
orthopnea and lower extremity swelling (L>R) during this time.
No chest pain, nausea, vomiting, abdominal pain, dysuria,
urinary frequency, or diarrhea.
- In the ED initial vitals were: 97.4 78 105/70 20 2L 100% Nasal
Cannula
- Exam notable for crackles in LLE & 1+ edema in LLE
- EKG: Afib with HR 78; left axis deviation; RBBB & LAFB with
TWI in I & avL, unchanged from baseline on ___
- Labs notable for: proBNP: 3743, Cr 1.4 (baseline 1.4). U/A
with few bacteria, mod ___
- Imaging showed CXR with edema
- Patient was given: Lasix 40mg IVx1 (at 5pm) & Ceftriaxone 1g
x1.
- Vitals on transfer: 97.4 85 135/76 18 95% Nasal Cannula
On the floor, patient feels well. She endorses shortness of
breath, but no chest pain or palpitations. She is able to answer
all questions appropriately, and she does not feel confused. She
does feel that her legs are more swollen than usual. No new
medicines and no changes to her Lasix dose recently.
ROS: On review of systems, denies any prior history of stroke,
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,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: cardiac catheterization
at
___ in ___ showing "small vessel disease", cardiac cath in
___ showing two vessel disease without any intervention
- PACING/ICD: None
# Atrial fibrillation (on coumadin)
# Coronary artery disease
# sCHF with EF 40%
3. OTHER PAST MEDICAL HISTORY:
# History of Non-Hodgkin's lymphoma
# Multinodular Goiter
# Chronic Low Back Pain
# s/p hysterectomy
# s/p bilateral knee replacements
# s/p bilateral eye surgery
Social History:
___
Family History:
Diabetes; Grandmother died of MI at ___. Father: MI in ___,
Mother: died before her ___ of "heart condition that was
undiagnosed"
Physical Exam:
==========================
ADMISSION PHYSICAL
==========================
VS: 97.4 78 148/85 18 90% on ra
ADMISSION WEIGHT: 87.4 kg (no clear dry weight)
GEN: well appearing elderly woman in NAD
HEENT: NCAT, no scleral icterus, PERRL, EOMI, moist mucous
membranes
NECK: JVP 12cm
CV: irregular rate & rhythm, no m/r/g
PULM: normal work of breathing on 2Lnc, bilateral crackles in
lung bases, no wheezes
ABD: soft, NT/ND, no suprapubic tenderness, normal bowel sounds
GU: no foley
EXT: warm, 2+ DP pulses, 1+ ___ edema on left, trace edema on
right
NEURO: CN II-XII intact, ___ strength in upper & lower
extremities, able to say day of the week backwards; A&Ox3
==========================
DISCHARGE PHYSICAL
==========================
VSS temp 97.6, BP 133/80, 67 RR 18 sats 99% RA
I/O: ___
Wt: 87.4-->86.9->85-->86.3-->86.1-->86.7 --> 87-> 85.6
GEN: well appearing elderly ___ woman in NAD,
sitting up in chair.
HEENT: NCAT, no scleral icterus.
CV: Irregularly irregular rate and rhythm, no
murmurs/gallops/rubs
PULM: normal work of breathing, bibasilar crackles stable from
yesterday's exam, no wheezing.
ABD: soft, NT/ND, normoactive bowel sounds
EXT: warm, 2+ DP pulses, no edema in the lower extremities
bilaterally
Pertinent Results:
==========================
ADMISSION LABS
==========================
___ 03:35PM BLOOD WBC-9.3 RBC-4.26 Hgb-12.2 Hct-39.5 MCV-93
MCH-28.6 MCHC-30.9* RDW-14.7 RDWSD-49.5* Plt ___
___ 03:35PM BLOOD Neuts-59.3 ___ Monos-11.5
Eos-0.3* Baso-0.5 Im ___ AbsNeut-5.54 AbsLymp-2.62
AbsMono-1.07* AbsEos-0.03* AbsBaso-0.05
___ 03:35PM BLOOD ___ PTT-28.3 ___
___ 03:35PM BLOOD Glucose-134* UreaN-32* Creat-1.4* Na-138
K-5.9* Cl-102 HCO3-26 AnGap-16
___ 03:35PM BLOOD ALT-22 AST-47* LD(LDH)-597* CK(CPK)-75
AlkPhos-70 TotBili-1.0
___ 03:35PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-3743*
___ 03:35PM BLOOD Albumin-3.4* Calcium-8.9 Phos-4.2 Mg-2.0
==========================
DISCHARGE LABS
==========================
___ 05:30AM BLOOD WBC-6.5 RBC-4.02 Hgb-11.5 Hct-37.3 MCV-93
MCH-28.6 MCHC-30.8* RDW-14.6 RDWSD-50.0* Plt ___
___ 05:30AM BLOOD ___ PTT-38.3* ___
___ 05:30AM BLOOD Glucose-183* UreaN-30* Creat-1.3* Na-141
K-4.1 Cl-102 HCO3-26 AnGap-17
___ 05:30AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.2
==========================
OTHER IMPORTANT LABS
==========================
___ 03:35PM BLOOD Digoxin-1.2
___ 02:54AM BLOOD cTropnT-<0.01
___ 02:38PM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:55AM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:04PM BLOOD CK-MB-2 cTropnT-<0.01
==========================
IMAGING
==========================
___ CHEST X RAY
1. Moderate pulmonary edema.
2. Moderate cardiomegaly.
3. No evidence pneumonia.
___OPPLER
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ ECHOCARDIOGRAM
The left atrial volume index is severely increased. The right
atrium is moderately dilated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity is mildly dilated. Overall
left ventricular systolic function is severely depressed (LVEF =
25%) secondary to akinesis of the inferior and posterior walls
and hypokinesis of the rest of the left ventricle. Doppler
parameters are most consistent with Grade II (moderate) left
ventricular diastolic dysfunction. The right ventricular free
wall thickness is normal. The right ventricular cavity is
moderately dilated with severe global free wall hypokinesis
(fractional area change < 0.15). The diameters of aorta at the
sinus, ascending and arch levels are normal. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is mild pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
contractile dysfunction of both ventricles is now severe.
==========================
STUDIES
==========================
___ DIPYRIDAMOLE NUCLEAR STRESS TEST
INTERPRETATION: ___ year old female with a history of CHF (EF
25%),
CAD with probable old inferior MI, atrial fibrillation, DMII,
HTN and
HLD referred for nuclear study for evaluation of shortness of
breath,
after serial negative cardiac markers. The patient was infused
with
0.142 mg/kg/min of dipyridamole over 4 minutes. The test was
terminated
due to completion of the protocol. The patient reported no
chest, neck,
back or arm pain. Baseline NSSTTW's in the setting of RBBB
persisted
through infusion and recovery. No significant ST segment changes
noted.
EKG showed atrial fibrillation with rare VPB's. Hemodynamic
response to
dipyridamole infusion was appropriate. The patient was infused
with 125
mg of aminophylline to reverse effects of dipyridamole.
IMPRESSION: No anginal or significant ST segment changes noted.
Nuclear
report sent separately.
1. Moderate, fixed, inferior wall perfusion defect more severe
at
the apical aspect. Partial reversibility seen in ___ is no
longer appreciated.
2. Worsened left ventricular systolic function since ___ with
reduction of
ejection fraction to 24%. 3. Moderate left ventricular
enlargement.
==========================
MICRO
==========================
___ BLOOD CULTURES - NGTD as of ___
___ URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI. 10,000-100,000 CFU/mL. SECOND
MORPHOLOGY.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
ESCHERICHIA COLI
|
|
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 16 I 16 I
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Brief Hospital Course:
___ with HFrEF (EF ___, Afib (on warfarin), T2DM, HTN,
?recent TIA, who presented with altered MS, fatigue, DOE. She
was admitted to ___ a few weeks ago with sx
concerning for TIA--MRI was negative thus d/c on ___ to rehab.
On ___ was confused, somnolent, U/A + Ecoli but not treated and
was given fluid thus became increasingly SOB, orthopnea, leg
edema.
Admitted to ___ Cardiology. Underwent IV diuresis to euvolemia
and was transitioned to torsemide 40 qam / 20 qpm. Had stress
test to eval for reversible ischemia; several fixed defects were
found. Treated with CTX x5d for UTI.
AFib is anticoagulated with warfarin; due to subtherapeutic INR
and CHADS2=5, she was bridged with heparin back to her warfarin.
INR therapeutic at discharge.
Also presented with clopidogrel on her medication list (in
addition to ASA, warfarin). Full details are not available but
suspect prescribed at ___ for TIA. It was discontinued as
her inpatient cardiology service and outpatient cardiologist Dr.
___ that the bleeding risk of triple AC exceeded the
expected benefit.
============
ACUTE ISSUES
============
# ACUTE-ON-CHRONIC SYSTOLIC HEART FAILURE EXACERBATION: Acute
on chronic exacerbation, possibly due to untreated UTI at rehab.
Troponins negative, BNP in 3700's. Most likely ischemic; known
hx 2vd, no reversible defects found on stress test this
admission.
- Discharge weight: 85.6 kg
- Preload: torsemide 40mg qAM, 20mg qPM
- NHBK: Metoprolol Succinate XL 100 mg PO DAILY
- Afterload: Losartan Potassium uptitrated to 75 mg PO/NG DAILY
- Contractility: Digoxin 0.0625 daily
- Device: none for now, plan to see EP as outpatient
- PMIBI ___ without reversible ischemia
# URINARY TRACT INFECTION: Treated with a course of ceftriaxone
ending ___. Pt did not have fevers or dysuria at discharge.
# ATRIAL FIBRILLATION: CHADS2=5
- RC: metoprolol succinate 100mg daily.
- AC: warfarin. bridged with heparin gtt this admit for INR < 2.
- warfarin therapy managed by ___
=======================
CHRONIC/RESOLVED ISSUES
=======================
# CKD: On admission, Cr was 1.4, which appears to be her
baseline. Stable at *** prior to discharge. Medications were
renally dosed.
# T2DM: On lantus ___ qAM/qHS, with HISS in-house.
# ASTHMA: Continued home albuterol inh
# GERD: Continued PPI
# CHRONIC PAIN: Continued home gabapentin 100mg PO BID.
Fractionated home Percocet to Acetaminophen 650 mg PO/NG TID
with OxyCODONE (Immediate Release) 5 mg PO/NG Q4H:PRN pain
# VITAMIN D DEFICIENCY: Continued home Vitamin D 1000 UNIT PO
DAILY
===================
TRANSITIONAL ISSUES
===================
# Discharge weight: 85.6 kg
# Started spironolactone
# ___ recommends discharge to home with ___ and family assist
# ___ need to see EP as outpatient for consideration of device
therapy for her heart failure as she has no reversible changes
seen on stress test.
# Next labs: ___ (chemistry 10, INR)
# INR managed by: ___
# Completed therapy for UTI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Digoxin 0.125 mg PO EVERY OTHER DAY
3. Furosemide 80 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Metoprolol Succinate XL 150 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Atorvastatin 80 mg PO QPM
8. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
9. Docusate Sodium 100 mg PO BID
10. Nitroglycerin SL 0.4 mg SL PRN Chest pain
11. Percocet (oxyCODONE-acetaminophen) ___ mg ORAL TID:PRN
pain
12. Potassium Chloride 10 mEq PO DAILY
13. Senna 17.2 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Levemir 40 Units Breakfast
Levemir 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
16. Gabapentin 100 mg PO TID
17. Warfarin 3 mg PO DAILY16
Discharge Medications:
1. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
2. Torsemide 40 mg PO QAM
0800 am
RX *torsemide 20 mg 2 tablet(s) by mouth every morning Disp #*60
Tablet Refills:*0
3. Torsemide 20 mg PO QPM
0200 pm
RX *torsemide 20 mg 1 tablet(s) by mouth every afternoon Disp
#*30 Tablet Refills:*0
4. Digoxin 0.0625 mg PO DAILY
RX *digoxin 125 mcg 0.5 (One half) tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Losartan Potassium 100 mg PO DAILY
RX *losartan 50 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
6. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 50 mg 2 tablet(s) by mouth daily Disp
#*60 Tablet Refills:*0
7. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Docusate Sodium 100 mg PO BID
11. Gabapentin 100 mg PO TID
12. Levemir 40 Units Breakfast
Levemir 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Nitroglycerin SL 0.4 mg SL PRN Chest pain
14. Pantoprazole 40 mg PO Q24H
15. Percocet (oxyCODONE-acetaminophen) ___ mg ORAL TID:PRN
pain
16. Potassium Chloride 10 mEq PO DAILY
Hold for K >
17. Senna 17.2 mg PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
19. Warfarin 3 mg PO 6X/WEEK (___)
20. Warfarin 4.5 mg PO 1X/WEEK (MO)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: acute on chronic systolic heart failure
exacerbation
Secondary diagnosis: coronary artery disease, urinary tract
infection, atrial fibrillation, hypertension, diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___.
You came to the hospital because you were having shortness of
breath and confusion. You were found to have fluid overload,
most likely due to a urine infection.
We treated you with diuretics to remove excess fluid and your
breathing improved. An ultrasound of your heart showed the
pumping function of your heart is decreased. A stress test did
not show any areas that could be fixed by procedures that
restore blood flow.
We also treated you with antibiotics for a urinary tract
infection.
Please take all of your medications every day and weigh yourself
every morning, call MD if weight goes up more than 3 lbs.
We wish you the ___,
Your ___ medical team.
Followup Instructions:
___
|
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Allergies: Morphine / Indocin / Nafcillin Chief Complaint: Shortness of breath. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms [MASKED] is a [MASKED] woman with a history of HFrEF (EF [MASKED] in [MASKED], atrial fibrillation, T2DM, HTN, and possibly a recent TIA, who presents with 4 days of progressive shortness of breath, fatigue, and altered mental status. She was admitted to [MASKED] from for a possible TIA. At that time, MRI and other diagnostic tests were negative, so she was discharged to [MASKED] on [MASKED]. Her Dig was held and [MASKED] was decreased at that hospitalization, but per reports, she was taking both at rehab. On [MASKED], her daughter visited her at rehab, and noticed that she was confused and somnolent. A urine culture was collected, which eventually grew >100,000 E Coli. The nursing staff encouraged Ms [MASKED] to drink lots of fluid, and her mental status improved by [MASKED]. However, for the past 2 days, she has become increasingly short of breath and she developed a 2L O2 requirement. She has also had more confusion. Per her daughter, she has had increased orthopnea and lower extremity swelling (L>R) during this time. No chest pain, nausea, vomiting, abdominal pain, dysuria, urinary frequency, or diarrhea. - In the ED initial vitals were: 97.4 78 105/70 20 2L 100% Nasal Cannula - Exam notable for crackles in LLE & 1+ edema in LLE - EKG: Afib with HR 78; left axis deviation; RBBB & LAFB with TWI in I & avL, unchanged from baseline on [MASKED] - Labs notable for: proBNP: 3743, Cr 1.4 (baseline 1.4). U/A with few bacteria, mod [MASKED] - Imaging showed CXR with edema - Patient was given: Lasix 40mg IVx1 (at 5pm) & Ceftriaxone 1g x1. - Vitals on transfer: 97.4 85 135/76 18 95% Nasal Cannula On the floor, patient feels well. She endorses shortness of breath, but no chest pain or palpitations. She is able to answer all questions appropriately, and she does not feel confused. She does feel that her legs are more swollen than usual. No new medicines and no changes to her Lasix dose recently. ROS: On review of systems, denies any prior history of stroke, 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, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Hypertension 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: cardiac catheterization at [MASKED] in [MASKED] showing "small vessel disease", cardiac cath in [MASKED] showing two vessel disease without any intervention - PACING/ICD: None # Atrial fibrillation (on coumadin) # Coronary artery disease # sCHF with EF 40% 3. OTHER PAST MEDICAL HISTORY: # History of Non-Hodgkin's lymphoma # Multinodular Goiter # Chronic Low Back Pain # s/p hysterectomy # s/p bilateral knee replacements # s/p bilateral eye surgery Social History: [MASKED] Family History: Diabetes; Grandmother died of MI at [MASKED]. Father: MI in [MASKED], Mother: died before her [MASKED] of "heart condition that was undiagnosed" Physical Exam: ========================== ADMISSION PHYSICAL ========================== VS: 97.4 78 148/85 18 90% on ra ADMISSION WEIGHT: 87.4 kg (no clear dry weight) GEN: well appearing elderly woman in NAD HEENT: NCAT, no scleral icterus, PERRL, EOMI, moist mucous membranes NECK: JVP 12cm CV: irregular rate & rhythm, no m/r/g PULM: normal work of breathing on 2Lnc, bilateral crackles in lung bases, no wheezes ABD: soft, NT/ND, no suprapubic tenderness, normal bowel sounds GU: no foley EXT: warm, 2+ DP pulses, 1+ [MASKED] edema on left, trace edema on right NEURO: CN II-XII intact, [MASKED] strength in upper & lower extremities, able to say day of the week backwards; A&Ox3 ========================== DISCHARGE PHYSICAL ========================== VSS temp 97.6, BP 133/80, 67 RR 18 sats 99% RA I/O: [MASKED] Wt: 87.4-->86.9->85-->86.3-->86.1-->86.7 --> 87-> 85.6 GEN: well appearing elderly [MASKED] woman in NAD, sitting up in chair. HEENT: NCAT, no scleral icterus. CV: Irregularly irregular rate and rhythm, no murmurs/gallops/rubs PULM: normal work of breathing, bibasilar crackles stable from yesterday's exam, no wheezing. ABD: soft, NT/ND, normoactive bowel sounds EXT: warm, 2+ DP pulses, no edema in the lower extremities bilaterally Pertinent Results: ========================== ADMISSION LABS ========================== [MASKED] 03:35PM BLOOD WBC-9.3 RBC-4.26 Hgb-12.2 Hct-39.5 MCV-93 MCH-28.6 MCHC-30.9* RDW-14.7 RDWSD-49.5* Plt [MASKED] [MASKED] 03:35PM BLOOD Neuts-59.3 [MASKED] Monos-11.5 Eos-0.3* Baso-0.5 Im [MASKED] AbsNeut-5.54 AbsLymp-2.62 AbsMono-1.07* AbsEos-0.03* AbsBaso-0.05 [MASKED] 03:35PM BLOOD [MASKED] PTT-28.3 [MASKED] [MASKED] 03:35PM BLOOD Glucose-134* UreaN-32* Creat-1.4* Na-138 K-5.9* Cl-102 HCO3-26 AnGap-16 [MASKED] 03:35PM BLOOD ALT-22 AST-47* LD(LDH)-597* CK(CPK)-75 AlkPhos-70 TotBili-1.0 [MASKED] 03:35PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-3743* [MASKED] 03:35PM BLOOD Albumin-3.4* Calcium-8.9 Phos-4.2 Mg-2.0 ========================== DISCHARGE LABS ========================== [MASKED] 05:30AM BLOOD WBC-6.5 RBC-4.02 Hgb-11.5 Hct-37.3 MCV-93 MCH-28.6 MCHC-30.8* RDW-14.6 RDWSD-50.0* Plt [MASKED] [MASKED] 05:30AM BLOOD [MASKED] PTT-38.3* [MASKED] [MASKED] 05:30AM BLOOD Glucose-183* UreaN-30* Creat-1.3* Na-141 K-4.1 Cl-102 HCO3-26 AnGap-17 [MASKED] 05:30AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.2 ========================== OTHER IMPORTANT LABS ========================== [MASKED] 03:35PM BLOOD Digoxin-1.2 [MASKED] 02:54AM BLOOD cTropnT-<0.01 [MASKED] 02:38PM BLOOD CK-MB-2 cTropnT-<0.01 [MASKED] 04:55AM BLOOD CK-MB-2 cTropnT-<0.01 [MASKED] 09:04PM BLOOD CK-MB-2 cTropnT-<0.01 ========================== IMAGING ========================== [MASKED] CHEST X RAY 1. Moderate pulmonary edema. 2. Moderate cardiomegaly. 3. No evidence pneumonia. OPPLER No evidence of deep venous thrombosis in the left lower extremity veins. [MASKED] ECHOCARDIOGRAM The left atrial volume index is severely increased. The right atrium is moderately dilated. The estimated right atrial pressure is [MASKED] mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is severely depressed (LVEF = 25%) secondary to akinesis of the inferior and posterior walls and hypokinesis of the rest of the left ventricle. Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. The right ventricular free wall thickness is normal. The right ventricular cavity is moderately dilated with severe global free wall hypokinesis (fractional area change < 0.15). The diameters of aorta at the sinus, ascending and arch levels are normal. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [MASKED], contractile dysfunction of both ventricles is now severe. ========================== STUDIES ========================== [MASKED] DIPYRIDAMOLE NUCLEAR STRESS TEST INTERPRETATION: [MASKED] year old female with a history of CHF (EF 25%), CAD with probable old inferior MI, atrial fibrillation, DMII, HTN and HLD referred for nuclear study for evaluation of shortness of breath, after serial negative cardiac markers. The patient was infused with 0.142 mg/kg/min of dipyridamole over 4 minutes. The test was terminated due to completion of the protocol. The patient reported no chest, neck, back or arm pain. Baseline NSSTTW's in the setting of RBBB persisted through infusion and recovery. No significant ST segment changes noted. EKG showed atrial fibrillation with rare VPB's. Hemodynamic response to dipyridamole infusion was appropriate. The patient was infused with 125 mg of aminophylline to reverse effects of dipyridamole. IMPRESSION: No anginal or significant ST segment changes noted. Nuclear report sent separately. 1. Moderate, fixed, inferior wall perfusion defect more severe at the apical aspect. Partial reversibility seen in [MASKED] is no longer appreciated. 2. Worsened left ventricular systolic function since [MASKED] with reduction of ejection fraction to 24%. 3. Moderate left ventricular enlargement. ========================== MICRO ========================== [MASKED] BLOOD CULTURES - NGTD as of [MASKED] [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. ESCHERICHIA COLI. 10,000-100,000 CFU/mL. SECOND MORPHOLOGY. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | ESCHERICHIA COLI | | AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- 16 I 16 I CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S <=16 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S Brief Hospital Course: [MASKED] with HFrEF (EF [MASKED], Afib (on warfarin), T2DM, HTN, ?recent TIA, who presented with altered MS, fatigue, DOE. She was admitted to [MASKED] a few weeks ago with sx concerning for TIA--MRI was negative thus d/c on [MASKED] to rehab. On [MASKED] was confused, somnolent, U/A + Ecoli but not treated and was given fluid thus became increasingly SOB, orthopnea, leg edema. Admitted to [MASKED] Cardiology. Underwent IV diuresis to euvolemia and was transitioned to torsemide 40 qam / 20 qpm. Had stress test to eval for reversible ischemia; several fixed defects were found. Treated with CTX x5d for UTI. AFib is anticoagulated with warfarin; due to subtherapeutic INR and CHADS2=5, she was bridged with heparin back to her warfarin. INR therapeutic at discharge. Also presented with clopidogrel on her medication list (in addition to ASA, warfarin). Full details are not available but suspect prescribed at [MASKED] for TIA. It was discontinued as her inpatient cardiology service and outpatient cardiologist Dr. [MASKED] that the bleeding risk of triple AC exceeded the expected benefit. ============ ACUTE ISSUES ============ # ACUTE-ON-CHRONIC SYSTOLIC HEART FAILURE EXACERBATION: Acute on chronic exacerbation, possibly due to untreated UTI at rehab. Troponins negative, BNP in 3700's. Most likely ischemic; known hx 2vd, no reversible defects found on stress test this admission. - Discharge weight: 85.6 kg - Preload: torsemide 40mg qAM, 20mg qPM - NHBK: Metoprolol Succinate XL 100 mg PO DAILY - Afterload: Losartan Potassium uptitrated to 75 mg PO/NG DAILY - Contractility: Digoxin 0.0625 daily - Device: none for now, plan to see EP as outpatient - PMIBI [MASKED] without reversible ischemia # URINARY TRACT INFECTION: Treated with a course of ceftriaxone ending [MASKED]. Pt did not have fevers or dysuria at discharge. # ATRIAL FIBRILLATION: CHADS2=5 - RC: metoprolol succinate 100mg daily. - AC: warfarin. bridged with heparin gtt this admit for INR < 2. - warfarin therapy managed by [MASKED] ======================= CHRONIC/RESOLVED ISSUES ======================= # CKD: On admission, Cr was 1.4, which appears to be her baseline. Stable at *** prior to discharge. Medications were renally dosed. # T2DM: On lantus [MASKED] qAM/qHS, with HISS in-house. # ASTHMA: Continued home albuterol inh # GERD: Continued PPI # CHRONIC PAIN: Continued home gabapentin 100mg PO BID. Fractionated home Percocet to Acetaminophen 650 mg PO/NG TID with OxyCODONE (Immediate Release) 5 mg PO/NG Q4H:PRN pain # VITAMIN D DEFICIENCY: Continued home Vitamin D 1000 UNIT PO DAILY =================== TRANSITIONAL ISSUES =================== # Discharge weight: 85.6 kg # Started spironolactone # [MASKED] recommends discharge to home with [MASKED] and family assist # [MASKED] need to see EP as outpatient for consideration of device therapy for her heart failure as she has no reversible changes seen on stress test. # Next labs: [MASKED] (chemistry 10, INR) # INR managed by: [MASKED] # Completed therapy for UTI Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Digoxin 0.125 mg PO EVERY OTHER DAY 3. Furosemide 80 mg PO DAILY 4. Losartan Potassium 50 mg PO DAILY 5. Metoprolol Succinate XL 150 mg PO DAILY 6. Pantoprazole 40 mg PO Q24H 7. Atorvastatin 80 mg PO QPM 8. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath 9. Docusate Sodium 100 mg PO BID 10. Nitroglycerin SL 0.4 mg SL PRN Chest pain 11. Percocet (oxyCODONE-acetaminophen) [MASKED] mg ORAL TID:PRN pain 12. Potassium Chloride 10 mEq PO DAILY 13. Senna 17.2 mg PO DAILY 14. Vitamin D 1000 UNIT PO DAILY 15. Levemir 40 Units Breakfast Levemir 8 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 16. Gabapentin 100 mg PO TID 17. Warfarin 3 mg PO DAILY16 Discharge Medications: 1. Spironolactone 12.5 mg PO DAILY RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Torsemide 40 mg PO QAM 0800 am RX *torsemide 20 mg 2 tablet(s) by mouth every morning Disp #*60 Tablet Refills:*0 3. Torsemide 20 mg PO QPM 0200 pm RX *torsemide 20 mg 1 tablet(s) by mouth every afternoon Disp #*30 Tablet Refills:*0 4. Digoxin 0.0625 mg PO DAILY RX *digoxin 125 mcg 0.5 (One half) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Losartan Potassium 100 mg PO DAILY RX *losartan 50 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 6. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 50 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 7. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 80 mg PO QPM 10. Docusate Sodium 100 mg PO BID 11. Gabapentin 100 mg PO TID 12. Levemir 40 Units Breakfast Levemir 8 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 13. Nitroglycerin SL 0.4 mg SL PRN Chest pain 14. Pantoprazole 40 mg PO Q24H 15. Percocet (oxyCODONE-acetaminophen) [MASKED] mg ORAL TID:PRN pain 16. Potassium Chloride 10 mEq PO DAILY Hold for K > 17. Senna 17.2 mg PO DAILY 18. Vitamin D 1000 UNIT PO DAILY 19. Warfarin 3 mg PO 6X/WEEK ([MASKED]) 20. Warfarin 4.5 mg PO 1X/WEEK (MO) Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary diagnosis: acute on chronic systolic heart failure exacerbation Secondary diagnosis: coronary artery disease, urinary tract infection, atrial fibrillation, hypertension, diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you during your stay at [MASKED] [MASKED]. You came to the hospital because you were having shortness of breath and confusion. You were found to have fluid overload, most likely due to a urine infection. We treated you with diuretics to remove excess fluid and your breathing improved. An ultrasound of your heart showed the pumping function of your heart is decreased. A stress test did not show any areas that could be fixed by procedures that restore blood flow. We also treated you with antibiotics for a urinary tract infection. Please take all of your medications every day and weigh yourself every morning, call MD if weight goes up more than 3 lbs. We wish you the [MASKED], Your [MASKED] medical team. Followup Instructions: [MASKED]
|
[] |
[
"N390",
"I4891",
"E119",
"I129",
"Z7901",
"Z794",
"N189",
"K219",
"J45909",
"G8929",
"E785",
"Z66"
] |
[
"I5023: Acute on chronic systolic (congestive) heart failure",
"G92: Toxic encephalopathy",
"N390: Urinary tract infection, site not specified",
"I4891: Unspecified atrial fibrillation",
"E559: Vitamin D deficiency, unspecified",
"E119: Type 2 diabetes mellitus without complications",
"B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"Z7901: Long term (current) use of anticoagulants",
"Z794: Long term (current) use of insulin",
"N189: Chronic kidney disease, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"J45909: Unspecified asthma, uncomplicated",
"G8929: Other chronic pain",
"E785: Hyperlipidemia, unspecified",
"Z8572: Personal history of non-Hodgkin lymphomas",
"I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris",
"Z66: Do not resuscitate",
"R079: Chest pain, unspecified"
] |
10,028,480
| 25,485,913
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Indocin / Nafcillin
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old AA woman with a PMH significant for
HTN, HLD, T2DM, HFrEF (LVEF 25% ___, stage 3 CKD, AFib on
warfarin, OSA on CPAP, who presented to the ___ ED with SOB,
lower extremity edema, and chest pain.
Pt reports worsening since ___ of usual upper, lower back
pain and chest pain. She came to pain clinic on day of admission
for her chronic back pain where they referred her to ED for her
dyspnea. Dyspnea has been worsening over the last week, worse
with exertion. Over the last 2 weeks, has been eating salty
foods (fried chicken, fast food) because her refrigerator broke.
Usually adheres to a healthy diet with home cooked meals with
very little added salt. CP is her usual angina by location and
character (stabbing, left of sternum), occurs both at rest and
on exertion. Does not radiate. Nitro gives complete relief, last
taken x2 at 6am on ___. She has had this same chest pain ___
times per week over "many years".
Notably, she has UTI with urine cultures positive for E. Coli
(___), currently on cefpodoxime 200 mg BID prescribed by her
gynecologist which she began ___. She is incontinent at
baseline. Denies dysuria, increased frequency, increased urinary
urgency, fevers, chills, nausea, vomiting, diarrhea.
Past Medical History:
Infarct-related Systolic CHF (EF 25% ___
Type 2 IDDM
HTN
CAD (cath at ___ in ___ showing "small vessel disease",
cardiac cath in ___ showing single vessel disease no
intervention)
Atrial fibrillation
CKD, stage 3
OSA on CPAP
Gout
Non-Hodgkin's lymphoma
Multinodular Goiter
Glaucoma
Chronic Low Back Pain s/p lumbar decompression surgery
Osteoporosis
Urinary incontinence
s/p TAH and BSO
s/p bilateral knee replacements
s/p bilateral eye surgery
Social History:
___
Family History:
Diabetes; Grandmother died of MI at ___. Father: MI in ___,
Mother: died before her ___ of "heart condition that was
undiagnosed"
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
GENERAL: Short of breath at rest, difficulty carrying
conversation, appears tired, pleasant
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with distended neck veins, no JVP
CARDIAC: Irregularly irregular, no rubs murmurs or gallops.
LUNGS: Clear to auscultation bilaterally, no wheezes or
crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Bowel sounds present
EXTREMITIES: 1+ pitting edema to shins bilaterally, no cyanosis
or clubbing
SKIN: No rashes, bilateral linear knee scars from knee
replacement surgery
PULSES: 2+ Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
=======================
VITALS: T 97.9 PO BP 99/65 Lying HR 99 RR 18 ___
WEIGHT: ADMISSION 94.2 kg 207.67 lb TODAY: 89.9 kg (standing)
Is/Os: 24H 480 cc/250 cc; since midnight 280/520 cc
GENERAL: Obese, resting in bed comfortably with nebs, no acute
distress
NECK: Supple, JVP unassessable given AFib
CARDIAC: Irregularly irregular, S4 and I/VI systolic murmur
loudest at apex. No rubs.
LUNGS: Clear to auscultation bilaterally, no wheezes, rhonchi or
rales.
ABDOMEN: Soft, NTND, obese.
GU: No foley in place. No suprapubic tenderness.
EXTREMITIES: no edema, cyanosis, clubbing.
SKIN: No rashes, bilateral linear knee scars from knee
replacement surgery
PULSES: 2+ Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
=============
___ 10:40AM BLOOD WBC-7.4 RBC-3.60* Hgb-10.5* Hct-34.7
MCV-96 MCH-29.2 MCHC-30.3* RDW-17.2* RDWSD-58.4* Plt ___
___ 10:40AM BLOOD Neuts-62.6 ___ Monos-11.7
Eos-0.4* Baso-0.5 NRBC-0.4* Im ___ AbsNeut-4.60#
AbsLymp-1.77 AbsMono-0.86* AbsEos-0.03* AbsBaso-0.04
___ 10:40AM BLOOD ___ PTT-39.3* ___
___ 10:40AM BLOOD Glucose-203* UreaN-60* Creat-2.3* Na-138
K-5.1 Cl-101 HCO3-21* AnGap-16
___ 10:40AM BLOOD CK-MB-5 cTropnT-0.02* proBNP-7265*
___ 10:40AM BLOOD Calcium-9.0 Phos-5.5* Mg-2.3
___ 10:49AM BLOOD Lactate-2.2*
DISCHARGE LABS:
==============
___ 07:30AM BLOOD WBC-6.6 RBC-3.40* Hgb-9.5* Hct-32.3*
MCV-95 MCH-27.9 MCHC-29.4* RDW-16.4* RDWSD-56.8* Plt ___
___ 07:30AM BLOOD ___
___ 07:10AM BLOOD Glucose-101* UreaN-63* Creat-1.8* Na-148*
K-3.8 Cl-103 HCO3-29 AnGap-16
___ 07:10AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.1
DIAGNOSTIC STUDIES:
==================
CXR (___):
FINDINGS:
The heart is enlarged, stable. The trachea is midline. There
is mild
pulmonary edema, unchanged when allowing for differences in
technique. Mild
degenerative changes are seen in the spine.
IMPRESSION:
Mild pulmonary edema. Cardiomegaly.
CXR (___):
FINDINGS:
Cardiac silhouette size remains mildly enlarged. Mediastinal
and hilar
contours are unremarkable. Lung volumes remain low. Mild
pulmonary edema
appears new in the interval. No focal consolidation, pleural
effusion, or
pneumothorax is seen. There are mild degenerative changes seen
in the
thoracic spine.
Mild pulmonary edema, new in the interval.
Brief Hospital Course:
Ms. ___ is an ___ year old woman with a PMH of HFrEF (25%
___, HTN, HLD, Type 2 DM, stage 3 CKD, Afib on warfarin,
OSA on CPAP, who presented with SOB, lower extremity edema, and
chest tightness, found to have acute on chronic heart failure
exacerbation secondary to high salt diet at home over last 2
weeks. Problems addressed during this hospitalization are listed
below:
ACTIVE ISSUES:
=================================
# Acute on Chronic Heart Failure with Reduced Ejection
Fraction(EF 25% ___:
Patient presented with elevated BNP (7265), worsening shortness
of breath, volume overloaded on physical exam and CXR. Etiology
most likely diet-related, as patient reported eating high salt
diet over the last 2 weeks (fridge at home broke). Patient
compliant with home medications (lives with her son who monitors
medications), no significant concern for missed MI as trop
negative on admission. Was diuresed with 40-80 IV Lasix as
needed, then transitioned to torsemide 80 mg PO BID (previously
discharged in ___ on torsemide 40 daily). Her hydralazine
was also decreased to 10 in order to make room to increase her
isosorbide mononitrate (XR) to 60 mg QD to alleviate her
non-exertional chest pain below. She also had her metoprolol
succinate XL increased from 50 mg daily to 200 mg daily.
# Coronary Artery Disease:
Non-exertional chest pain is chronic issue that occurs ___ times
per week over many years. Presented with chest tightness. Trops
elevated on admission (0.02-->0.04-->0.03), but MB flat, likely
related to CKD. Cath at ___ in ___ showed "small vessel
disease", repeat cardiac cath in ___ showed single vessel
disease without any intervention. Had one episode of CP this
admission, relieved with 2 SL nitros, no EKG changes, trops
<0.01. Continue aspirin 81 mg, atorvastatin 40 mg, SL nitro as
needed, and isosorbide mononitrate 60 mg (increased from prior
discharge) as described above.
# UTI
# Urge incontinence
Patient has a history of urge incontinence for approx. ___ year.
Made appt to see OBGYN in ___, planned urodynamic study on ___
but was aborted given a urinalysis showed + nitrates and over
100 WBCs. Patient incontinent at home and mostly using adult
diapers, tried intermittent cath briefly. Asymptomatic
throughout admission; foley was placed to monitor ins and outs.
Urine was notably hazy. Urine culture from ___ grew
pansensitive E. coli. Completed course of cefpodoxime 200 mg BID
(___) prescribed by outpatient gynecologist. Will need
follow up with obgyn again. Sent home with another course of
cefpodoxime 200 mg BID (___) given a positive UA.
# ___:
Admission Cr 2.3, values ranged from 1.7-2.6 throughout hospital
course (baseline Cr 1.9), Most likely etiology reduced renal
perfusion and increased venous pressure from CHF exacerbation.
CHRONIC/STABLE ISSUES:
=================================
# Chronic Low Back Pain:
Present throughout admission, remained at baseline. Continued
home Gabapentin 100 mg PO TID, home Lidocaine 5% patch PRN.
Given oxycodone 5 mg PO Q4H PRN. Held home oxycodone
acetaminophen 7.5-325 mg oral TID.
# Type 2 IDDM:
Morning sugars 40-60s before breakfast, patient confirms that
this happens at home too. Optimized with glargine 34 units at
bedtime and ISS. Will need follow-up with endocrinologist as
outpatient.
# HTN:
Continued metoprolol, hydralazine, and isosorbide mononitrate.
Changes to dosing as above.
# Permanent Atrial Fib w/ RVR:
Continued metoprolol as above and home warfarin 7.5 decreased to
3.5 mg QD due to supratherapeutic INRs on admission (peak INR
3.8).
# OSA on CPAP:
Continued CPAP at night.
#Normocytic Anemia:
Remained stable (9.4-10.5).
#Gout:
Held home allopurinol ___ BID.
>30 minutes spent on discharge planning/coordination of care.
TRANSITIONAL ISSUES:
====================
- Please see changes and additions to medications.
- Patient requires follow-up with the heart failure nurse
practitioner at the cardiac direct access unit on ___.
- Please check basic metabolic panel (potassium, creatinine)
within 1 week, as home torsemide dose increased from 40 to 80 mg
BID on discharge.
- Please check INR and ensure patient compliant and therapeutic
with new warfarin dose of 3.5 mg daily.
- Patient was started on cefpodoxime for a urinary tract
infection (Last ___.
- Patient need to have a urodynamic study performed. This was
previously deferred given a UTI. Please re-check urinalysis for
evidence of UTI prior to obgyn appt on ___.
- Her hydralazine was decreased to 10mg TID to increase the
Imdur to 60mg daily for better anti-anginal therapy.
- Patient requires follow-up with ___ with
her endocrinologist Dr. ___ within 2 weeks of discharge
to adjust home insulin regimen.
- Consider switching from warfarin to rivaroxaban/apixaban
(renal dosing), given very low TTR on warfarin.
- CODE STATUS: Full code (confirmed)
- CONTACT: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Cyanocobalamin 1000 mcg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 100 mg PO TID
6. HydrALAZINE 20 mg PO Q8H
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. oxyCODONE-acetaminophen 7.5-325 mg oral TID
10. Pantoprazole 40 mg PO Q24H
11. Senna 17.2 mg PO BID
12. Vitamin D 1000 UNIT PO DAILY
13. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous
per sliding scale
14. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL)
subcutaneous 34 units in the morning, 14 units in the evening
15. Torsemide 40 mg PO QAM
16. Warfarin 3.5 mg PO DAILY16
17. Allopurinol ___ mg PO BID
18. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 3 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*5
Tablet Refills:*0
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*6
Tablet Refills:*0
2. HydrALAZINE 10 mg PO Q8H
RX *hydralazine 10 mg 1 (One) tablet(s) by mouth every eight (8)
hours Disp #*90 Tablet Refills:*0
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 (One) tablet(s) by mouth once
a day Disp #*30 Tablet Refills:*0
4. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate 200 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Torsemide 80 mg PO BID
RX *torsemide 20 mg 4 tablet(s) by mouth twice a day Disp #*240
Tablet Refills:*0
6. Allopurinol ___ mg PO BID
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Cyanocobalamin 1000 mcg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Gabapentin 100 mg PO TID
12. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous
per sliding scale
13. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL)
subcutaneous 34 units in the morning, 14 units in the evening
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. oxyCODONE-acetaminophen 7.5-325 mg oral TID
16. Pantoprazole 40 mg PO Q24H
17. Senna 17.2 mg PO BID
18. Vitamin D 1000 UNIT PO DAILY
19. Warfarin 3.5 mg PO DAILY16
20.Hospital Bed
Hospital Bed
Length: ___ years
Diagnosis: Chronic diastolic (congestive) heart failure (I50.32)
Limited mobility, severe shortness of breath on exertion
21.Oxygen
Oxygen Therapy
Length: ___ years
Portable O2 tank and concentrator unit
Diagnosis: I50.32 Chronic diastolic (congestive) heart failure
Severe shortness of breath on exertion and desaturation to <88%
22.Outpatient Lab Work
ICD9: 428.3
Please check:
Chem 10, INR on ___.
Please fax results to ___, MD : ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==================
Acute on chronic heart failure with reduced ejection fraction
Acute on chronic Kidney Injury
Secondary Diagnosis:
====================
Coronary Artery Disease
Hypertension
Hyperlipidemia
Type 2 diabetes mellitus
Stage 3 Chronic kidney disease
Atrial fibrillation
Obstructive Sleep Apnea
Urinary tract infection
Gout
Chronic back pain
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why was I admitted to the hospital?
- You came to the hospital because you were having shortness of
breath and swelling in your legs.
- You were found to have extra fluid in your body. We believe
this happened because you ate a high salt diet for several weeks
before coming to the hospital, and this worsened your heart
failure.
What happened while I was admitted?
- We treated you with medication to remove this extra fluid from
your body. Your shortness of breath and swelling improved with
this medication.
- You developed some chest pain in the hospital, which was
similar to the chest pain you often experience at home. We
monitored this with blood tests and EKGs, which evaluate the
electrical activity of the heart.
- We also continued to treat you with antibiotics for a urinary
tract infection that you had before you came to the hospital.
What should I do when I go home?
- Please follow up with your primary care doctor and our heart
failure clinic as listed below.
- Please maintain a low salt diet (salt causes your body to
retain fluid, which makes you short of breath).
- Please continue to take your antibiotic (cefpodoxime) for the
urinary tract infection for the next 3 days. (Last ___
- Please weigh yourself in the morning everyday. Call your
primary care doctor or the heart failure clinic if your weight
increases by more than 3 lbs over ___ days.
We wish you all the ___,
-Your ___ cardiology team
Followup Instructions:
___
|
[
"I130",
"I5023",
"E1122",
"N390",
"G4733",
"I482",
"B9620",
"Z96653",
"G8929",
"M109",
"I2510",
"Z7901",
"Z794",
"D649",
"Z8572",
"N183",
"K5903",
"T402X5A",
"Y929",
"E785"
] |
Allergies: Morphine / Indocin / Nafcillin Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a [MASKED] year old AA woman with a PMH significant for HTN, HLD, T2DM, HFrEF (LVEF 25% [MASKED], stage 3 CKD, AFib on warfarin, OSA on CPAP, who presented to the [MASKED] ED with SOB, lower extremity edema, and chest pain. Pt reports worsening since [MASKED] of usual upper, lower back pain and chest pain. She came to pain clinic on day of admission for her chronic back pain where they referred her to ED for her dyspnea. Dyspnea has been worsening over the last week, worse with exertion. Over the last 2 weeks, has been eating salty foods (fried chicken, fast food) because her refrigerator broke. Usually adheres to a healthy diet with home cooked meals with very little added salt. CP is her usual angina by location and character (stabbing, left of sternum), occurs both at rest and on exertion. Does not radiate. Nitro gives complete relief, last taken x2 at 6am on [MASKED]. She has had this same chest pain [MASKED] times per week over "many years". Notably, she has UTI with urine cultures positive for E. Coli ([MASKED]), currently on cefpodoxime 200 mg BID prescribed by her gynecologist which she began [MASKED]. She is incontinent at baseline. Denies dysuria, increased frequency, increased urinary urgency, fevers, chills, nausea, vomiting, diarrhea. Past Medical History: Infarct-related Systolic CHF (EF 25% [MASKED] Type 2 IDDM HTN CAD (cath at [MASKED] in [MASKED] showing "small vessel disease", cardiac cath in [MASKED] showing single vessel disease no intervention) Atrial fibrillation CKD, stage 3 OSA on CPAP Gout Non-Hodgkin's lymphoma Multinodular Goiter Glaucoma Chronic Low Back Pain s/p lumbar decompression surgery Osteoporosis Urinary incontinence s/p TAH and BSO s/p bilateral knee replacements s/p bilateral eye surgery Social History: [MASKED] Family History: Diabetes; Grandmother died of MI at [MASKED]. Father: MI in [MASKED], Mother: died before her [MASKED] of "heart condition that was undiagnosed" Physical Exam: ADMISSION PHYSICAL EXAM: ====================== GENERAL: Short of breath at rest, difficulty carrying conversation, appears tired, pleasant HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with distended neck veins, no JVP CARDIAC: Irregularly irregular, no rubs murmurs or gallops. LUNGS: Clear to auscultation bilaterally, no wheezes or crackles. ABDOMEN: Soft, NTND. No HSM or tenderness. Bowel sounds present EXTREMITIES: 1+ pitting edema to shins bilaterally, no cyanosis or clubbing SKIN: No rashes, bilateral linear knee scars from knee replacement surgery PULSES: 2+ Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAM: ======================= VITALS: T 97.9 PO BP 99/65 Lying HR 99 RR 18 [MASKED] WEIGHT: ADMISSION 94.2 kg 207.67 lb TODAY: 89.9 kg (standing) Is/Os: 24H 480 cc/250 cc; since midnight 280/520 cc GENERAL: Obese, resting in bed comfortably with nebs, no acute distress NECK: Supple, JVP unassessable given AFib CARDIAC: Irregularly irregular, S4 and I/VI systolic murmur loudest at apex. No rubs. LUNGS: Clear to auscultation bilaterally, no wheezes, rhonchi or rales. ABDOMEN: Soft, NTND, obese. GU: No foley in place. No suprapubic tenderness. EXTREMITIES: no edema, cyanosis, clubbing. SKIN: No rashes, bilateral linear knee scars from knee replacement surgery PULSES: 2+ Distal pulses palpable and symmetric Pertinent Results: ADMISSION LABS: ============= [MASKED] 10:40AM BLOOD WBC-7.4 RBC-3.60* Hgb-10.5* Hct-34.7 MCV-96 MCH-29.2 MCHC-30.3* RDW-17.2* RDWSD-58.4* Plt [MASKED] [MASKED] 10:40AM BLOOD Neuts-62.6 [MASKED] Monos-11.7 Eos-0.4* Baso-0.5 NRBC-0.4* Im [MASKED] AbsNeut-4.60# AbsLymp-1.77 AbsMono-0.86* AbsEos-0.03* AbsBaso-0.04 [MASKED] 10:40AM BLOOD [MASKED] PTT-39.3* [MASKED] [MASKED] 10:40AM BLOOD Glucose-203* UreaN-60* Creat-2.3* Na-138 K-5.1 Cl-101 HCO3-21* AnGap-16 [MASKED] 10:40AM BLOOD CK-MB-5 cTropnT-0.02* proBNP-7265* [MASKED] 10:40AM BLOOD Calcium-9.0 Phos-5.5* Mg-2.3 [MASKED] 10:49AM BLOOD Lactate-2.2* DISCHARGE LABS: ============== [MASKED] 07:30AM BLOOD WBC-6.6 RBC-3.40* Hgb-9.5* Hct-32.3* MCV-95 MCH-27.9 MCHC-29.4* RDW-16.4* RDWSD-56.8* Plt [MASKED] [MASKED] 07:30AM BLOOD [MASKED] [MASKED] 07:10AM BLOOD Glucose-101* UreaN-63* Creat-1.8* Na-148* K-3.8 Cl-103 HCO3-29 AnGap-16 [MASKED] 07:10AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.1 DIAGNOSTIC STUDIES: ================== CXR ([MASKED]): FINDINGS: The heart is enlarged, stable. The trachea is midline. There is mild pulmonary edema, unchanged when allowing for differences in technique. Mild degenerative changes are seen in the spine. IMPRESSION: Mild pulmonary edema. Cardiomegaly. CXR ([MASKED]): FINDINGS: Cardiac silhouette size remains mildly enlarged. Mediastinal and hilar contours are unremarkable. Lung volumes remain low. Mild pulmonary edema appears new in the interval. No focal consolidation, pleural effusion, or pneumothorax is seen. There are mild degenerative changes seen in the thoracic spine. Mild pulmonary edema, new in the interval. Brief Hospital Course: Ms. [MASKED] is an [MASKED] year old woman with a PMH of HFrEF (25% [MASKED], HTN, HLD, Type 2 DM, stage 3 CKD, Afib on warfarin, OSA on CPAP, who presented with SOB, lower extremity edema, and chest tightness, found to have acute on chronic heart failure exacerbation secondary to high salt diet at home over last 2 weeks. Problems addressed during this hospitalization are listed below: ACTIVE ISSUES: ================================= # Acute on Chronic Heart Failure with Reduced Ejection Fraction(EF 25% [MASKED]: Patient presented with elevated BNP (7265), worsening shortness of breath, volume overloaded on physical exam and CXR. Etiology most likely diet-related, as patient reported eating high salt diet over the last 2 weeks (fridge at home broke). Patient compliant with home medications (lives with her son who monitors medications), no significant concern for missed MI as trop negative on admission. Was diuresed with 40-80 IV Lasix as needed, then transitioned to torsemide 80 mg PO BID (previously discharged in [MASKED] on torsemide 40 daily). Her hydralazine was also decreased to 10 in order to make room to increase her isosorbide mononitrate (XR) to 60 mg QD to alleviate her non-exertional chest pain below. She also had her metoprolol succinate XL increased from 50 mg daily to 200 mg daily. # Coronary Artery Disease: Non-exertional chest pain is chronic issue that occurs [MASKED] times per week over many years. Presented with chest tightness. Trops elevated on admission (0.02-->0.04-->0.03), but MB flat, likely related to CKD. Cath at [MASKED] in [MASKED] showed "small vessel disease", repeat cardiac cath in [MASKED] showed single vessel disease without any intervention. Had one episode of CP this admission, relieved with 2 SL nitros, no EKG changes, trops <0.01. Continue aspirin 81 mg, atorvastatin 40 mg, SL nitro as needed, and isosorbide mononitrate 60 mg (increased from prior discharge) as described above. # UTI # Urge incontinence Patient has a history of urge incontinence for approx. [MASKED] year. Made appt to see OBGYN in [MASKED], planned urodynamic study on [MASKED] but was aborted given a urinalysis showed + nitrates and over 100 WBCs. Patient incontinent at home and mostly using adult diapers, tried intermittent cath briefly. Asymptomatic throughout admission; foley was placed to monitor ins and outs. Urine was notably hazy. Urine culture from [MASKED] grew pansensitive E. coli. Completed course of cefpodoxime 200 mg BID ([MASKED]) prescribed by outpatient gynecologist. Will need follow up with obgyn again. Sent home with another course of cefpodoxime 200 mg BID ([MASKED]) given a positive UA. # [MASKED]: Admission Cr 2.3, values ranged from 1.7-2.6 throughout hospital course (baseline Cr 1.9), Most likely etiology reduced renal perfusion and increased venous pressure from CHF exacerbation. CHRONIC/STABLE ISSUES: ================================= # Chronic Low Back Pain: Present throughout admission, remained at baseline. Continued home Gabapentin 100 mg PO TID, home Lidocaine 5% patch PRN. Given oxycodone 5 mg PO Q4H PRN. Held home oxycodone acetaminophen 7.5-325 mg oral TID. # Type 2 IDDM: Morning sugars 40-60s before breakfast, patient confirms that this happens at home too. Optimized with glargine 34 units at bedtime and ISS. Will need follow-up with endocrinologist as outpatient. # HTN: Continued metoprolol, hydralazine, and isosorbide mononitrate. Changes to dosing as above. # Permanent Atrial Fib w/ RVR: Continued metoprolol as above and home warfarin 7.5 decreased to 3.5 mg QD due to supratherapeutic INRs on admission (peak INR 3.8). # OSA on CPAP: Continued CPAP at night. #Normocytic Anemia: Remained stable (9.4-10.5). #Gout: Held home allopurinol [MASKED] BID. >30 minutes spent on discharge planning/coordination of care. TRANSITIONAL ISSUES: ==================== - Please see changes and additions to medications. - Patient requires follow-up with the heart failure nurse practitioner at the cardiac direct access unit on [MASKED]. - Please check basic metabolic panel (potassium, creatinine) within 1 week, as home torsemide dose increased from 40 to 80 mg BID on discharge. - Please check INR and ensure patient compliant and therapeutic with new warfarin dose of 3.5 mg daily. - Patient was started on cefpodoxime for a urinary tract infection (Last [MASKED]. - Patient need to have a urodynamic study performed. This was previously deferred given a UTI. Please re-check urinalysis for evidence of UTI prior to obgyn appt on [MASKED]. - Her hydralazine was decreased to 10mg TID to increase the Imdur to 60mg daily for better anti-anginal therapy. - Patient requires follow-up with [MASKED] with her endocrinologist Dr. [MASKED] within 2 weeks of discharge to adjust home insulin regimen. - Consider switching from warfarin to rivaroxaban/apixaban (renal dosing), given very low TTR on warfarin. - CODE STATUS: Full code (confirmed) - CONTACT: [MASKED] (daughter) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Cyanocobalamin 1000 mcg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Gabapentin 100 mg PO TID 6. HydrALAZINE 20 mg PO Q8H 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 8. Metoprolol Succinate XL 50 mg PO DAILY 9. oxyCODONE-acetaminophen 7.5-325 mg oral TID 10. Pantoprazole 40 mg PO Q24H 11. Senna 17.2 mg PO BID 12. Vitamin D 1000 UNIT PO DAILY 13. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous per sliding scale 14. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL) subcutaneous 34 units in the morning, 14 units in the evening 15. Torsemide 40 mg PO QAM 16. Warfarin 3.5 mg PO DAILY16 17. Allopurinol [MASKED] mg PO BID 18. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain Discharge Medications: 1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 3 Days RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*5 Tablet Refills:*0 RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0 2. HydrALAZINE 10 mg PO Q8H RX *hydralazine 10 mg 1 (One) tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*0 3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY RX *isosorbide mononitrate 60 mg 1 (One) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. Metoprolol Succinate XL 200 mg PO DAILY RX *metoprolol succinate 200 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Torsemide 80 mg PO BID RX *torsemide 20 mg 4 tablet(s) by mouth twice a day Disp #*240 Tablet Refills:*0 6. Allopurinol [MASKED] mg PO BID 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 40 mg PO QPM 9. Cyanocobalamin 1000 mcg PO DAILY 10. Docusate Sodium 100 mg PO BID 11. Gabapentin 100 mg PO TID 12. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous per sliding scale 13. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL) subcutaneous 34 units in the morning, 14 units in the evening 14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 15. oxyCODONE-acetaminophen 7.5-325 mg oral TID 16. Pantoprazole 40 mg PO Q24H 17. Senna 17.2 mg PO BID 18. Vitamin D 1000 UNIT PO DAILY 19. Warfarin 3.5 mg PO DAILY16 20.Hospital Bed Hospital Bed Length: [MASKED] years Diagnosis: Chronic diastolic (congestive) heart failure (I50.32) Limited mobility, severe shortness of breath on exertion 21.Oxygen Oxygen Therapy Length: [MASKED] years Portable O2 tank and concentrator unit Diagnosis: I50.32 Chronic diastolic (congestive) heart failure Severe shortness of breath on exertion and desaturation to <88% 22.Outpatient Lab Work ICD9: 428.3 Please check: Chem 10, INR on [MASKED]. Please fax results to [MASKED], MD : [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis: ================== Acute on chronic heart failure with reduced ejection fraction Acute on chronic Kidney Injury Secondary Diagnosis: ==================== Coronary Artery Disease Hypertension Hyperlipidemia Type 2 diabetes mellitus Stage 3 Chronic kidney disease Atrial fibrillation Obstructive Sleep Apnea Urinary tract infection Gout Chronic back pain Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid Discharge Instructions: Dear Ms. [MASKED], It was a pleasure to care for you at the [MASKED] [MASKED]. Why was I admitted to the hospital? - You came to the hospital because you were having shortness of breath and swelling in your legs. - You were found to have extra fluid in your body. We believe this happened because you ate a high salt diet for several weeks before coming to the hospital, and this worsened your heart failure. What happened while I was admitted? - We treated you with medication to remove this extra fluid from your body. Your shortness of breath and swelling improved with this medication. - You developed some chest pain in the hospital, which was similar to the chest pain you often experience at home. We monitored this with blood tests and EKGs, which evaluate the electrical activity of the heart. - We also continued to treat you with antibiotics for a urinary tract infection that you had before you came to the hospital. What should I do when I go home? - Please follow up with your primary care doctor and our heart failure clinic as listed below. - Please maintain a low salt diet (salt causes your body to retain fluid, which makes you short of breath). - Please continue to take your antibiotic (cefpodoxime) for the urinary tract infection for the next 3 days. (Last [MASKED] - Please weigh yourself in the morning everyday. Call your primary care doctor or the heart failure clinic if your weight increases by more than 3 lbs over [MASKED] days. We wish you all the [MASKED], -Your [MASKED] cardiology team Followup Instructions: [MASKED]
|
[] |
[
"I130",
"E1122",
"N390",
"G4733",
"G8929",
"M109",
"I2510",
"Z7901",
"Z794",
"D649",
"Y929",
"E785"
] |
[
"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",
"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"N390: Urinary tract infection, site not specified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"I482: Chronic atrial fibrillation",
"B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere",
"Z96653: Presence of artificial knee joint, bilateral",
"G8929: Other chronic pain",
"M109: Gout, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z7901: Long term (current) use of anticoagulants",
"Z794: Long term (current) use of insulin",
"D649: Anemia, unspecified",
"Z8572: Personal history of non-Hodgkin lymphomas",
"N183: Chronic kidney disease, stage 3 (moderate)",
"K5903: Drug induced constipation",
"T402X5A: Adverse effect of other opioids, initial encounter",
"Y929: Unspecified place or not applicable",
"E785: Hyperlipidemia, unspecified"
] |
10,028,480
| 27,911,538
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Indocin / Nafcillin
Attending: ___.
Chief Complaint:
Dyspnea, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of HFrEF (infarct related, EF 25% ___,
CAD, atrial fibrillation, T2DM, HTN, who presents with complaint
of chest pain and dyspnea.
Patient states that over the last several days she has felt
more tired, with decreased appetite and progressively worsening
lower extremity edema. Patient states that this morning around
9AM she was sitting down when she had sudden onset of chest pain
described as ___ chest, non-radiating. She states that
pain has decreased somewhat but is still present and has been
fairly constant since onset. She has felt progressively more
short of breath over the past few days as well. She has had
orthopnea and a dry cough. She denies fever, chills, nausea,
vomiting.
Of note, pt was seen in the ED two days ago for left hand pain,
thought due to gout. Attempt at wrist aspiration yielded a dry
tap. She was prescribed colchicine.
Past Medical History:
Infarct-related Systolic CHF (EF 25% ___
DM
HTN
CAD (cath at ___ in ___ showing "small vessel disease",
cardiac cath in ___ showing two vessel disease without any
intervention)
Atrial fibrillation
Gout
Non-Hodgkin's lymphoma
Multinodular Goiter
Chronic Low Back Pain
s/p hysterectomy
s/p bilateral knee replacements
s/p bilateral eye surgery
OSA on CPAP
Social History:
___
Family History:
Diabetes; Grandmother died of MI at ___. Father: MI in ___,
Mother: died before her ___ of "heart condition that was
undiagnosed"
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98 ___ 18 94%2LNC
Weight: 85.7 kg
GENERAL: Well developed, well nourished in NAD. 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 elevated to jawline
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. irregular rhythm. Normal S1, S2. No murmurs, rubs, or
gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Diffuse
crackles to bilateral shoulder blades
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. 1+ pitting edema to knees
bilaterally
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM:
Vitals: 97.9, HR ___, 100s-120s/60s-70s, RR ___, 98% RA
Weight: 82.1 kg
General: Chronically ill appearing elderly female sitting in
chair
HEENT: NC/AT, sclerae anicteric, OP clear
Neck: JVP elevated to 9cm H2O at 90 degrees
Lungs: Lungs CTAB, breathes somewhat deliberately but speaking
full sentences, no w/r/r
CV: RRR, no m/g/r
Abdomen: Nontender, nondistended, NABS
Ext: No pitting ___, WWP; L wrist ROM limited by pain, TTP
Pertinent Results:
ADMISSION LABS:
----------------
___ 10:20AM BLOOD WBC-10.2* RBC-3.99 Hgb-11.7 Hct-35.3
MCV-89 MCH-29.3 MCHC-33.1 RDW-14.3 RDWSD-45.5 Plt ___
___ 10:20AM BLOOD Neuts-75.3* Lymphs-14.1* Monos-9.8
Eos-0.1* Baso-0.2 Im ___ AbsNeut-7.65* AbsLymp-1.43
AbsMono-1.00* AbsEos-0.01* AbsBaso-0.02
___ 10:20AM BLOOD ___ PTT-28.4 ___
___ 10:20AM BLOOD Glucose-302* UreaN-28* Creat-1.5* Na-133
K-7.1* Cl-97 HCO3-20* AnGap-23*
___ 08:50PM BLOOD K-2.7*
___ 10:20AM BLOOD CK(CPK)-140
___ 08:50PM BLOOD ALT-10 AST-11 LD(LDH)-206 AlkPhos-62
TotBili-1.7*
___ 10:20AM BLOOD CK-MB-2 cTropnT-0.08* proBNP-8312*
___ 08:50PM BLOOD CK-MB-2 cTropnT-0.12*
___ 08:50PM BLOOD Albumin-3.2* Mg-1.6
___ 12:38PM BLOOD K-4.2
___ 08:53PM BLOOD Lactate-2.4*
DISCHARGE LABS:
----------------
___ 07:45AM BLOOD WBC-6.9 RBC-4.29 Hgb-12.5 Hct-39.5 MCV-92
MCH-29.1 MCHC-31.6* RDW-15.3 RDWSD-49.7* Plt ___
___ 07:45AM BLOOD Glucose-79 UreaN-34* Creat-1.7* Na-143
K-4.0 Cl-105 HCO3-21* AnGap-21*
___ 07:45AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0
MICROBIOLOGY: NONE
IMAGING:
----------
CXR ___
Moderate pulmonary edema with cardiomegaly. Superimposed
pneumonia cannot be excluded in the appropriate clinical
setting.
TTE ___
The left atrium is mildly dilated. No left atrial mass/thrombus
seen ___ excluded by transesophageal echocardiography). No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
mildly dilated with severe hypokinesis of the septum and
inferior walls and mildl hypokinesis of the remaining segments
(Biplane LVEF= 25%). Left ventricular cardiac index is depressed
(<2.0 L/min/m2). No intraventricular thrormbus is seen. There is
no ventricular septal defect. The right ventricular cavity is
mildly dilated with moderate global free wall hypokinesis. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no systolic prolapse. Moderate to severe (3+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mildly dilated biventricular cavity sizes with
regional and global systolic dysfunction c/w multivessel CAD or
other diffuse process. Moderate to severe mitral regurgitation.
Mild pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Brief Hospital Course:
___ with h/o ischemic CHF (EF 25% ___, CAD, afib on
apixaban, DM2 on insulin, HTN, who presents with chest pain and
dyspnea, admitted for acute on chronic systolic CHF.
# Acute on chronic Systolic CHF
Patient presented w dyspnea, volume overload on CXR, elevated
JVP, proBNP 8312 above prior values (1200-3000s). Unclear
precipitant, as denies dietary indiscretion, missed meds, or
other illness aside from "gout" wrist pain. TTE similar to prior
(LVEF 25%, mild biventricular dilation, severe LV hypokinesis of
the septum and inferior walls and mild hypokinesis of the
remaining segments, 3+ MR, mild pulmonary HTN). Troponin
elevated likely demand in setting of acute exacerbation, and it
trended down during admission. Diuresed well with 120 IV Lasix
BID, transitioned to Torsemide 40 mg BID. Continued home
Losartan. Started Imdur 30 mg daily, Hydralazine 25 mg TID, and
restarted spironolactone 25 mg daily for afterload reduction.
Continued home Metoprolol Succinate, but increased the dose to
75 mg BID.
#Chest pain
#Type 2 NSTEMI
On admission, patient had chest pain associated with mild
Troponinemia without EKG changes, thought to most likely be
demand ischemia from CHF exacerbation. Troponin peaked at 0.16
and she did not continue to have chest pain or discomfort.
Likely demand ischemia due to CHF exacerbation.
#CAD
History of 2 vessel CAD (Left main proximal 20% and LAD proximal
30% w diffuse dz) confirmed on cath ___ at ___. Had previous
cath ___ (___) with "small vessel disease." Last nuclear stress
test ___ with moderate fixed inferior wall defect. Continued
home metoprolol, losartan, aspirin, and atorvastatin.
#Wrist pain: Likely gout
Has chronic back and knee pain, on Percocet at home, with
history of crystal proven gout in ___, given 1.8mg colchicine
and dry tap in ED prior to admission on ___. Continued to have
significant pain and swelling on admission, improved with
Colchicine 0.6mg BID and Tylenol ___ mg TID. Uric acid 10.8,
consistent with prior levels. Consider starting uric acid
lowering agent after acute flare.
#IDDM
Morning levemir 44U qAM was decreased to 34U qAM for borderline
fasting blood sugars in the ___, and her pm dose was decreased
from 14U to 10U. Continued sliding scale Humalog.
#Atrial fibrillation: Continued home apixaban, metop succinate,
digoxin
#CKD: Likely multifactorial from hypertension and diabetes, no
evidence of ___. Nephrology f/u arranged.
#HLD: Continued atorvastatin 40mg qHS
#OSA: Used home CPAP machine
TRANSITIONAL ISSUES:
--------------------
- Torsemide increased to 40mg BID
- Discharge weight: 82.1 kg / 181 lbs
- Discharge Cr: 1.7
- Started Imdur 30 mg daily, Hydralazine 25 mg TID, and
Spironolactone 25 mg daily.
- Increased Metoprolol Succinate dose from 100mg once daily to
75mg BID
- Started Colchicine 0.6 mg BID for gout. Can be stopped once
acute flare resolves.
- Consider uric acid lowering agent after acute flare
- Discharged with rolling walker and home ___
- Decreased insulin dosing in house as detailed above, please
monitor closely as outpatient and adjust as necessary
# CONTACT: Daughter/HCP: ___, Cell phone: ___
# Code Status: Full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. oxyCODONE-acetaminophen 7.5-325 mg oral TID
3. Apixaban 2.5 mg PO BID
4. Losartan Potassium 100 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Senna 17.2 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. Cyanocobalamin 1000 mcg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Levemir 44 Units Breakfast
Levemir 14 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
12. Torsemide 40 mg PO QAM
13. Torsemide 20 mg PO QPM
14. Potassium Chloride 10 mEq PO DAILY
15. Gabapentin 100 mg PO TID
16. Digoxin 0.0625 mg PO DAILY
17. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Colchicine 0.6 mg PO BID
RX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp #*20
Tablet Refills:*0
2. HydrALAZINE 25 mg PO TID
RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Spironolactone 25 mg PO DAILY
RX *spironolactone 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Levemir 34 Units Breakfast
Levemir 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Metoprolol Succinate XL 75 mg PO BID
RX *metoprolol succinate [Toprol XL] 50 mg 1.5 tablet(s) by
mouth twice a day Disp #*90 Tablet Refills:*0
7. Torsemide 40 mg PO BID
RX *torsemide 20 mg 2 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
8. Apixaban 2.5 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 40 mg PO QPM
11. Cyanocobalamin 1000 mcg PO DAILY
12. Digoxin 0.0625 mg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Gabapentin 100 mg PO TID
15. Losartan Potassium 100 mg PO DAILY
16. oxyCODONE-acetaminophen 7.5-325 mg oral TID
17. Pantoprazole 40 mg PO Q24H
18. Senna 17.2 mg PO BID
19. Vitamin D 1000 UNIT PO DAILY
20.Outpatient Physical Therapy
Rolling Walker
Dx: CHF, ICD-10 I50.2
Px: Good
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
acute on chronic systolic heart failure
chest pain
type 2 NSTEMI
wrist pain / gout
atrial fibrillation
IDDM
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 came to the hospital because you were short of breath and
had too much fluid built up in your body.
You got IV medicine called Lasix and you got rid of the extra
fluid. Your breathing improved and you did not need oxygen
anymore.
You also started medicine called Colchicine for gout in your
wrist. You should take this until you feel better and then talk
to your doctor about starting a medicine called allopurinol to
prevent gout flares from happening.
Please see below for changes in your medicines and your
follow-up appointments.
Please weigh yourself every morning, call Dr. ___ office
at ___ if weight goes up more than 3 pounds in one day,
or 5 pounds in one week.
It was a pleasure caring for you and we wish you the ___,
Your ___ Cardiology Team
Followup Instructions:
___
|
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Allergies: Morphine / Indocin / Nafcillin Chief Complaint: Dyspnea, chest pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with a history of HFrEF (infarct related, EF 25% [MASKED], CAD, atrial fibrillation, T2DM, HTN, who presents with complaint of chest pain and dyspnea. Patient states that over the last several days she has felt more tired, with decreased appetite and progressively worsening lower extremity edema. Patient states that this morning around 9AM she was sitting down when she had sudden onset of chest pain described as [MASKED] chest, non-radiating. She states that pain has decreased somewhat but is still present and has been fairly constant since onset. She has felt progressively more short of breath over the past few days as well. She has had orthopnea and a dry cough. She denies fever, chills, nausea, vomiting. Of note, pt was seen in the ED two days ago for left hand pain, thought due to gout. Attempt at wrist aspiration yielded a dry tap. She was prescribed colchicine. Past Medical History: Infarct-related Systolic CHF (EF 25% [MASKED] DM HTN CAD (cath at [MASKED] in [MASKED] showing "small vessel disease", cardiac cath in [MASKED] showing two vessel disease without any intervention) Atrial fibrillation Gout Non-Hodgkin's lymphoma Multinodular Goiter Chronic Low Back Pain s/p hysterectomy s/p bilateral knee replacements s/p bilateral eye surgery OSA on CPAP Social History: [MASKED] Family History: Diabetes; Grandmother died of MI at [MASKED]. Father: MI in [MASKED], Mother: died before her [MASKED] of "heart condition that was undiagnosed" Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 98 [MASKED] 18 94%2LNC Weight: 85.7 kg GENERAL: Well developed, well nourished in NAD. 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 elevated to jawline CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. irregular rhythm. Normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. LUNGS: No chest wall deformities or tenderness. Diffuse crackles to bilateral shoulder blades ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. 1+ pitting edema to knees bilaterally SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM: Vitals: 97.9, HR [MASKED], 100s-120s/60s-70s, RR [MASKED], 98% RA Weight: 82.1 kg General: Chronically ill appearing elderly female sitting in chair HEENT: NC/AT, sclerae anicteric, OP clear Neck: JVP elevated to 9cm H2O at 90 degrees Lungs: Lungs CTAB, breathes somewhat deliberately but speaking full sentences, no w/r/r CV: RRR, no m/g/r Abdomen: Nontender, nondistended, NABS Ext: No pitting [MASKED], WWP; L wrist ROM limited by pain, TTP Pertinent Results: ADMISSION LABS: ---------------- [MASKED] 10:20AM BLOOD WBC-10.2* RBC-3.99 Hgb-11.7 Hct-35.3 MCV-89 MCH-29.3 MCHC-33.1 RDW-14.3 RDWSD-45.5 Plt [MASKED] [MASKED] 10:20AM BLOOD Neuts-75.3* Lymphs-14.1* Monos-9.8 Eos-0.1* Baso-0.2 Im [MASKED] AbsNeut-7.65* AbsLymp-1.43 AbsMono-1.00* AbsEos-0.01* AbsBaso-0.02 [MASKED] 10:20AM BLOOD [MASKED] PTT-28.4 [MASKED] [MASKED] 10:20AM BLOOD Glucose-302* UreaN-28* Creat-1.5* Na-133 K-7.1* Cl-97 HCO3-20* AnGap-23* [MASKED] 08:50PM BLOOD K-2.7* [MASKED] 10:20AM BLOOD CK(CPK)-140 [MASKED] 08:50PM BLOOD ALT-10 AST-11 LD(LDH)-206 AlkPhos-62 TotBili-1.7* [MASKED] 10:20AM BLOOD CK-MB-2 cTropnT-0.08* proBNP-8312* [MASKED] 08:50PM BLOOD CK-MB-2 cTropnT-0.12* [MASKED] 08:50PM BLOOD Albumin-3.2* Mg-1.6 [MASKED] 12:38PM BLOOD K-4.2 [MASKED] 08:53PM BLOOD Lactate-2.4* DISCHARGE LABS: ---------------- [MASKED] 07:45AM BLOOD WBC-6.9 RBC-4.29 Hgb-12.5 Hct-39.5 MCV-92 MCH-29.1 MCHC-31.6* RDW-15.3 RDWSD-49.7* Plt [MASKED] [MASKED] 07:45AM BLOOD Glucose-79 UreaN-34* Creat-1.7* Na-143 K-4.0 Cl-105 HCO3-21* AnGap-21* [MASKED] 07:45AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0 MICROBIOLOGY: NONE IMAGING: ---------- CXR [MASKED] Moderate pulmonary edema with cardiomegaly. Superimposed pneumonia cannot be excluded in the appropriate clinical setting. TTE [MASKED] The left atrium is mildly dilated. No left atrial mass/thrombus seen [MASKED] excluded by transesophageal echocardiography). 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. The left ventricular cavity is mildly dilated with severe hypokinesis of the septum and inferior walls and mildl hypokinesis of the remaining segments (Biplane LVEF= 25%). Left ventricular cardiac index is depressed (<2.0 L/min/m2). No intraventricular thrormbus is seen. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no systolic prolapse. Moderate to severe (3+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mildly dilated biventricular cavity sizes with regional and global systolic dysfunction c/w multivessel CAD or other diffuse process. Moderate to severe mitral regurgitation. Mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [MASKED], the findings are similar. Brief Hospital Course: [MASKED] with h/o ischemic CHF (EF 25% [MASKED], CAD, afib on apixaban, DM2 on insulin, HTN, who presents with chest pain and dyspnea, admitted for acute on chronic systolic CHF. # Acute on chronic Systolic CHF Patient presented w dyspnea, volume overload on CXR, elevated JVP, proBNP 8312 above prior values (1200-3000s). Unclear precipitant, as denies dietary indiscretion, missed meds, or other illness aside from "gout" wrist pain. TTE similar to prior (LVEF 25%, mild biventricular dilation, severe LV hypokinesis of the septum and inferior walls and mild hypokinesis of the remaining segments, 3+ MR, mild pulmonary HTN). Troponin elevated likely demand in setting of acute exacerbation, and it trended down during admission. Diuresed well with 120 IV Lasix BID, transitioned to Torsemide 40 mg BID. Continued home Losartan. Started Imdur 30 mg daily, Hydralazine 25 mg TID, and restarted spironolactone 25 mg daily for afterload reduction. Continued home Metoprolol Succinate, but increased the dose to 75 mg BID. #Chest pain #Type 2 NSTEMI On admission, patient had chest pain associated with mild Troponinemia without EKG changes, thought to most likely be demand ischemia from CHF exacerbation. Troponin peaked at 0.16 and she did not continue to have chest pain or discomfort. Likely demand ischemia due to CHF exacerbation. #CAD History of 2 vessel CAD (Left main proximal 20% and LAD proximal 30% w diffuse dz) confirmed on cath [MASKED] at [MASKED]. Had previous cath [MASKED] ([MASKED]) with "small vessel disease." Last nuclear stress test [MASKED] with moderate fixed inferior wall defect. Continued home metoprolol, losartan, aspirin, and atorvastatin. #Wrist pain: Likely gout Has chronic back and knee pain, on Percocet at home, with history of crystal proven gout in [MASKED], given 1.8mg colchicine and dry tap in ED prior to admission on [MASKED]. Continued to have significant pain and swelling on admission, improved with Colchicine 0.6mg BID and Tylenol [MASKED] mg TID. Uric acid 10.8, consistent with prior levels. Consider starting uric acid lowering agent after acute flare. #IDDM Morning levemir 44U qAM was decreased to 34U qAM for borderline fasting blood sugars in the [MASKED], and her pm dose was decreased from 14U to 10U. Continued sliding scale Humalog. #Atrial fibrillation: Continued home apixaban, metop succinate, digoxin #CKD: Likely multifactorial from hypertension and diabetes, no evidence of [MASKED]. Nephrology f/u arranged. #HLD: Continued atorvastatin 40mg qHS #OSA: Used home CPAP machine TRANSITIONAL ISSUES: -------------------- - Torsemide increased to 40mg BID - Discharge weight: 82.1 kg / 181 lbs - Discharge Cr: 1.7 - Started Imdur 30 mg daily, Hydralazine 25 mg TID, and Spironolactone 25 mg daily. - Increased Metoprolol Succinate dose from 100mg once daily to 75mg BID - Started Colchicine 0.6 mg BID for gout. Can be stopped once acute flare resolves. - Consider uric acid lowering agent after acute flare - Discharged with rolling walker and home [MASKED] - Decreased insulin dosing in house as detailed above, please monitor closely as outpatient and adjust as necessary # CONTACT: Daughter/HCP: [MASKED], Cell phone: [MASKED] # Code Status: Full (confirmed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. oxyCODONE-acetaminophen 7.5-325 mg oral TID 3. Apixaban 2.5 mg PO BID 4. Losartan Potassium 100 mg PO DAILY 5. Metoprolol Succinate XL 100 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Senna 17.2 mg PO BID 8. Docusate Sodium 100 mg PO BID 9. Cyanocobalamin 1000 mcg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. Levemir 44 Units Breakfast Levemir 14 Units Dinner Insulin SC Sliding Scale using HUM Insulin 12. Torsemide 40 mg PO QAM 13. Torsemide 20 mg PO QPM 14. Potassium Chloride 10 mEq PO DAILY 15. Gabapentin 100 mg PO TID 16. Digoxin 0.0625 mg PO DAILY 17. Pantoprazole 40 mg PO Q24H Discharge Medications: 1. Colchicine 0.6 mg PO BID RX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 2. HydrALAZINE 25 mg PO TID RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills:*0 3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Spironolactone 25 mg PO DAILY RX *spironolactone 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Levemir 34 Units Breakfast Levemir 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin 6. Metoprolol Succinate XL 75 mg PO BID RX *metoprolol succinate [Toprol XL] 50 mg 1.5 tablet(s) by mouth twice a day Disp #*90 Tablet Refills:*0 7. Torsemide 40 mg PO BID RX *torsemide 20 mg 2 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Apixaban 2.5 mg PO BID 9. Aspirin 81 mg PO DAILY 10. Atorvastatin 40 mg PO QPM 11. Cyanocobalamin 1000 mcg PO DAILY 12. Digoxin 0.0625 mg PO DAILY 13. Docusate Sodium 100 mg PO BID 14. Gabapentin 100 mg PO TID 15. Losartan Potassium 100 mg PO DAILY 16. oxyCODONE-acetaminophen 7.5-325 mg oral TID 17. Pantoprazole 40 mg PO Q24H 18. Senna 17.2 mg PO BID 19. Vitamin D 1000 UNIT PO DAILY 20.Outpatient Physical Therapy Rolling Walker Dx: CHF, ICD-10 I50.2 Px: Good [MASKED]: 13 months Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: acute on chronic systolic heart failure chest pain type 2 NSTEMI wrist pain / gout atrial fibrillation IDDM Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You came to the hospital because you were short of breath and had too much fluid built up in your body. You got IV medicine called Lasix and you got rid of the extra fluid. Your breathing improved and you did not need oxygen anymore. You also started medicine called Colchicine for gout in your wrist. You should take this until you feel better and then talk to your doctor about starting a medicine called allopurinol to prevent gout flares from happening. Please see below for changes in your medicines and your follow-up appointments. Please weigh yourself every morning, call Dr. [MASKED] office at [MASKED] if weight goes up more than 3 pounds in one day, or 5 pounds in one week. It was a pleasure caring for you and we wish you the [MASKED], Your [MASKED] Cardiology Team Followup Instructions: [MASKED]
|
[] |
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[
"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",
"I214: Non-ST elevation (NSTEMI) myocardial infarction",
"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"N189: Chronic kidney disease, unspecified",
"I4891: Unspecified atrial fibrillation",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z794: Long term (current) use of insulin",
"M109: Gout, unspecified",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"E785: Hyperlipidemia, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"I272: Other secondary pulmonary hypertension",
"I340: Nonrheumatic mitral (valve) insufficiency",
"I252: Old myocardial infarction",
"R0902: Hypoxemia",
"Z8572: Personal history of non-Hodgkin lymphomas",
"Z96653: Presence of artificial knee joint, bilateral",
"M545: Low back pain",
"E042: Nontoxic multinodular goiter",
"Z8249: Family history of ischemic heart disease and other diseases of the circulatory system"
] |
10,028,735
| 22,813,076
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Facial pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o M transferred For trauma evaluation after a fall. Patient
poorly fell down a flight of stairs. Had imaging which showed a
facial fractures as well as a small cerebral contusion.
Here patient complains of pain to his head and neck. Denies
other injuries.
Past Medical History:
PMHx: CAD, angina, MI, GERD, HCV, HL, migraines, OSA, atrophic L
kidney
PSHx: appendectomy, carpal tunnel release, spine surgery
(cervical)
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Temp: 97.2 HR: 86 BP: 134/75 Resp: 18 O(2)Sat: 96 Normal
Constitutional: Constitutional: Lying in bed, protecting
airway
Head / Eyes: NC, PERRL, EOMI, Left periorbital ecchymosis
ENT: OP WNL
Resp: CTAB
Cards: RRR.
Abd: S/NT/ND
Pelvis stable
Skin: no rash, warm and dry
Ext: No c/c/e
Neuro: speech fluent
Psych: normal mood
DISCHARGE PHYSICAL EXAM:
Gen: awake, alert, pleasant and interactive.
CV: rrr
PULM: Clear to auscultation bilaterally.
ABD: Soft, non-tender, non-distended. active bowel sounds
EXT: Warm and dry. 2+ ___ pulses.
Pertinent Results:
___ 03:22AM BLOOD WBC-5.6 RBC-4.32* Hgb-11.7* Hct-35.7*
MCV-83 MCH-27.1 MCHC-32.8 RDW-14.3 RDWSD-42.6 Plt Ct-96*
___ 03:22AM BLOOD Glucose-103* UreaN-11 Creat-0.9 Na-139
K-4.5 Cl-98 HCO3-30 AnGap-11
___ 01:30AM BLOOD ALT-26 AST-45* AlkPhos-102 TotBili-0.6
___ 03:22AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.8
___ 01:43AM BLOOD Lactate-1.3
Brief Hospital Course:
Mr. ___ is a ___ yo M who presented to emergency department
after reportedly a fall down a flight of stairs sustaining left
sided facial trauma. He was hemodynamically stable. CT head
negative for acute intracranial process. Imaging reveals a small
left zygomatic arch fracture, left orbital floor fracture, and
lateral orbital wall fracture. The patient was seen and
evaluated by plastic surgery who recommended non-operative
management of his fractures. the patient was evaluated for
ophthalmology for eye injury/muscle entrapment which there was
none. He was admitted to the surgical floor for observation and
pain control.
Pain medication were titrated with good effect. On HD4 he was
discharged to home on sinus precautions, 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:
The Preadmission Medication list is accurate and complete.
1. NIFEdipine (Extended Release) 30 mg PO DAILY
2. Simvastatin 80 mg PO QPM
3. Terazosin 2 mg PO QHS
4. FLUoxetine 60 mg PO DAILY
5. Sumatriptan Succinate 6 mg SC ONCE:PRN headache
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. Omeprazole 20 mg PO DAILY
8. HYDROmorphone (Dilaudid) 4 mg PO TID pain
9. Diazepam 10 mg PO QHS anxiety
10. Gabapentin 300 mg PO TID
11. Morphine SR (MS ___ 120 mg PO Q12H
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
do not exceed 4000 mg Tylenol/ 24 hours.
2. Docusate Sodium 100 mg PO BID
3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
Alternate with Tylenol.
4. Omeprazole 20 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Senna 8.6 mg PO BID:PRN constipation
7. HYDROmorphone (Dilaudid) 4 mg PO Q8H:PRN Pain - Severe
8. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN BREAKTHROUGH PAIN
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
four (4) hours Disp #*20 Tablet Refills:*0
9. Diazepam 10 mg PO QHS anxiety
10. FLUoxetine 60 mg PO DAILY
11. Gabapentin 300 mg PO TID
12. Morphine SR (MS ___ 120 mg PO Q12H
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Simvastatin 80 mg PO QPM
15. Sumatriptan Succinate 6 mg SC ONCE:PRN headache
16. Terazosin 2 mg PO QHS
17. HELD- NIFEdipine (Extended Release) 30 mg PO DAILY This
medication was held. Do not restart NIFEdipine (Extended
Release) until instructed by primary care provider.
Discharge Disposition:
Home
Discharge Diagnosis:
Left comminuted Maxillary sinus fracture- both walls
Small Left zygomatic arch fracture
Small Left orbital floor fracture
Small lateral orbital wall fracture
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 Acute Care Trauma Surgery service on
___ after a fall sustaining multiple facial injuries. You
were seen by the plastic surgery team who evaluated your facial
fractures and recommended non-operative management at this time
and follow up in outpatient clinic to determine if further
surgery is needed. Please continue to follow sinus precautions
(no nose blowing, sneeze with your mouth open, no drinking
through straws). You were evaluated by the ophthalmology team
who determined there are no injuries to your eyes that require
intervention at this time. Please follow up in clinic to
re-evaluate your vision and assess for worsening symptoms.
You are now doing better, tolerating a regular diet, and ready
to be discharge to 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:
___
|
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Allergies: Sulfa (Sulfonamide Antibiotics) Chief Complaint: Facial pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] y/o M transferred For trauma evaluation after a fall. Patient poorly fell down a flight of stairs. Had imaging which showed a facial fractures as well as a small cerebral contusion. Here patient complains of pain to his head and neck. Denies other injuries. Past Medical History: PMHx: CAD, angina, MI, GERD, HCV, HL, migraines, OSA, atrophic L kidney PSHx: appendectomy, carpal tunnel release, spine surgery (cervical) Social History: [MASKED] Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: Temp: 97.2 HR: 86 BP: 134/75 Resp: 18 O(2)Sat: 96 Normal Constitutional: Constitutional: Lying in bed, protecting airway Head / Eyes: NC, PERRL, EOMI, Left periorbital ecchymosis ENT: OP WNL Resp: CTAB Cards: RRR. Abd: S/NT/ND Pelvis stable Skin: no rash, warm and dry Ext: No c/c/e Neuro: speech fluent Psych: normal mood DISCHARGE PHYSICAL EXAM: Gen: awake, alert, pleasant and interactive. CV: rrr PULM: Clear to auscultation bilaterally. ABD: Soft, non-tender, non-distended. active bowel sounds EXT: Warm and dry. 2+ [MASKED] pulses. Pertinent Results: [MASKED] 03:22AM BLOOD WBC-5.6 RBC-4.32* Hgb-11.7* Hct-35.7* MCV-83 MCH-27.1 MCHC-32.8 RDW-14.3 RDWSD-42.6 Plt Ct-96* [MASKED] 03:22AM BLOOD Glucose-103* UreaN-11 Creat-0.9 Na-139 K-4.5 Cl-98 HCO3-30 AnGap-11 [MASKED] 01:30AM BLOOD ALT-26 AST-45* AlkPhos-102 TotBili-0.6 [MASKED] 03:22AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.8 [MASKED] 01:43AM BLOOD Lactate-1.3 Brief Hospital Course: Mr. [MASKED] is a [MASKED] yo M who presented to emergency department after reportedly a fall down a flight of stairs sustaining left sided facial trauma. He was hemodynamically stable. CT head negative for acute intracranial process. Imaging reveals a small left zygomatic arch fracture, left orbital floor fracture, and lateral orbital wall fracture. The patient was seen and evaluated by plastic surgery who recommended non-operative management of his fractures. the patient was evaluated for ophthalmology for eye injury/muscle entrapment which there was none. He was admitted to the surgical floor for observation and pain control. Pain medication were titrated with good effect. On HD4 he was discharged to home on sinus precautions, 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: The Preadmission Medication list is accurate and complete. 1. NIFEdipine (Extended Release) 30 mg PO DAILY 2. Simvastatin 80 mg PO QPM 3. Terazosin 2 mg PO QHS 4. FLUoxetine 60 mg PO DAILY 5. Sumatriptan Succinate 6 mg SC ONCE:PRN headache 6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 7. Omeprazole 20 mg PO DAILY 8. HYDROmorphone (Dilaudid) 4 mg PO TID pain 9. Diazepam 10 mg PO QHS anxiety 10. Gabapentin 300 mg PO TID 11. Morphine SR (MS [MASKED] 120 mg PO Q12H Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild do not exceed 4000 mg Tylenol/ 24 hours. 2. Docusate Sodium 100 mg PO BID 3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity Alternate with Tylenol. 4. Omeprazole 20 mg PO DAILY 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. Senna 8.6 mg PO BID:PRN constipation 7. HYDROmorphone (Dilaudid) 4 mg PO Q8H:PRN Pain - Severe 8. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN BREAKTHROUGH PAIN RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 9. Diazepam 10 mg PO QHS anxiety 10. FLUoxetine 60 mg PO DAILY 11. Gabapentin 300 mg PO TID 12. Morphine SR (MS [MASKED] 120 mg PO Q12H 13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 14. Simvastatin 80 mg PO QPM 15. Sumatriptan Succinate 6 mg SC ONCE:PRN headache 16. Terazosin 2 mg PO QHS 17. HELD- NIFEdipine (Extended Release) 30 mg PO DAILY This medication was held. Do not restart NIFEdipine (Extended Release) until instructed by primary care provider. Discharge Disposition: Home Discharge Diagnosis: Left comminuted Maxillary sinus fracture- both walls Small Left zygomatic arch fracture Small Left orbital floor fracture Small lateral orbital wall fracture 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 Acute Care Trauma Surgery service on [MASKED] after a fall sustaining multiple facial injuries. You were seen by the plastic surgery team who evaluated your facial fractures and recommended non-operative management at this time and follow up in outpatient clinic to determine if further surgery is needed. Please continue to follow sinus precautions (no nose blowing, sneeze with your mouth open, no drinking through straws). You were evaluated by the ophthalmology team who determined there are no injuries to your eyes that require intervention at this time. Please follow up in clinic to re-evaluate your vision and assess for worsening symptoms. You are now doing better, tolerating a regular diet, and ready to be discharge to 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]
|
[] |
[
"N189",
"F17210",
"Y929",
"I2510",
"I252",
"K219"
] |
[
"S0240DA: Maxillary fracture, left side, initial encounter for closed fracture",
"S0232XA: Fracture of orbital floor, left side, initial encounter for closed fracture",
"B1920: Unspecified viral hepatitis C without hepatic coma",
"H1132: Conjunctival hemorrhage, left eye",
"S022XXA: Fracture of nasal bones, initial encounter for closed fracture",
"S0240FA: Zygomatic fracture, left side, initial encounter for closed fracture",
"N189: Chronic kidney disease, unspecified",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"Y929: Unspecified place or not applicable",
"W109XXA: Fall (on) (from) unspecified stairs and steps, initial encounter",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"I252: Old myocardial infarction",
"K219: Gastro-esophageal reflux disease without esophagitis"
] |
10,028,930
| 26,238,833
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___- Diagnostic Angiogram- Negative
History of Present Illness:
___ year old male who presented to OSH with left sided
frontal headache x 5 days after working out at the gym. The
patient reports he generally doesn't have trouble with
headaches,
and states he took some Tylenol initially with relief although
reports over the course of several days Tylenol was no longer
relieving his headache therefore he presented to ___ on ___ for further evaluation. A NCHCT was
performed and was negative for hemorrhage therefore he was
discharged to home. The patient returned the following day as
headache symptoms persisted. He underwent an MRI/MRA which
revealed no acute intracranial process, however there is a note
of minute focus of relatively nodular signal in the region of
the
anterior communicating artery on MR angiography which measures
approximately 2mm and could represent prominent infundibulum at
the origin of the anterior communicating artery from left A1. A
2
mm Microaneurysm is possible here. He also underwent an LP which
revealed 120 RBS in tube 1 with 1 WBC and 120 RBCs in Tube 3
with
less than 1 WBC. The patient was then transferred to ___ for
further Neurosurgical evaluation and diagnostic angiogram with
possible intervention.
Past Medical History:
BPH, Appendicitis requiring appendectomy, Hernia repair
Social History:
___
Family History:
No history of aneurysms.
Physical Exam:
On Discharge ___: Eyes open spontaneously, Aox3, PERRL ___
bilaterally, face symmetric, tongue midline, no pronator drift.
Speech clear and comprehension intact. Moves all extremities
with full strength ___. Right groin dressing clean dry and
intact. Groin soft, no hematoma. Distal pulses intact to
bilateral lower extremities.
Pertinent Results:
CAROTID/CEREBRAL BILAT Study Date of ___ 1:58 ___
IMPRESSION:
1. Diagnostic cerebral angiogram within normal limits, with
fenestration of the A-comm.
RECOMMENDATION(S):
1. Neurology consultation for headaches management.
Brief Hospital Course:
___ year old male with 5 days of headaches who was transferred
from OSH with concern of 2mm ACA aneurysm.
#Headaches:
The patient was taken for a diagnostic angiogram upon arrival to
___. It was within normal limits, and demonstrated a
fenestration of the A-comm. The patient recovered in the PACU
and was transferred to the ___ when stable. On Post-operative
check he was neurologically intact and his right groin was soft
and there was no concern for hematoma. Distal pulses were
intact. Neurology was consulted to assess for further causes of
headaches. Notes and lab results were obtained from outside
hospital Neurology consult for interpretation by the Neurology
team. It was determined by Neurology that the patients headaches
were caused by Occipital Neuralgia. It was recommended that he
was to be started on Gabapentin 300 mg po Q HS. Detailed
instructions were given to him for management of pain and when
to stop gabapentin as well as when to follow up as an
outpatient. This was all listed in his discharge information.
The patient was cleared for safe discharge to home by the
Neurosurgery service. He was given prescriptions and follow up
information.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Pain -
Moderate
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
capsule(s) by mouth every eight (8) hours Disp #*40 Capsule
Refills:*0
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 300 mg PO QHS
As instructed on discharge instructions
RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Headache
Occipital Neuralgia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Dr. ___
___
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 may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
Please do not take this with Fioricet as this contains
acetaminophen. Please do not exceed greater than 4 grams of
acetaminophen in 24 hours.
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.
Fatigue is very normal.
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
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
Occipital Neuralgia
You were seen and evaluated by the Neurology service while at
___ for further evaluation of your headaches. It was
determined that you are currently suffering from Occipital
Neuralgia.
Please begin taking Gabapentin 300 mg by mouth every night at
bedtime. You have been given a prescription for this medication
at the time of discharge.
If you experience relief of headache with the Gabapentin
please continue to take this medication for an additional 4
weeks AFTER your headache symptoms have resolved.
If you do not have relief of headache after ___ weeks please
follow up with the local pain clinic or you may follow up with
Dr. ___ Neurology at ___ for a possible occipital
nerve block. Dr. ___ phone number is ___.
Followup Instructions:
___
|
[
"M5481",
"Z87891"
] |
Allergies: No Allergies/ADRs on File Chief Complaint: Headache Major Surgical or Invasive Procedure: [MASKED]- Diagnostic Angiogram- Negative History of Present Illness: [MASKED] year old male who presented to OSH with left sided frontal headache x 5 days after working out at the gym. The patient reports he generally doesn't have trouble with headaches, and states he took some Tylenol initially with relief although reports over the course of several days Tylenol was no longer relieving his headache therefore he presented to [MASKED] on [MASKED] for further evaluation. A NCHCT was performed and was negative for hemorrhage therefore he was discharged to home. The patient returned the following day as headache symptoms persisted. He underwent an MRI/MRA which revealed no acute intracranial process, however there is a note of minute focus of relatively nodular signal in the region of the anterior communicating artery on MR angiography which measures approximately 2mm and could represent prominent infundibulum at the origin of the anterior communicating artery from left A1. A 2 mm Microaneurysm is possible here. He also underwent an LP which revealed 120 RBS in tube 1 with 1 WBC and 120 RBCs in Tube 3 with less than 1 WBC. The patient was then transferred to [MASKED] for further Neurosurgical evaluation and diagnostic angiogram with possible intervention. Past Medical History: BPH, Appendicitis requiring appendectomy, Hernia repair Social History: [MASKED] Family History: No history of aneurysms. Physical Exam: On Discharge [MASKED]: Eyes open spontaneously, Aox3, PERRL [MASKED] bilaterally, face symmetric, tongue midline, no pronator drift. Speech clear and comprehension intact. Moves all extremities with full strength [MASKED]. Right groin dressing clean dry and intact. Groin soft, no hematoma. Distal pulses intact to bilateral lower extremities. Pertinent Results: CAROTID/CEREBRAL BILAT Study Date of [MASKED] 1:58 [MASKED] IMPRESSION: 1. Diagnostic cerebral angiogram within normal limits, with fenestration of the A-comm. RECOMMENDATION(S): 1. Neurology consultation for headaches management. Brief Hospital Course: [MASKED] year old male with 5 days of headaches who was transferred from OSH with concern of 2mm ACA aneurysm. #Headaches: The patient was taken for a diagnostic angiogram upon arrival to [MASKED]. It was within normal limits, and demonstrated a fenestration of the A-comm. The patient recovered in the PACU and was transferred to the [MASKED] when stable. On Post-operative check he was neurologically intact and his right groin was soft and there was no concern for hematoma. Distal pulses were intact. Neurology was consulted to assess for further causes of headaches. Notes and lab results were obtained from outside hospital Neurology consult for interpretation by the Neurology team. It was determined by Neurology that the patients headaches were caused by Occipital Neuralgia. It was recommended that he was to be started on Gabapentin 300 mg po Q HS. Detailed instructions were given to him for management of pain and when to stop gabapentin as well as when to follow up as an outpatient. This was all listed in his discharge information. The patient was cleared for safe discharge to home by the Neurosurgery service. He was given prescriptions and follow up information. Medications on Admission: None Discharge Medications: 1. Acetaminophen-Caff-Butalbital [MASKED] TAB PO Q8H:PRN Pain - Moderate RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg [MASKED] capsule(s) by mouth every eight (8) hours Disp #*40 Capsule Refills:*0 2. Docusate Sodium 100 mg PO BID 3. Gabapentin 300 mg PO QHS As instructed on discharge instructions RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*1 Discharge Disposition: Home Discharge Diagnosis: Headache Occipital Neuralgia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Dr. [MASKED] [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 may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. Please do not take this with Fioricet as this contains acetaminophen. Please do not exceed greater than 4 grams of acetaminophen in 24 hours. 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. Fatigue is very normal. 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 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 Occipital Neuralgia You were seen and evaluated by the Neurology service while at [MASKED] for further evaluation of your headaches. It was determined that you are currently suffering from Occipital Neuralgia. Please begin taking Gabapentin 300 mg by mouth every night at bedtime. You have been given a prescription for this medication at the time of discharge. If you experience relief of headache with the Gabapentin please continue to take this medication for an additional 4 weeks AFTER your headache symptoms have resolved. If you do not have relief of headache after [MASKED] weeks please follow up with the local pain clinic or you may follow up with Dr. [MASKED] Neurology at [MASKED] for a possible occipital nerve block. Dr. [MASKED] phone number is [MASKED]. Followup Instructions: [MASKED]
|
[] |
[
"Z87891"
] |
[
"M5481: Occipital neuralgia",
"Z87891: Personal history of nicotine dependence"
] |
10,029,074
| 24,064,303
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left temporal cavernous malformation
Major Surgical or Invasive Procedure:
___ - Left craniotomy for resection of left temporal
cavernous malformation
History of Present Illness:
___ is a ___ year old male with a known left temporal
cavernous malformation who presented electively on ___
for a left craniotomy for resection.
Past Medical History:
- cervical spondylosis
- depression
- left temporal cavernous malformation
- status post hernia repair
- status post right hip surgery
Social History:
___
Family History:
Noncontributory.
Physical Exam:
On Discharge:
-------------
General:
Vital Signs: T 98.8F, HR 70, BP 127/73, O2Sat 94% on room air
Exam:
Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious [ ]None
Orientation: [x]Person [x]Place [x]Time
Follows Commands: [ ]Simple [x]Complex [ ]None
Pupils: Pupils equally round and reactive to light bilaterally.
Extraocular Movements: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]No
Tongue Midline: [x]Yes [ ]No
Drift: [ ]Yes [x]No
Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [x]Yes [ ]No
Motor:
Trapezius Deltoid Biceps Triceps Grip
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.
Left Craniotomy Incision:
[x]Clean, dry, intact
[x]Sutures
Pertinent Results:
Please see ___ for relevant laboratory and imaging results.
Brief Hospital Course:
___ year old male with a known left temporal cavernous
malformation.
#Left temporal cavernous malformation
The patient presented electively on ___ and was taken to
the OR for a left craniotomy for resection of the left temporal
cavernous malformation. The operation was uncomplicated. Please
see OMR for further intraoperative details. The patient was
extubated in the OR and recovered in the PACU postoperatively.
He was then transferred to the step down unit for close
neurologic monitoring. He was started on Keppra postoperatively
for seizure prophylaxis. He was also put on a dexamethasone
taper to help with his headaches. The patient remained
neurologically stable postoperatively. On ___, he was
afebrile with stable vital signs, mobilizing independently,
tolerating a diet, voiding and stooling without difficulty, and
his pain was well controlled with oral pain medications. He was
discharged home with no needs on ___ in stable condition.
He will follow-up for suture removal ___ days after surgery and
with Dr. ___ ___ weeks after surgery.
#Disposition
The patient was mobilizing independently postoperatively. He was
discharged home with no needs on ___ in stable condition.
Medications on Admission:
- cholecalciferol
- escitalopram oxalate 10mg PO once daily
- fish oil
- riboflavin
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
Do not exceed 3000mg in 24 hours. Wean off as tolerated.
2. Dexamethasone 4 mg PO Q8H Duration: 1 Dose
Step 1.
This is dose # 1 of 4 tapered doses
RX *dexamethasone 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*1 Tablet Refills:*0
3. Dexamethasone 3 mg PO Q8H Duration: 3 Doses
Step 2.
This is dose # 2 of 4 tapered doses
Tapered dose - DOWN
RX *dexamethasone 1.5 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*6 Tablet Refills:*0
4. Dexamethasone 2 mg PO Q8H Duration: 3 Doses
Step 3.
This is dose # 3 of 4 tapered doses
Tapered dose - DOWN
RX *dexamethasone 2 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*3 Tablet Refills:*0
5. Dexamethasone 2 mg PO Q12H Duration: 2 Doses
Step 4.
This is dose # 4 of 4 tapered doses
Tapered dose - DOWN
RX *dexamethasone 2 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*2 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
Do not take if having loose stools. ___ stop taking once off
oxycodone.
7. Famotidine 20 mg PO BID
___ stop taking once off dexamethasone.
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*7
Tablet Refills:*0
8. LevETIRAcetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Wean off as tolerated.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
as needed for pain Disp #*40 Tablet Refills:*0
10. Senna 17.2 mg PO QHS:PRN Constipation - Second Line
Do not take if having loose stools. ___ stop taking once off
oxycodone.
11. Escitalopram Oxalate 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left temporal cavernous malformation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory, independent.
Discharge Instructions:
Care of the surgical incision:
- Keep your surgical incision clean and dry.
- Do not rub, scrub, scratch, or pick at any scabs along the
surgical incision.
- You may use water to wash your hair around your surgical
incision, but do not use shampoo until your sutures are removed.
You will need to have your sutures removed ___ days after
surgery.
- When you are allowed to use shampoo, let the shampoo run off
the surgical incision, and gently pad the surgical incision with
a towel to dry.
Activity:
- Start to resume all activities as tolerated, but start slowly
and increase at your own pace.
- Do not operate any motorized vehicle for at least 10 days
after your surgery. Do not operate any motorized vehicle while
taking narcotics.
Medications:
- Please do not take any blood thinning medications such as
aspirin, clopidogrel (Plavix), warfarin (Coumadin), etc. until
cleared by your neurosurgeon.
- Please do not take any anti-inflammatory medications such as
Advil, Aleve, ibuprofen, Motrin, etc. until cleared by your
neurosurgeon.
Please call your neurosurgeon if you experience:
- Redness, swelling, or drainage from your surgical incision.
- Fever greater than 101.4 degrees Fahrenheit.
- Headaches not relieved with prescribed medications.
- Any neurologic issues such as changes in vision, speech, or
movement.
- Any problems with medications such as lethargy, nausea, or
vomiting.
Postoperative experiences - Physical:
- Fatigue is common. This will slowly resolve over time.
- Numbness or tingling at the surgical incision is common. This
can take weeks or months to fully resolve.
- Muffled hearing in the ear on the same side as your surgical
incision is common.
- Jaw pain on the same side as your surgical incision is common.
This goes away after about 1 month.
- Low back pain or shooting pain down the leg is possible. This
should resolve with increased activity.
- You may experience constipation. Constipation can be prevented
by drinking plenty of fluids, increasing the fiber in your diet,
and exercising. You may also use an over-the-counter stool
softener if needed.
Postoperative experiences - Emotional:
- You may experience depression. Symptoms of depression can
include feeling sad or "down," loneliness, confusion,
irritability, frustration, distractibility, low self-esteem,
relationship challenges, and insomnia. If you experience any of
these symptoms, please contact your primary care provider for ___
referral to a psychologist or psychiatrist.
Followup Instructions:
___
|
[
"Q282",
"F329",
"M479",
"D72828",
"T380X5A",
"Y92239"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Left temporal cavernous malformation Major Surgical or Invasive Procedure: [MASKED] - Left craniotomy for resection of left temporal cavernous malformation History of Present Illness: [MASKED] is a [MASKED] year old male with a known left temporal cavernous malformation who presented electively on [MASKED] for a left craniotomy for resection. Past Medical History: - cervical spondylosis - depression - left temporal cavernous malformation - status post hernia repair - status post right hip surgery Social History: [MASKED] Family History: Noncontributory. Physical Exam: On Discharge: ------------- General: Vital Signs: T 98.8F, HR 70, BP 127/73, O2Sat 94% on room air Exam: Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious [ ]None Orientation: [x]Person [x]Place [x]Time Follows Commands: [ ]Simple [x]Complex [ ]None Pupils: Pupils equally round and reactive to light bilaterally. Extraocular Movements: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]No Tongue Midline: [x]Yes [ ]No Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension Intact: [x]Yes [ ]No Motor: Trapezius Deltoid Biceps Triceps Grip 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. Left Craniotomy Incision: [x]Clean, dry, intact [x]Sutures Pertinent Results: Please see [MASKED] for relevant laboratory and imaging results. Brief Hospital Course: [MASKED] year old male with a known left temporal cavernous malformation. #Left temporal cavernous malformation The patient presented electively on [MASKED] and was taken to the OR for a left craniotomy for resection of the left temporal cavernous malformation. The operation was uncomplicated. Please see OMR for further intraoperative details. The patient was extubated in the OR and recovered in the PACU postoperatively. He was then transferred to the step down unit for close neurologic monitoring. He was started on Keppra postoperatively for seizure prophylaxis. He was also put on a dexamethasone taper to help with his headaches. The patient remained neurologically stable postoperatively. On [MASKED], he was afebrile with stable vital signs, mobilizing independently, tolerating a diet, voiding and stooling without difficulty, and his pain was well controlled with oral pain medications. He was discharged home with no needs on [MASKED] in stable condition. He will follow-up for suture removal [MASKED] days after surgery and with Dr. [MASKED] [MASKED] weeks after surgery. #Disposition The patient was mobilizing independently postoperatively. He was discharged home with no needs on [MASKED] in stable condition. Medications on Admission: - cholecalciferol - escitalopram oxalate 10mg PO once daily - fish oil - riboflavin Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild Do not exceed 3000mg in 24 hours. Wean off as tolerated. 2. Dexamethasone 4 mg PO Q8H Duration: 1 Dose Step 1. This is dose # 1 of 4 tapered doses RX *dexamethasone 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*1 Tablet Refills:*0 3. Dexamethasone 3 mg PO Q8H Duration: 3 Doses Step 2. This is dose # 2 of 4 tapered doses Tapered dose - DOWN RX *dexamethasone 1.5 mg 2 tablet(s) by mouth every eight (8) hours Disp #*6 Tablet Refills:*0 4. Dexamethasone 2 mg PO Q8H Duration: 3 Doses Step 3. This is dose # 3 of 4 tapered doses Tapered dose - DOWN RX *dexamethasone 2 mg 1 tablet(s) by mouth every eight (8) hours Disp #*3 Tablet Refills:*0 5. Dexamethasone 2 mg PO Q12H Duration: 2 Doses Step 4. This is dose # 4 of 4 tapered doses Tapered dose - DOWN RX *dexamethasone 2 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*2 Tablet Refills:*0 6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line Do not take if having loose stools. [MASKED] stop taking once off oxycodone. 7. Famotidine 20 mg PO BID [MASKED] stop taking once off dexamethasone. RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*7 Tablet Refills:*0 8. LevETIRAcetam 500 mg PO BID RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 9. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate Wean off as tolerated. RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours as needed for pain Disp #*40 Tablet Refills:*0 10. Senna 17.2 mg PO QHS:PRN Constipation - Second Line Do not take if having loose stools. [MASKED] stop taking once off oxycodone. 11. Escitalopram Oxalate 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Left temporal cavernous malformation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory, independent. Discharge Instructions: Care of the surgical incision: - Keep your surgical incision clean and dry. - Do not rub, scrub, scratch, or pick at any scabs along the surgical incision. - You may use water to wash your hair around your surgical incision, but do not use shampoo until your sutures are removed. You will need to have your sutures removed [MASKED] days after surgery. - When you are allowed to use shampoo, let the shampoo run off the surgical incision, and gently pad the surgical incision with a towel to dry. Activity: - Start to resume all activities as tolerated, but start slowly and increase at your own pace. - Do not operate any motorized vehicle for at least 10 days after your surgery. Do not operate any motorized vehicle while taking narcotics. Medications: - Please do not take any blood thinning medications such as aspirin, clopidogrel (Plavix), warfarin (Coumadin), etc. until cleared by your neurosurgeon. - Please do not take any anti-inflammatory medications such as Advil, Aleve, ibuprofen, Motrin, etc. until cleared by your neurosurgeon. Please call your neurosurgeon if you experience: - Redness, swelling, or drainage from your surgical incision. - Fever greater than 101.4 degrees Fahrenheit. - Headaches not relieved with prescribed medications. - Any neurologic issues such as changes in vision, speech, or movement. - Any problems with medications such as lethargy, nausea, or vomiting. Postoperative experiences - Physical: - Fatigue is common. This will slowly resolve over time. - Numbness or tingling at the surgical incision is common. This can take weeks or months to fully resolve. - Muffled hearing in the ear on the same side as your surgical incision is common. - Jaw pain on the same side as your surgical incision is common. This goes away after about 1 month. - Low back pain or shooting pain down the leg is possible. This should resolve with increased activity. - You may experience constipation. Constipation can be prevented by drinking plenty of fluids, increasing the fiber in your diet, and exercising. You may also use an over-the-counter stool softener if needed. Postoperative experiences - Emotional: - You may experience depression. Symptoms of depression can include feeling sad or "down," loneliness, confusion, irritability, frustration, distractibility, low self-esteem, relationship challenges, and insomnia. If you experience any of these symptoms, please contact your primary care provider for [MASKED] referral to a psychologist or psychiatrist. Followup Instructions: [MASKED]
|
[] |
[
"F329"
] |
[
"Q282: Arteriovenous malformation of cerebral vessels",
"F329: Major depressive disorder, single episode, unspecified",
"M479: Spondylosis, unspecified",
"D72828: Other elevated white blood cell count",
"T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter",
"Y92239: Unspecified place in hospital as the place of occurrence of the external cause"
] |
10,029,108
| 20,360,088
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
lisinopril / banana
Attending: ___
Chief Complaint:
Rectal pain
Major Surgical or Invasive Procedure:
___: Exam under anesthesia and incision and drainage of
posterior perirectal abscess.
History of Present Illness:
___ hx CAD/MI x2, DM presenting with ___ rectal pain described
as burning in nature, exacerbated by sitting and with defection
and notes subjective fever last night. WBC 9.1, CTAP with 2cm
rim-enhancing collection in posterior midline at level of
sphincters. No personal or family history of inflammatory bowel
disease or colorectal cancer. No prior episodes. No change in
bowel habits.
At time of consultation, pt AFVSS with DRE notable for
fluctuance and tenderness in the posterior midline, no blood or
drainage.
Past Medical History:
PMH: DM2, HTN, glaucoma, HL, CAD/MIx2
PSH: Prostate needle-biopsy ___
Social History:
___
Family History:
No family history of IBD, CRC. Father: CAD/PVD
Physical Exam:
Admission Physical Exam:
Weight:
VS: T 99.0, HR 101, BP 110/78, RR 16, SaO2 100%rm air
GEN: NAD, A/Ox3
HEENT: EOMI, MMM
CV: tachycardic
PULM: CTAB
BACK: No CVAT
ABD: soft, NT/ND
PELVIS: perianal exam - unremarkable. DRE: posterior midline
fluctuance and tenderness at level of sphincters, no blood, no
drainage.
EXT: warm, well-perfused
Discharge Physical Exam:
Pertinent Results:
___ 10:20AM GLUCOSE-139* UREA N-15 CREAT-1.3* SODIUM-138
POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15
___ 10:20AM WBC-6.4 RBC-3.53* HGB-11.1* HCT-34.0* MCV-96
MCH-31.4 MCHC-32.6 RDW-13.4 RDWSD-47.7*
___ 10:20AM PLT COUNT-155
___ 04:17AM GLUCOSE-101* UREA N-18 CREAT-1.2 SODIUM-138
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15
___ 04:17AM WBC-7.9 RBC-3.54* HGB-11.1* HCT-34.0* MCV-96
MCH-31.4 MCHC-32.6 RDW-13.2 RDWSD-47.3*
___ 04:17AM PLT COUNT-149*
___ 11:05PM LACTATE-1.8
___ 05:55PM GLUCOSE-81 UREA N-20 CREAT-1.3* SODIUM-140
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-22 ANION GAP-22*
___ 05:55PM WBC-9.1 RBC-4.23* HGB-13.1* HCT-40.2 MCV-95
MCH-31.0 MCHC-32.6 RDW-13.3 RDWSD-46.5*
___ 05:55PM NEUTS-71.6* ___ MONOS-6.6 EOS-1.1
BASOS-0.4 IM ___ AbsNeut-6.49* AbsLymp-1.81 AbsMono-0.60
AbsEos-0.10 AbsBaso-0.04
___ 05:55PM PLT COUNT-175
___ 05:40PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG
___ 05:40PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 05:40PM URINE MUCOUS-RARE
Imaging:
___: CT Pelvis:
1. 2.0 cm rim enhancing midline fluid collection just posterior
concerning forpossible perirectal abscess.
2. Sigmoid colon diverticulosis without evidence of
diverticulitis. Enlarged prostate.
Brief Hospital Course:
Mr. ___ is a ___ year-old male who presented to ___ with
complaints of rectal pain and received a CT pelvis which showed
him to have a perirectal abscess. He was admitted to the Acute
Care Surgery team for further medical evaluation. On ___,
the patient was taken to the Operating Room and underwent
incision and drainage of his perirectal abscess. He tolerated
this procedure well (reader, please see operative note for
further information). Post-operatively, the patient received IV
antibiotics. on post op day 1, patient noticed to have some pain
and induration just anterior to the incision, MRI showed small
residual abscess, we took him back to the OR and another I&D
(please refer to the operative note for more information). He
tolerated this procedure well and transferred to the regular
floor.
The remainder of the ___ hospital course is summarized by
systems below:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with oral pain medication once
tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient's diet was advanced sequentially to a
Regular diet, which was well tolerated. Patient's intake and
output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, and he received antibiotics post-operatively..
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Polyethylene Glycol 3350:PRN, Gatifloxacin 0.5%'''',
Prednisolone 1% q2h, Metformin 1000, HCTZ 25, Losartan 25,
Toprol XL 50, Atorvastatin 80, Alphagan 0.1%, Cosopt 2% L eye'',
Latanprost ___ 81
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
5. Lorazepam 1 mg PO Q4H:PRN Anxiety
6. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Senna 8.6 mg PO BID:PRN constipation
10. Hydrochlorothiazide 25 mg PO DAILY
11. Losartan Potassium 25 mg PO DAILY
12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. gatifloxacin 0.5 % ophthalmic QID
15. Docusate Sodium 100 mg PO BID
16. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q3 Disp #*30 Tablet
Refills:*0
17. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth q12 Disp #*2
Tablet Refills:*0
18. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth q8 Disp #*3 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perirectal abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You presented to the ___ and
were found to have an abscess. You were admitted to the Acute
Care Surgery team for further medical management. On ___,
you were taken to the Operating Room and underwent an incision
and drainage of your abscess which you tolerated well. You were
started on antibiotics to treat and prevent infection.
Your pain is better controlled and you are tolerating a regular
diet. You are now medically cleared to be discharged to home.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ 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:
___
|
[
"K611",
"I959",
"E785",
"I10",
"E119",
"B9620",
"F17210",
"I2510",
"I252",
"H409",
"N400",
"K5790",
"Z7982"
] |
Allergies: lisinopril / banana Chief Complaint: Rectal pain Major Surgical or Invasive Procedure: [MASKED]: Exam under anesthesia and incision and drainage of posterior perirectal abscess. History of Present Illness: [MASKED] hx CAD/MI x2, DM presenting with [MASKED] rectal pain described as burning in nature, exacerbated by sitting and with defection and notes subjective fever last night. WBC 9.1, CTAP with 2cm rim-enhancing collection in posterior midline at level of sphincters. No personal or family history of inflammatory bowel disease or colorectal cancer. No prior episodes. No change in bowel habits. At time of consultation, pt AFVSS with DRE notable for fluctuance and tenderness in the posterior midline, no blood or drainage. Past Medical History: PMH: DM2, HTN, glaucoma, HL, CAD/MIx2 PSH: Prostate needle-biopsy [MASKED] Social History: [MASKED] Family History: No family history of IBD, CRC. Father: CAD/PVD Physical Exam: Admission Physical Exam: Weight: VS: T 99.0, HR 101, BP 110/78, RR 16, SaO2 100%rm air GEN: NAD, A/Ox3 HEENT: EOMI, MMM CV: tachycardic PULM: CTAB BACK: No CVAT ABD: soft, NT/ND PELVIS: perianal exam - unremarkable. DRE: posterior midline fluctuance and tenderness at level of sphincters, no blood, no drainage. EXT: warm, well-perfused Discharge Physical Exam: Pertinent Results: [MASKED] 10:20AM GLUCOSE-139* UREA N-15 CREAT-1.3* SODIUM-138 POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15 [MASKED] 10:20AM WBC-6.4 RBC-3.53* HGB-11.1* HCT-34.0* MCV-96 MCH-31.4 MCHC-32.6 RDW-13.4 RDWSD-47.7* [MASKED] 10:20AM PLT COUNT-155 [MASKED] 04:17AM GLUCOSE-101* UREA N-18 CREAT-1.2 SODIUM-138 POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15 [MASKED] 04:17AM WBC-7.9 RBC-3.54* HGB-11.1* HCT-34.0* MCV-96 MCH-31.4 MCHC-32.6 RDW-13.2 RDWSD-47.3* [MASKED] 04:17AM PLT COUNT-149* [MASKED] 11:05PM LACTATE-1.8 [MASKED] 05:55PM GLUCOSE-81 UREA N-20 CREAT-1.3* SODIUM-140 POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-22 ANION GAP-22* [MASKED] 05:55PM WBC-9.1 RBC-4.23* HGB-13.1* HCT-40.2 MCV-95 MCH-31.0 MCHC-32.6 RDW-13.3 RDWSD-46.5* [MASKED] 05:55PM NEUTS-71.6* [MASKED] MONOS-6.6 EOS-1.1 BASOS-0.4 IM [MASKED] AbsNeut-6.49* AbsLymp-1.81 AbsMono-0.60 AbsEos-0.10 AbsBaso-0.04 [MASKED] 05:55PM PLT COUNT-175 [MASKED] 05:40PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 05:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG [MASKED] 05:40PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 [MASKED] 05:40PM URINE MUCOUS-RARE Imaging: [MASKED]: CT Pelvis: 1. 2.0 cm rim enhancing midline fluid collection just posterior concerning forpossible perirectal abscess. 2. Sigmoid colon diverticulosis without evidence of diverticulitis. Enlarged prostate. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year-old male who presented to [MASKED] with complaints of rectal pain and received a CT pelvis which showed him to have a perirectal abscess. He was admitted to the Acute Care Surgery team for further medical evaluation. On [MASKED], the patient was taken to the Operating Room and underwent incision and drainage of his perirectal abscess. He tolerated this procedure well (reader, please see operative note for further information). Post-operatively, the patient received IV antibiotics. on post op day 1, patient noticed to have some pain and induration just anterior to the incision, MRI showed small residual abscess, we took him back to the OR and another I&D (please refer to the operative note for more information). He tolerated this procedure well and transferred to the regular floor. The remainder of the [MASKED] hospital course is summarized by systems below: Neuro: The patient was alert and oriented throughout hospitalization; pain was managed with oral pain medication once tolerating a diet. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient's diet was advanced sequentially to a Regular diet, which was well tolerated. Patient's intake and output were closely monitored ID: The patient's fever curves were closely watched for signs of infection, and he received antibiotics post-operatively.. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and [MASKED] dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Polyethylene Glycol 3350:PRN, Gatifloxacin 0.5%'''', Prednisolone 1% q2h, Metformin 1000, HCTZ 25, Losartan 25, Toprol XL 50, Atorvastatin 80, Alphagan 0.1%, Cosopt 2% L eye'', Latanprost [MASKED] 81 Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID 5. Lorazepam 1 mg PO Q4H:PRN Anxiety 6. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Senna 8.6 mg PO BID:PRN constipation 10. Hydrochlorothiazide 25 mg PO DAILY 11. Losartan Potassium 25 mg PO DAILY 12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID 13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 14. gatifloxacin 0.5 % ophthalmic QID 15. Docusate Sodium 100 mg PO BID 16. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN pain RX *oxycodone 5 mg [MASKED] tablet(s) by mouth q3 Disp #*30 Tablet Refills:*0 17. Ciprofloxacin HCl 750 mg PO Q12H RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth q12 Disp #*2 Tablet Refills:*0 18. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth q8 Disp #*3 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Perirectal abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You presented to the [MASKED] and were found to have an abscess. You were admitted to the Acute Care Surgery team for further medical management. On [MASKED], you were taken to the Operating Room and underwent an incision and drainage of your abscess which you tolerated well. You were started on antibiotics to treat and prevent infection. Your pain is better controlled and you are tolerating a regular diet. You are now medically cleared to be discharged to home. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. 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]
|
[] |
[
"E785",
"I10",
"E119",
"F17210",
"I2510",
"I252",
"N400"
] |
[
"K611: Rectal abscess",
"I959: Hypotension, unspecified",
"E785: Hyperlipidemia, unspecified",
"I10: Essential (primary) hypertension",
"E119: Type 2 diabetes mellitus without complications",
"B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"I252: Old myocardial infarction",
"H409: Unspecified glaucoma",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding",
"Z7982: Long term (current) use of aspirin"
] |
10,029,291
| 22,205,327
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lamotrigine / levetiracetam
Attending: ___.
Chief Complaint:
"Found down."
Major Surgical or Invasive Procedure:
Left HD line insertion
Right IJ line insertion
HD line placement (removed ___
Intubation, s/p extubation ___
History of Present Illness:
___ with unknown medical history, but is resident of a group
home was found down by her ___. Pt presented initially to OSH
ED, where she was evaluated with CT head which was negative. CTA
showed bilateral saddle pulmonary embolisms and whe was started
on heparin gtt w/6000U bolus and 1800cc/hr. She was transferred
to ___ for further evaluation. An arrival to ___, the
patient continued to be hypoxemic and became altered and was
intubated for airway protection. During intubation, the patient
was noted to be progressively more hypotensive. A radial A-line
was placed. She was evaluated with a stat CT head which showed
no acute intracranial pathology. The patient's hemodynamics
improved.
___ the ED, initial vitals were: HR 124, BP 105/76, RR 32, O2 99%
on NRB
Labs:
- WBC 14.0, Hgb 13.0, HCT 41.2, Plt 148
- Cr 1.2, HCO3 11, Phos 7.2
- ALT 213, AST 184, AP 85, Alb 3.3
- troponin 0.04, BNP 19699
- UA SG > 1.050, protein 100, few bacteria
- INR 8.0
- ABG pH 7.12, pCO2 34, pO2 372, HCO3 12, lactate 3.9
Imaging:
CXR:
1. Tip of the ET tube situated 5.2 cm above the carina at the
thoracic inlet.
2. Dilatation of the main and left pulmonary artery compatible
with known pulmonary embolism
CT head: Somewhat motion degraded study. This limitation, no
acute intracranial process.
Bedside TTE showed R heart strain
Consults: Cardiology
Patient was given: fentanyl
Decision was made to admit to CCU for management of PE
REVIEW OF SYSTEMS:
(+) per HPI, all other ROS otherwise negative
Past Medical History:
- PTSD
- T2DM
- GERD
- Hyperlipidemia
- Sleep walking and night terrors
- COPD
- Subclinical hypothyroidism
- Mood disorder with psychosis
- Anorexia Nervosa
- Tobacco use
- Renal insufficiency
- History of empyema
- Borderline personality disease
- Lower extremity edema
- Diabetic foot ulcer
Social History:
___
Family History:
No family history of heart disease, clotting disorder, or
malignancy
Physical Exam:
Admission exam:
VS: T97.8, HR 106, BP 66/45, RR 36, O2 98%
Weight: 83.5kg
GEN: intubated, sedated
HEENT: purple discoloration to upper chest
NECK: JVD appears elevated but difficult to appreciate
CV: tachycardic, nl S1 S2, on M/R/G
LUNGS: CTA anteriorly over ventilator
ABD: soft, NT, ND, NABS
EXT: WWP, no edema
NEURO: opens eyes to name
___ exam:
VS: 98.1 123/73 59 18 99RA
I/O: 1800/poorly recorded +3BMs
Weights: not recorded
Gen: NAD, laying ___ bed
HEENT: no elevated JVD, dysphonic, MMM
CV: RRR, no m/r/g
Resp: CTAB
Abd: soft, NT/ND, BS+
Ext: no edema, WWP
Neuro: Follows commands appropriately, ___ strength ___ UE and
___ A&Ox3
Pertinent Results:
MICROBIOLOGY:
==============================================
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___
11:25AM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification.
MRSA SCREEN (Final ___: No MRSA isolated.
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
YEAST. RARE GROWTH.
THIS ORGANISM CONSIDERED TO BE PART OF THE COMMENSAL
RESPIRATORY
FLORA.
Blood Culture, Routine (Final ___:
VIRIDANS STREPTOCOCCI.
Isolated from only one set ___ the previous five days.
WORKUP REQUESTED BY ___.
FINAL SENSITIVITIES. CEFTRIAXONE REQUESTED.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
|
CEFTRIAXONE-----------<=0.12 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- 2 R
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ 0.5 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ PAIRS AND CHAINS.
IMAGING/REPORTS
==============================================
TTE ___:
The left atrium and right atrium are normal ___ cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). The right ventricular cavity is mildly dilated
with severe global free wall hypokinesis. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Dilated right ventricle with severe RV systolic
dysfunction. Normal left ventricular systolic function. Mild
pulmonary hypertension ___ the setting of severe RV
dysfunction).
CT head ___: FINDINGS: The study is somewhat motion degraded.
Given this limitation, there is no evidence of infarction,
hemorrhage, edema, or mass. The ventricles and sulci are normal
___ size and configuration.
There is no evidence of 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: 1. Somewhat motion degraded study. This limitation,
no acute intracranial process.
Abdominal U/s ___: FINDINGS: LIVER: The hepatic parenchyma
appears within normal limits. The contour of the liver is
smooth. There is a focal echogenic mass ___ the left lobe
measuring 1.7 x 1.3 x 1.4 cm, with geographic borders. The main
portal vein is patent with hepatopetal flow. There is no
ascites. The hepatic veins are patent.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
measures 6 mm.
GALLBLADDER: The gallbladder contains sludge, but is
non-dilated, and there is no pericholecystic fluid.
PANCREAS: Imaged portion of the pancreas appears within normal
limits, without masses or pancreatic ductal dilation, with
portions of the pancreatic tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 10.6 cm.
KIDNEYS: The right kidney measures 13 cm. The left kidney
measures 12.6 cm. Normal cortical echogenicity and
corticomedullary differentiation is seen bilaterally. There is
no evidence of masses, stones, or hydronephrosis ___ the kidneys.
Limited evaluation of renal vascularity demonstrates patent
renal arteries veins with normal waveforms.
RETROPERITONEUM: Visualized portions of aorta and IVC are within
normal
limits.
IMPRESSION:
1. Patent hepatic veins and main portal vein. Patent bilateral
renal
vasculature. Evaluation of the renal vasculature is slightly
limited due to patient's body habitus.
2. Incidental geographic hyperechoic lesion ___ the left lobe of
liver likely hemangioma or focal fatty infiltration ___ the
absence of a history of known neoplasm).
3. Sludge within the gallbladder, without evidence of
cholecystitis.
CT head ___:
IMPRESSION:
1. When compared to prior examination of ___, there
is apparent increased sulcal effacement of the bilateral
cerebral convexities, which may be representative of edema from
prolonged hypoxia and ischemia. The finding may be artifactual
secondary to technique however MRI could be performed for
confirmation.
2. There is no diffuse loss of gray-white differentiation nor is
there
evidence of acute large territorial infarct. No intracranial
hemorrhage.
MRI brain ___
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift or infarction. The ventricles and sulci are
normal ___ caliber and
configuration. There is mucosal thickening ___ the visualized
paranasal sinuses. The orbits are unremarkable. There is fluid
opacification of bilateral mastoid air cells with secretions ___
the nasopharynx, likely secondary to intubation.
IMPRESSION:
1. No acute intracranial abnormality.
2. Paranasal sinus inflammatory disease.
TTE ___:
Normal left ventricular wall thickness, cavity size, and global
systolic function (3D LVEF = 57 %). The right ventricular cavity
is mildly dilated with mild global free wall hypokinesis.
Tricuspid annular plane systolic excursion is normal (1.7 cm,
mildly abnormal ___ setting of mild RV dilation). There is
abnormal systolic septal motion/position consistent with right
ventricular pressure overload. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. No masses or
vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. No masses or vegetations are seen on the mitral valve,
but cannot be fully excluded due to suboptimal image quality.
Trivial mitral regurgitation is seen. No masses or vegetations
are seen on the tricuspid valve, but cannot be fully excluded
due to suboptimal image quality. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: No echocardiographic evidence of cardiac emboli
noted. Mild RV dilation and systolic function (worse toward the
apex) with distal D-shaped septum (reverse ___ sign).
Compared with the prior study (images reviewed) of ___, RV
appears less dilated and systolic function more vigorous
EKG ___: Clinical indication for EKG: R06.02 - Shortness of
breath
Sinus rhythm. Anteroseptal and lateral T wave changes may be due
to ischemia. Compared to the previous tracing of ___ right
bundle-branch block has resolved.
___: Clinical indication for EKG: ___.___ - QT interval for
medication monitoring
Sinus bradycardia. Q-T interval prolongation. Biphasic T waves
___
leads II, III, and aVF. Deep T wave inversion ___ leads V1-V5,
similar to that recorded on ___. Rule out myocardial
infarction. Followup and clinical correlation are suggested.
___ Video Oropharyngeal Swallow Study:
Barium passes freely through the oropharynx and esophagus
without evidence of obstruction. There was gross aspiration of
nectar thick and thin liquids.
IMPRESSION: Gross aspiration of nectar thick and thin liquids.
ADMISSION LABORATORY STUDIES
==============================================
___ 01:13AM BLOOD WBC-14.0* RBC-4.24 Hgb-13.0 Hct-41.2
MCV-97 MCH-30.7 MCHC-31.6* RDW-14.2 RDWSD-49.8* Plt ___
___ 01:13AM BLOOD Neuts-71.3* ___ Monos-6.4
Eos-0.1* Baso-0.2 NRBC-0.1* Im ___ AbsNeut-9.94*
AbsLymp-2.98 AbsMono-0.89* AbsEos-0.02* AbsBaso-0.03
___ 01:13AM BLOOD ___ PTT-150* ___
___ 11:00AM BLOOD Fibrino-46*
___ 01:13AM BLOOD Glucose-358* UreaN-22* Creat-1.2* Na-140
K-4.6 Cl-112* HCO3-11* AnGap-22*
___ 01:13AM BLOOD ALT-213* AST-184* AlkPhos-85 TotBili-0.5
___ 01:13AM BLOOD ___
___ 01:13AM BLOOD Albumin-3.3* Calcium-7.4* Phos-7.2*
Mg-1.9
___ 01:20AM BLOOD Lactate-3.9*
___ 02:41AM BLOOD O2 Sat-99
___ 01:13AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:13AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
___ 01:13AM URINE RBC-7* WBC-1 Bacteri-FEW Yeast-NONE Epi-3
___ 01:13AM URINE Mucous-FEW
COAGULATION STUDIES
==============================================
___ 06:30AM BLOOD ___
___ 12:55PM BLOOD ___
___ 06:35AM BLOOD ___ PTT-32.9 ___
___ 06:10AM BLOOD ___ PTT-39.3* ___
___ 06:10AM BLOOD ___ PTT-38.8* ___
___ 05:00AM BLOOD ___ PTT-35.3 ___
LIVER FUNCTION TESTS
==============================================
___ 06:10AM BLOOD ALT-42* AST-21 LD(___)-219 AlkPhos-98
TotBili-0.6
___ 04:54AM BLOOD ALT-125* AST-20 LD(___)-235 AlkPhos-98
TotBili-0.5
___ 04:25AM BLOOD ALT-278* AST-26 LD(___)-320* AlkPhos-122*
TotBili-0.5
___ 05:03AM BLOOD ALT-1508* AST-214* AlkPhos-196*
TotBili-2.1*
___ 04:45AM BLOOD ALT-3371* AST-1124* LD(___)-574*
AlkPhos-119* TotBili-1.6*
___ 05:21AM BLOOD ALT-4866* AST-2844* LD(___)-1714*
AlkPhos-119* TotBili-1.1
___ 05:30AM BLOOD ALT-6960* AST-9075* LD(___)-9805*
CK(CPK)-386* AlkPhos-104 TotBili-0.7
___ 06:35PM BLOOD ALT-8010* ___
CK(CPK)-320* AlkPhos-93 TotBili-0.5
___ 11:00AM BLOOD ALT-6740* AST-8035* CK(CPK)-289*
AlkPhos-94 TotBili-0.7
___ 01:13AM BLOOD ALT-213* AST-184* AlkPhos-85 TotBili-0.5
OTHER PETINENT LABORATORY STUDIES
==============================================
___ 01:13AM BLOOD cTropnT-0.04*
___ 11:00AM BLOOD CK-MB-10 MB Indx-3.5 cTropnT-0.24*
___ 06:35PM BLOOD CK-MB-10 MB Indx-3.1 cTropnT-0.44*
___ 05:30AM BLOOD CK-MB-7 cTropnT-0.36*
___ 04:30PM BLOOD calTIBC-164* Ferritn-1560* TRF-126*
___ 05:30AM BLOOD TSH-2.5
___ 04:30PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
___ 04:34PM BLOOD Smooth-NEGATIVE
___ 04:30PM BLOOD AMA-NEGATIVE
___ 04:30PM BLOOD IgG-343* IgA-156 IgM-92
___ 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
___ 04:30PM BLOOD HCV Ab-NEGATIVE
DISCHARGE LABORATORY STUDIES
==============================================
___ 06:30AM BLOOD WBC-7.3 RBC-4.32 Hgb-13.1 Hct-41.5 MCV-96
MCH-30.3 MCHC-31.6* RDW-14.8 RDWSD-51.6* Plt ___
___ 06:30AM BLOOD ___
___ 06:30AM BLOOD Glucose-239* UreaN-18 Creat-1.3* Na-137
K-5.0 Cl-100 HCO3-26 AnGap-16
___ 06:10AM BLOOD ALT-42* AST-21 LD(LDH)-219 AlkPhos-98
TotBili-0.6
___ 06:30AM BLOOD Calcium-9.9 Phos-5.0* Mg-1.___ with PMH PTSD, T2DM, HLD, COPD, tobacco use, borderline
personality disorder who presented after being found down by
___, found to have massive pulmonary embolism (s/p tPA, now on
Coumadin), with course c/b oliguric renal failure ___ ATN,
initially on HD, now resolved off HD), shock liver (resolved),
strep viridans bacteremia, cdif (on po vanc, last day ___.
#SADDLE PULMONARY EMBOLISM:
Pt initially was found down by her ___ and brought to an outside
hospital where a CTA showed bilateral saddle pulmonary
embolisms, for which she was started on heparin drip and
transferred to ___. On arrival to ___, she was hypotensive
and hypoxic and she was emergently intubated. BNP 19699,
troponin leak to 0.44, and TTE showing dilated right ventricle
with severe RV systolic dysfunction were highly concerning for
massive PE. ___, she became hypotensive requiring
epinephrine and phenylephrine. Given her hemodynamic
instability, she was transitioned to full dose tPA. She was
transitioned to Coumadin with a heparin drip bridge. Follow up
TTE showed improvement ___ right heart strain. She was
discharged on Coumadin with a goal INR of 2 to 3. Given that
this is apparently an unprovoked PE, she will likely require
lifelong anticoagulation.
#ACUTE HYPOXIC RESPIRATORY FAILURE: Patient required intubation
as stated above secondary to massive PE. She was admitted to the
CCU for the majority of her hospital course. She was extubated
on ___ and did not require O2 by the time of discharge.
# DELIRIUM/COMPLEX PSYCHIATRIC HISTORY:
Pt has a complex psychiatric history of reported anorexia
nervosa (restrictive type), borderline personality disorder, and
bipolar affective disorder. During hospitalization, pt
developed waxing and waning sensorium and agitation. Psychiatry
and neurology were consulted. MRI and CT of the head were
negative. Her altered mental status was felt to be secondary to
delirum due to her medical illness. Given level of sedation and
multifactorial delirium, her home Ziprasidone, Prazosin,
Gabapentin and Clonazepam were initially held. Pt required
Precedex with a slow wean given agitation. Pt was managed on
TID perphenazine and clonidine Clonidine was eventually weaned
off and she was restarted on her home Prazosin. To prevent
withdrawal, her home Topiramate was weaned. After weaning, she
was more alert and oriented, and endorsed suicidal ideations and
tried to tie a cord around her neck while pressing the call
button for the nurse simultaneously. Given risk to harm herself
she was placed on 1:1 sitter. Pt later denied any thoughts of
self harm or symptoms of depression. Per psychiatry, she was
not felt to meet criteria for involuntary psychiatric
hospitalization and patient declined offer of voluntary
admission. Pt was discharged with follow up scheduled with
outpatient psychiatrist on ___. Pt was discharged on her
home doses of Clonazepam, Gabapentin, Perphenazine and Prazosin.
She was started on lower doses of her home Ziprasidone, and
Topiramate.
#Clostridium Difficile Colitis:
Pt noted to have diarrhea and found to have positive cdif on
___. She was initially started PO vancomycin and PO flagyl (___) and then narrowed to PO vancomycin on ___. Pt discharged
with a plan to complete a 14-day course of PO vancomycin for
treatment of cdif (last day ___.
#Vocal cord paralysis:
After extubation, pt noted to have dysphonia and aspiration on
bedside swallow. Pt seen by ENT, who noted left sided vocal
cord paralysis. Started on PPI BID. Pt to follow up with ENT
as an outpatient for further management. Speech and swallow
identified aspiration and recommended on puree solids and nectar
thick liquids and noted all per oral intake must be done with
left head turn with every bite/sip.
# OLIGURIC RENAL FAILURE:
Pt developed oliguric renal failure, likely due to hypotension
from the massive pulmonary embolism plus contrast injury. Pt
seen by renal consult, who noted muddy brown casts ___ urine
sediment, consistent with ATN. Creatinine peaked at 6.4 (from
admission creatinine of 1.2). Pt received hemodialysis for
volume and solute clearance (from ___ to ___. She
developed rapid recovery so hemodialysis was discontinued and
the HD line was pulled on ___. Creatinine on discharge was
1.3. She will need outpatient follow up with nephrology.
# BACTEREMIA, STREP VIRIDANS
Pt febrile on ___ and found to have strep viridans bacteremia.
Strep viridans may be a contaminant, however, the patient has a
reported h/o poor dentition and dental pain and temporarily
related fever was concerning for true strep viridans bacteremia.
She was initially on IV vancomycin (___). TTE showed no
evidence of endocarditis. Discontinued ceftriaxone and flagyl
___ given no recurrent fevers. Pt remained afebrile during
the rest of the hospitalization and had no subsequent positive
blood cultures.
#Cystitis
Pt found to have pan-sensitive e. coli UTI, for which she
received a course of IV Ceftriaxone.
# TRANSAMINITS:
Pt found to have transaminitis with AST and ALT ___ the
thousands, elevated INR and normal bilirubin and ALP. Her acute
hepatitis was likely secondary to ischemic hepatopathy.
Hepatology was consulted. Resolving on discharge.
CHRONIC ISSUES:
================
# T2DM: managed with ISS during hsopitalization
# COPD: continued on home medications
# HLD: f/u home medications
#Hypothyroidism: continued on home levothyroxine
TRANSITIONAL ISSUES
========================================
1. Pt needs to complete a 14-day course of PO vancomycin for
treatment of cdif (last day ___
2. Pt with new vocal cord paralysis, for which she is scheduled
for ENT follow up. She was started on Pantoprazole 40mg Q12H and
will need vocal cord injections. She will need CT
head/neck/chest with contrast to evaluate the course of the
recurrent laryngeal nerve and vagus nerve. She is recommended to
have modified diet of puree solids and nectar thick liquids and
noted all per oral intake must be done with left head turn with
every bite/sip.
3. Pt needs outpatient follow up with nephrology with ___
___. Her office can be reached at ___.
4. Pt should have outpatient workup for hypercoagulobility
predisposition, including anti-phospholipid antibody syndrome
given family history of miscarriages and mother who had an
unprovoked DVT.
5. Pt should undergo age-appropriate cancer screening given the
concern that PE may be provoked by underlying malignancy.
6. Pt discharged on Coumadin, which will be followed by her PCP.
INR on discharge (___) was 1.9. She will need repeat INR
check on ___. Coumadin course is projected to be lifelong
given unprovoked VTE.
7. Home statin held given elevated transaminases ___ setting of
shock liver. This may be restarted ___ the outpatient setting as
LFTs continue to improve.
8. Pt's home psychiatric medications were adjusted during
hospitalization. Pt was discharged on her home doses of
Clonazepam, Gabapentin, Perphenazine and Prazosin. She was
started on lower doses of her home Ziprasidone, and Topiramate.
Pt scheduled for follow-up with outpatient Psychiatrist. If pt
is interested ___ pursuing partial hospital program, she can call
Arbour Counseling at ___. If suicidal thoughts occur,
pt instructed to call ___ or present to nearest emergency room.
9. Pt recently discontinued her home Metformin. She required
insulin sliding scale during hospitalization. Pt should have
outpatient consideration of restarting medications for diabetes.
# CODE: Full
# CONTACT: daughter/HCP ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
2. Flovent HFA (fluticasone) 44 mcg/actuation inhalation 1 puff
2x/day
3. ZIPRASidone Hydrochloride 80 mg PO QHS
4. ClonazePAM 1 mg PO BID
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Loratadine 10 mg PO DAILY
7. Gabapentin 800 mg PO TID
8. Perphenazine 8 mg PO TID
9. Prazosin 5 mg PO QHS
10. Pantoprazole 40 mg PO Q12H
11. Topiramate (Topamax) 150 mg PO BID
12. Simvastatin 40 mg PO QPM
13. Ibuprofen 600 mg PO Q6H:PRN pain
14. Naproxen 250 mg PO Q12H:PRN pain
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN wheezing
Discharge Medications:
1. ClonazePAM 1 mg PO BID
RX *clonazepam 1 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
2. Gabapentin 800 mg PO TID
RX *gabapentin 800 mg 1 tablet(s) by mouth three times a day
Disp #*15 Tablet Refills:*0
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Prazosin 5 mg PO QHS
RX *prazosin 5 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
5. Topiramate (Topamax) 25 mg PO BID
RX *topiramate 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. ZIPRASidone Hydrochloride 40 mg PO QHS
RX *ziprasidone HCl 40 mg 1 capsule(s) by mouth at bedtime Disp
#*30 Capsule Refills:*0
7. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours
Disp #*30 Capsule Refills:*0
8. Warfarin 4 mg PO DAILY16
RX *warfarin 2 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*0
9. Flovent HFA (fluticasone) 44 mcg/actuation inhalation 1 puff
2x/day
10. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN wheezing
12. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
13. Perphenazine 8 mg PO TID
RX *perphenazine 8 mg 1 tablet(s) by mouth three times a day
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Massive pulmonary embolus
Acute hypoxic respiratory failure
Acute tubular necrosis
Shock liver
Clostridium difficile colitis
Complicated cystitis
Toxometabolic delirium
Secondary:
Hypothyroidism
Borderline personality disorder
History of suicide attempts
Post traumatic stress disorder
Bipolar disorder
Psychosis
Anorexia nervosa
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ after
being found by your ___. You were found to have a very large
blood clot to your lungs. This caused you to have low blood
pressure, and your liver and kidneys sustained some damage from
this. You required dialysis because of your kidney failure.
However, both your liver and your kidneys recovered, and you
will not need dialysis for the foreseeable future. You will need
to follow up with a kidney doctor (___) after your
discharge.
You needed to be intubated so that a breathing machine could
help you breathe. As the blood clot to your lungs got better,
you were able to be taken off the machine. However, after you
came off the machine, you were found to have paralysis of your
vocal cords. This is why you have lost your voice. You will need
to follow up with our Ear/Nose/Throat (ENT) doctors after your
___ for further management.
Your blood clot improved with blood thinners, and you will need
to continue on these for the foreseeable future. You will
continue to take a blood thinner called Coumadin (aka Warfarin).
You will have to have your Coumadin level (aka "INR") monitored
frequently, and your dose adjusted as needed.
You were also found to have an infection ___ your large intestine
(called C diff). You were treated with antibiotics for this.
You need to continue taking vancomycin (last day ___.
Please take all medications as prescribed and please follow up
with the appointments we have arranged. It is very important
that you see your primary care doctor, your kidney doctor, your
psychiatrist, and your ENT doctor after you leave the hospital
to ensure ongoing care.
Do not make any medication changes to your psychiatric
medications until you follow up with your Psychiatrist. If you
would like to do a partial program, please contact ___
___ at ___. If you have any feelings that you
are unsafe, or feel like you are going to harm yourself or
others, please call ___ or go to the Emergency Department
immediately.
It was a pleasure taking care of you.
Sincerely,
Your ___ Team
Followup Instructions:
___
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"R490"
] |
Allergies: lamotrigine / levetiracetam Chief Complaint: "Found down." Major Surgical or Invasive Procedure: Left HD line insertion Right IJ line insertion HD line placement (removed [MASKED] Intubation, s/p extubation [MASKED] History of Present Illness: [MASKED] with unknown medical history, but is resident of a group home was found down by her [MASKED]. Pt presented initially to OSH ED, where she was evaluated with CT head which was negative. CTA showed bilateral saddle pulmonary embolisms and whe was started on heparin gtt w/6000U bolus and 1800cc/hr. She was transferred to [MASKED] for further evaluation. An arrival to [MASKED], the patient continued to be hypoxemic and became altered and was intubated for airway protection. During intubation, the patient was noted to be progressively more hypotensive. A radial A-line was placed. She was evaluated with a stat CT head which showed no acute intracranial pathology. The patient's hemodynamics improved. [MASKED] the ED, initial vitals were: HR 124, BP 105/76, RR 32, O2 99% on NRB Labs: - WBC 14.0, Hgb 13.0, HCT 41.2, Plt 148 - Cr 1.2, HCO3 11, Phos 7.2 - ALT 213, AST 184, AP 85, Alb 3.3 - troponin 0.04, BNP 19699 - UA SG > 1.050, protein 100, few bacteria - INR 8.0 - ABG pH 7.12, pCO2 34, pO2 372, HCO3 12, lactate 3.9 Imaging: CXR: 1. Tip of the ET tube situated 5.2 cm above the carina at the thoracic inlet. 2. Dilatation of the main and left pulmonary artery compatible with known pulmonary embolism CT head: Somewhat motion degraded study. This limitation, no acute intracranial process. Bedside TTE showed R heart strain Consults: Cardiology Patient was given: fentanyl Decision was made to admit to CCU for management of PE REVIEW OF SYSTEMS: (+) per HPI, all other ROS otherwise negative Past Medical History: - PTSD - T2DM - GERD - Hyperlipidemia - Sleep walking and night terrors - COPD - Subclinical hypothyroidism - Mood disorder with psychosis - Anorexia Nervosa - Tobacco use - Renal insufficiency - History of empyema - Borderline personality disease - Lower extremity edema - Diabetic foot ulcer Social History: [MASKED] Family History: No family history of heart disease, clotting disorder, or malignancy Physical Exam: Admission exam: VS: T97.8, HR 106, BP 66/45, RR 36, O2 98% Weight: 83.5kg GEN: intubated, sedated HEENT: purple discoloration to upper chest NECK: JVD appears elevated but difficult to appreciate CV: tachycardic, nl S1 S2, on M/R/G LUNGS: CTA anteriorly over ventilator ABD: soft, NT, ND, NABS EXT: WWP, no edema NEURO: opens eyes to name [MASKED] exam: VS: 98.1 123/73 59 18 99RA I/O: 1800/poorly recorded +3BMs Weights: not recorded Gen: NAD, laying [MASKED] bed HEENT: no elevated JVD, dysphonic, MMM CV: RRR, no m/r/g Resp: CTAB Abd: soft, NT/ND, BS+ Ext: no edema, WWP Neuro: Follows commands appropriately, [MASKED] strength [MASKED] UE and [MASKED] A&Ox3 Pertinent Results: MICROBIOLOGY: ============================================== C. difficile DNA amplification assay (Final [MASKED]: Reported to and read back by [MASKED] [MASKED] 11:25AM. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. MRSA SCREEN (Final [MASKED]: No MRSA isolated. URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed [MASKED] MCG/ML [MASKED] ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S GRAM STAIN (Final [MASKED]: >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [MASKED]: MODERATE GROWTH Commensal Respiratory Flora. YEAST. RARE GROWTH. THIS ORGANISM CONSIDERED TO BE PART OF THE COMMENSAL RESPIRATORY FLORA. Blood Culture, Routine (Final [MASKED]: VIRIDANS STREPTOCOCCI. Isolated from only one set [MASKED] the previous five days. WORKUP REQUESTED BY [MASKED]. FINAL SENSITIVITIES. CEFTRIAXONE REQUESTED. SENSITIVITIES: MIC expressed [MASKED] MCG/ML [MASKED] VIRIDANS STREPTOCOCCI | CEFTRIAXONE-----------<=0.12 S CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- 2 R PENICILLIN G----------<=0.06 S VANCOMYCIN------------ 0.5 S Anaerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI [MASKED] PAIRS AND CHAINS. IMAGING/REPORTS ============================================== TTE [MASKED]: The left atrium and right atrium are normal [MASKED] cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is mildly dilated with severe global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Dilated right ventricle with severe RV systolic dysfunction. Normal left ventricular systolic function. Mild pulmonary hypertension [MASKED] the setting of severe RV dysfunction). CT head [MASKED]: FINDINGS: The study is somewhat motion degraded. Given this limitation, there is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal [MASKED] size and configuration. There is no evidence of 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: 1. Somewhat motion degraded study. This limitation, no acute intracranial process. Abdominal U/s [MASKED]: FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is a focal echogenic mass [MASKED] the left lobe measuring 1.7 x 1.3 x 1.4 cm, with geographic borders. The main portal vein is patent with hepatopetal flow. There is no ascites. The hepatic veins are patent. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 6 mm. GALLBLADDER: The gallbladder contains sludge, but is non-dilated, and there is no pericholecystic fluid. PANCREAS: Imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 10.6 cm. KIDNEYS: The right kidney measures 13 cm. The left kidney measures 12.6 cm. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones, or hydronephrosis [MASKED] the kidneys. Limited evaluation of renal vascularity demonstrates patent renal arteries veins with normal waveforms. RETROPERITONEUM: Visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Patent hepatic veins and main portal vein. Patent bilateral renal vasculature. Evaluation of the renal vasculature is slightly limited due to patient's body habitus. 2. Incidental geographic hyperechoic lesion [MASKED] the left lobe of liver likely hemangioma or focal fatty infiltration [MASKED] the absence of a history of known neoplasm). 3. Sludge within the gallbladder, without evidence of cholecystitis. CT head [MASKED]: IMPRESSION: 1. When compared to prior examination of [MASKED], there is apparent increased sulcal effacement of the bilateral cerebral convexities, which may be representative of edema from prolonged hypoxia and ischemia. The finding may be artifactual secondary to technique however MRI could be performed for confirmation. 2. There is no diffuse loss of gray-white differentiation nor is there evidence of acute large territorial infarct. No intracranial hemorrhage. MRI brain [MASKED] FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal [MASKED] caliber and configuration. There is mucosal thickening [MASKED] the visualized paranasal sinuses. The orbits are unremarkable. There is fluid opacification of bilateral mastoid air cells with secretions [MASKED] the nasopharynx, likely secondary to intubation. IMPRESSION: 1. No acute intracranial abnormality. 2. Paranasal sinus inflammatory disease. TTE [MASKED]: Normal left ventricular wall thickness, cavity size, and global systolic function (3D LVEF = 57 %). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. Tricuspid annular plane systolic excursion is normal (1.7 cm, mildly abnormal [MASKED] setting of mild RV dilation). There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Trivial mitral regurgitation is seen. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: No echocardiographic evidence of cardiac emboli noted. Mild RV dilation and systolic function (worse toward the apex) with distal D-shaped septum (reverse [MASKED] sign). Compared with the prior study (images reviewed) of [MASKED], RV appears less dilated and systolic function more vigorous EKG [MASKED]: Clinical indication for EKG: R06.02 - Shortness of breath Sinus rhythm. Anteroseptal and lateral T wave changes may be due to ischemia. Compared to the previous tracing of [MASKED] right bundle-branch block has resolved. [MASKED]: Clinical indication for EKG: [MASKED].[MASKED] - QT interval for medication monitoring Sinus bradycardia. Q-T interval prolongation. Biphasic T waves [MASKED] leads II, III, and aVF. Deep T wave inversion [MASKED] leads V1-V5, similar to that recorded on [MASKED]. Rule out myocardial infarction. Followup and clinical correlation are suggested. [MASKED] Video Oropharyngeal Swallow Study: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was gross aspiration of nectar thick and thin liquids. IMPRESSION: Gross aspiration of nectar thick and thin liquids. ADMISSION LABORATORY STUDIES ============================================== [MASKED] 01:13AM BLOOD WBC-14.0* RBC-4.24 Hgb-13.0 Hct-41.2 MCV-97 MCH-30.7 MCHC-31.6* RDW-14.2 RDWSD-49.8* Plt [MASKED] [MASKED] 01:13AM BLOOD Neuts-71.3* [MASKED] Monos-6.4 Eos-0.1* Baso-0.2 NRBC-0.1* Im [MASKED] AbsNeut-9.94* AbsLymp-2.98 AbsMono-0.89* AbsEos-0.02* AbsBaso-0.03 [MASKED] 01:13AM BLOOD [MASKED] PTT-150* [MASKED] [MASKED] 11:00AM BLOOD Fibrino-46* [MASKED] 01:13AM BLOOD Glucose-358* UreaN-22* Creat-1.2* Na-140 K-4.6 Cl-112* HCO3-11* AnGap-22* [MASKED] 01:13AM BLOOD ALT-213* AST-184* AlkPhos-85 TotBili-0.5 [MASKED] 01:13AM BLOOD [MASKED] [MASKED] 01:13AM BLOOD Albumin-3.3* Calcium-7.4* Phos-7.2* Mg-1.9 [MASKED] 01:20AM BLOOD Lactate-3.9* [MASKED] 02:41AM BLOOD O2 Sat-99 [MASKED] 01:13AM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 01:13AM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG [MASKED] 01:13AM URINE RBC-7* WBC-1 Bacteri-FEW Yeast-NONE Epi-3 [MASKED] 01:13AM URINE Mucous-FEW COAGULATION STUDIES ============================================== [MASKED] 06:30AM BLOOD [MASKED] [MASKED] 12:55PM BLOOD [MASKED] [MASKED] 06:35AM BLOOD [MASKED] PTT-32.9 [MASKED] [MASKED] 06:10AM BLOOD [MASKED] PTT-39.3* [MASKED] [MASKED] 06:10AM BLOOD [MASKED] PTT-38.8* [MASKED] [MASKED] 05:00AM BLOOD [MASKED] PTT-35.3 [MASKED] LIVER FUNCTION TESTS ============================================== [MASKED] 06:10AM BLOOD ALT-42* AST-21 LD([MASKED])-219 AlkPhos-98 TotBili-0.6 [MASKED] 04:54AM BLOOD ALT-125* AST-20 LD([MASKED])-235 AlkPhos-98 TotBili-0.5 [MASKED] 04:25AM BLOOD ALT-278* AST-26 LD([MASKED])-320* AlkPhos-122* TotBili-0.5 [MASKED] 05:03AM BLOOD ALT-1508* AST-214* AlkPhos-196* TotBili-2.1* [MASKED] 04:45AM BLOOD ALT-3371* AST-1124* LD([MASKED])-574* AlkPhos-119* TotBili-1.6* [MASKED] 05:21AM BLOOD ALT-4866* AST-2844* LD([MASKED])-1714* AlkPhos-119* TotBili-1.1 [MASKED] 05:30AM BLOOD ALT-6960* AST-9075* LD([MASKED])-9805* CK(CPK)-386* AlkPhos-104 TotBili-0.7 [MASKED] 06:35PM BLOOD ALT-8010* [MASKED] CK(CPK)-320* AlkPhos-93 TotBili-0.5 [MASKED] 11:00AM BLOOD ALT-6740* AST-8035* CK(CPK)-289* AlkPhos-94 TotBili-0.7 [MASKED] 01:13AM BLOOD ALT-213* AST-184* AlkPhos-85 TotBili-0.5 OTHER PETINENT LABORATORY STUDIES ============================================== [MASKED] 01:13AM BLOOD cTropnT-0.04* [MASKED] 11:00AM BLOOD CK-MB-10 MB Indx-3.5 cTropnT-0.24* [MASKED] 06:35PM BLOOD CK-MB-10 MB Indx-3.1 cTropnT-0.44* [MASKED] 05:30AM BLOOD CK-MB-7 cTropnT-0.36* [MASKED] 04:30PM BLOOD calTIBC-164* Ferritn-1560* TRF-126* [MASKED] 05:30AM BLOOD TSH-2.5 [MASKED] 04:30PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [MASKED] 04:34PM BLOOD Smooth-NEGATIVE [MASKED] 04:30PM BLOOD AMA-NEGATIVE [MASKED] 04:30PM BLOOD IgG-343* IgA-156 IgM-92 [MASKED] 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [MASKED] 04:30PM BLOOD HCV Ab-NEGATIVE DISCHARGE LABORATORY STUDIES ============================================== [MASKED] 06:30AM BLOOD WBC-7.3 RBC-4.32 Hgb-13.1 Hct-41.5 MCV-96 MCH-30.3 MCHC-31.6* RDW-14.8 RDWSD-51.6* Plt [MASKED] [MASKED] 06:30AM BLOOD [MASKED] [MASKED] 06:30AM BLOOD Glucose-239* UreaN-18 Creat-1.3* Na-137 K-5.0 Cl-100 HCO3-26 AnGap-16 [MASKED] 06:10AM BLOOD ALT-42* AST-21 LD(LDH)-219 AlkPhos-98 TotBili-0.6 [MASKED] 06:30AM BLOOD Calcium-9.9 Phos-5.0* Mg-1.[MASKED] with PMH PTSD, T2DM, HLD, COPD, tobacco use, borderline personality disorder who presented after being found down by [MASKED], found to have massive pulmonary embolism (s/p tPA, now on Coumadin), with course c/b oliguric renal failure [MASKED] ATN, initially on HD, now resolved off HD), shock liver (resolved), strep viridans bacteremia, cdif (on po vanc, last day [MASKED]. #SADDLE PULMONARY EMBOLISM: Pt initially was found down by her [MASKED] and brought to an outside hospital where a CTA showed bilateral saddle pulmonary embolisms, for which she was started on heparin drip and transferred to [MASKED]. On arrival to [MASKED], she was hypotensive and hypoxic and she was emergently intubated. BNP 19699, troponin leak to 0.44, and TTE showing dilated right ventricle with severe RV systolic dysfunction were highly concerning for massive PE. [MASKED], she became hypotensive requiring epinephrine and phenylephrine. Given her hemodynamic instability, she was transitioned to full dose tPA. She was transitioned to Coumadin with a heparin drip bridge. Follow up TTE showed improvement [MASKED] right heart strain. She was discharged on Coumadin with a goal INR of 2 to 3. Given that this is apparently an unprovoked PE, she will likely require lifelong anticoagulation. #ACUTE HYPOXIC RESPIRATORY FAILURE: Patient required intubation as stated above secondary to massive PE. She was admitted to the CCU for the majority of her hospital course. She was extubated on [MASKED] and did not require O2 by the time of discharge. # DELIRIUM/COMPLEX PSYCHIATRIC HISTORY: Pt has a complex psychiatric history of reported anorexia nervosa (restrictive type), borderline personality disorder, and bipolar affective disorder. During hospitalization, pt developed waxing and waning sensorium and agitation. Psychiatry and neurology were consulted. MRI and CT of the head were negative. Her altered mental status was felt to be secondary to delirum due to her medical illness. Given level of sedation and multifactorial delirium, her home Ziprasidone, Prazosin, Gabapentin and Clonazepam were initially held. Pt required Precedex with a slow wean given agitation. Pt was managed on TID perphenazine and clonidine Clonidine was eventually weaned off and she was restarted on her home Prazosin. To prevent withdrawal, her home Topiramate was weaned. After weaning, she was more alert and oriented, and endorsed suicidal ideations and tried to tie a cord around her neck while pressing the call button for the nurse simultaneously. Given risk to harm herself she was placed on 1:1 sitter. Pt later denied any thoughts of self harm or symptoms of depression. Per psychiatry, she was not felt to meet criteria for involuntary psychiatric hospitalization and patient declined offer of voluntary admission. Pt was discharged with follow up scheduled with outpatient psychiatrist on [MASKED]. Pt was discharged on her home doses of Clonazepam, Gabapentin, Perphenazine and Prazosin. She was started on lower doses of her home Ziprasidone, and Topiramate. #Clostridium Difficile Colitis: Pt noted to have diarrhea and found to have positive cdif on [MASKED]. She was initially started PO vancomycin and PO flagyl ([MASKED]) and then narrowed to PO vancomycin on [MASKED]. Pt discharged with a plan to complete a 14-day course of PO vancomycin for treatment of cdif (last day [MASKED]. #Vocal cord paralysis: After extubation, pt noted to have dysphonia and aspiration on bedside swallow. Pt seen by ENT, who noted left sided vocal cord paralysis. Started on PPI BID. Pt to follow up with ENT as an outpatient for further management. Speech and swallow identified aspiration and recommended on puree solids and nectar thick liquids and noted all per oral intake must be done with left head turn with every bite/sip. # OLIGURIC RENAL FAILURE: Pt developed oliguric renal failure, likely due to hypotension from the massive pulmonary embolism plus contrast injury. Pt seen by renal consult, who noted muddy brown casts [MASKED] urine sediment, consistent with ATN. Creatinine peaked at 6.4 (from admission creatinine of 1.2). Pt received hemodialysis for volume and solute clearance (from [MASKED] to [MASKED]. She developed rapid recovery so hemodialysis was discontinued and the HD line was pulled on [MASKED]. Creatinine on discharge was 1.3. She will need outpatient follow up with nephrology. # BACTEREMIA, STREP VIRIDANS Pt febrile on [MASKED] and found to have strep viridans bacteremia. Strep viridans may be a contaminant, however, the patient has a reported h/o poor dentition and dental pain and temporarily related fever was concerning for true strep viridans bacteremia. She was initially on IV vancomycin ([MASKED]). TTE showed no evidence of endocarditis. Discontinued ceftriaxone and flagyl [MASKED] given no recurrent fevers. Pt remained afebrile during the rest of the hospitalization and had no subsequent positive blood cultures. #Cystitis Pt found to have pan-sensitive e. coli UTI, for which she received a course of IV Ceftriaxone. # TRANSAMINITS: Pt found to have transaminitis with AST and ALT [MASKED] the thousands, elevated INR and normal bilirubin and ALP. Her acute hepatitis was likely secondary to ischemic hepatopathy. Hepatology was consulted. Resolving on discharge. CHRONIC ISSUES: ================ # T2DM: managed with ISS during hsopitalization # COPD: continued on home medications # HLD: f/u home medications #Hypothyroidism: continued on home levothyroxine TRANSITIONAL ISSUES ======================================== 1. Pt needs to complete a 14-day course of PO vancomycin for treatment of cdif (last day [MASKED] 2. Pt with new vocal cord paralysis, for which she is scheduled for ENT follow up. She was started on Pantoprazole 40mg Q12H and will need vocal cord injections. She will need CT head/neck/chest with contrast to evaluate the course of the recurrent laryngeal nerve and vagus nerve. She is recommended to have modified diet of puree solids and nectar thick liquids and noted all per oral intake must be done with left head turn with every bite/sip. 3. Pt needs outpatient follow up with nephrology with [MASKED] [MASKED]. Her office can be reached at [MASKED]. 4. Pt should have outpatient workup for hypercoagulobility predisposition, including anti-phospholipid antibody syndrome given family history of miscarriages and mother who had an unprovoked DVT. 5. Pt should undergo age-appropriate cancer screening given the concern that PE may be provoked by underlying malignancy. 6. Pt discharged on Coumadin, which will be followed by her PCP. INR on discharge ([MASKED]) was 1.9. She will need repeat INR check on [MASKED]. Coumadin course is projected to be lifelong given unprovoked VTE. 7. Home statin held given elevated transaminases [MASKED] setting of shock liver. This may be restarted [MASKED] the outpatient setting as LFTs continue to improve. 8. Pt's home psychiatric medications were adjusted during hospitalization. Pt was discharged on her home doses of Clonazepam, Gabapentin, Perphenazine and Prazosin. She was started on lower doses of her home Ziprasidone, and Topiramate. Pt scheduled for follow-up with outpatient Psychiatrist. If pt is interested [MASKED] pursuing partial hospital program, she can call Arbour Counseling at [MASKED]. If suicidal thoughts occur, pt instructed to call [MASKED] or present to nearest emergency room. 9. Pt recently discontinued her home Metformin. She required insulin sliding scale during hospitalization. Pt should have outpatient consideration of restarting medications for diabetes. # CODE: Full # CONTACT: daughter/HCP [MASKED] [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H 2. Flovent HFA (fluticasone) 44 mcg/actuation inhalation 1 puff 2x/day 3. ZIPRASidone Hydrochloride 80 mg PO QHS 4. ClonazePAM 1 mg PO BID 5. Levothyroxine Sodium 25 mcg PO DAILY 6. Loratadine 10 mg PO DAILY 7. Gabapentin 800 mg PO TID 8. Perphenazine 8 mg PO TID 9. Prazosin 5 mg PO QHS 10. Pantoprazole 40 mg PO Q12H 11. Topiramate (Topamax) 150 mg PO BID 12. Simvastatin 40 mg PO QPM 13. Ibuprofen 600 mg PO Q6H:PRN pain 14. Naproxen 250 mg PO Q12H:PRN pain 15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN wheezing Discharge Medications: 1. ClonazePAM 1 mg PO BID RX *clonazepam 1 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 2. Gabapentin 800 mg PO TID RX *gabapentin 800 mg 1 tablet(s) by mouth three times a day Disp #*15 Tablet Refills:*0 3. Levothyroxine Sodium 25 mcg PO DAILY 4. Prazosin 5 mg PO QHS RX *prazosin 5 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 5. Topiramate (Topamax) 25 mg PO BID RX *topiramate 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. ZIPRASidone Hydrochloride 40 mg PO QHS RX *ziprasidone HCl 40 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 7. Vancomycin Oral Liquid [MASKED] mg PO Q6H RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours Disp #*30 Capsule Refills:*0 8. Warfarin 4 mg PO DAILY16 RX *warfarin 2 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet Refills:*0 9. Flovent HFA (fluticasone) 44 mcg/actuation inhalation 1 puff 2x/day 10. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H 11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN wheezing 12. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 13. Perphenazine 8 mg PO TID RX *perphenazine 8 mg 1 tablet(s) by mouth three times a day Disp #*20 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary: Massive pulmonary embolus Acute hypoxic respiratory failure Acute tubular necrosis Shock liver Clostridium difficile colitis Complicated cystitis Toxometabolic delirium Secondary: Hypothyroidism Borderline personality disorder History of suicide attempts Post traumatic stress disorder Bipolar disorder Psychosis Anorexia nervosa Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You were seen at [MASKED] after being found by your [MASKED]. You were found to have a very large blood clot to your lungs. This caused you to have low blood pressure, and your liver and kidneys sustained some damage from this. You required dialysis because of your kidney failure. However, both your liver and your kidneys recovered, and you will not need dialysis for the foreseeable future. You will need to follow up with a kidney doctor ([MASKED]) after your discharge. You needed to be intubated so that a breathing machine could help you breathe. As the blood clot to your lungs got better, you were able to be taken off the machine. However, after you came off the machine, you were found to have paralysis of your vocal cords. This is why you have lost your voice. You will need to follow up with our Ear/Nose/Throat (ENT) doctors after your [MASKED] for further management. Your blood clot improved with blood thinners, and you will need to continue on these for the foreseeable future. You will continue to take a blood thinner called Coumadin (aka Warfarin). You will have to have your Coumadin level (aka "INR") monitored frequently, and your dose adjusted as needed. You were also found to have an infection [MASKED] your large intestine (called C diff). You were treated with antibiotics for this. You need to continue taking vancomycin (last day [MASKED]. Please take all medications as prescribed and please follow up with the appointments we have arranged. It is very important that you see your primary care doctor, your kidney doctor, your psychiatrist, and your ENT doctor after you leave the hospital to ensure ongoing care. Do not make any medication changes to your psychiatric medications until you follow up with your Psychiatrist. If you would like to do a partial program, please contact [MASKED] [MASKED] at [MASKED]. If you have any feelings that you are unsafe, or feel like you are going to harm yourself or others, please call [MASKED] or go to the Emergency Department immediately. It was a pleasure taking care of you. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"J9601",
"Z794",
"K219",
"J449",
"E785",
"I129",
"N189",
"Y92230"
] |
[
"I2602: Saddle embolus of pulmonary artery with acute cor pulmonale",
"K7201: Acute and subacute hepatic failure with coma",
"N170: Acute kidney failure with tubular necrosis",
"R578: Other shock",
"G92: Toxic encephalopathy",
"A047: Enterocolitis due to Clostridium difficile",
"F5001: Anorexia nervosa, restricting type",
"J9601: Acute respiratory failure with hypoxia",
"E1142: Type 2 diabetes mellitus with diabetic polyneuropathy",
"E11621: Type 2 diabetes mellitus with foot ulcer",
"Z794: Long term (current) use of insulin",
"F4310: Post-traumatic stress disorder, unspecified",
"F39: Unspecified mood [affective] disorder",
"F28: Other psychotic disorder not due to a substance or known physiological condition",
"F514: Sleep terrors [night terrors]",
"F603: Borderline personality disorder",
"K219: Gastro-esophageal reflux disease without esophagitis",
"J449: Chronic obstructive pulmonary disease, unspecified",
"Z720: Tobacco use",
"E785: Hyperlipidemia, unspecified",
"E038: Other specified hypothyroidism",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"N189: Chronic kidney disease, unspecified",
"N141: Nephropathy induced by other drugs, medicaments and biological substances",
"T508X5A: Adverse effect of diagnostic agents, initial encounter",
"Y92238: Other place in hospital as the place of occurrence of the external cause",
"E876: Hypokalemia",
"Z915: Personal history of self-harm",
"F1220: Cannabis dependence, uncomplicated",
"T4275XA: Adverse effect of unspecified antiepileptic and sedative-hypnotic drugs, initial encounter",
"Y92230: Patient room in hospital as the place of occurrence of the external cause",
"F319: Bipolar disorder, unspecified",
"I4581: Long QT syndrome",
"K047: Periapical abscess without sinus",
"B954: Other streptococcus as the cause of diseases classified elsewhere",
"Z1639: Resistance to other specified antimicrobial drug",
"R1312: Dysphagia, oropharyngeal phase",
"T17920A: Food in respiratory tract, part unspecified causing asphyxiation, initial encounter",
"R490: Dysphonia"
] |
10,029,429
| 22,981,727
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / Penicillins
Attending: ___.
Chief Complaint:
R distal femur periprosthetic fx
Major Surgical or Invasive Procedure:
Surgical fixation (open reduction, internal fixation), R distal
femur
History of Present Illness:
___ female hx of CHF (EF 65% last TTE ___, A. fib (on
Eliquis) who presents after a mechanical fall after slipping on
a raw vegetable on the ground at the grocery market. She denied
head strike or loss of consciousness. She denied any
presyncopal symptoms. She was brought to ___
where her initial evaluation and workup revealed a right
periprosthetic distal femur fracture. She states that she last
took her Eliquis the morning of her fall. She denies any other
complaints including neck pain, chest pain, shortness of breath,
pain in the left lower or bilateral upper extremities. She
states that she ambulates with a cane and is functionally
independent of ADLs and IADLs.
Past Medical History:
Hypertension
CAD
CHF
Hyperlipidemia
Hypothyroidism
Atrial fibrillation
Social History:
___
Family History:
NC
Physical Exam:
Admission Physical Exam
Vitals: AVSS
General: Well-appearing female in mild distress due to her right
thigh pain
Neck: No C-spine tenderness or palpable step-offs, full passive
range of motion of the neck
Right lower extremity:
- Skin intact
- No deformity evident, moderate ecchymosis and swelling
- Soft, but tender distal thigh and proximal leg
- Full, painless ROM at bilateral hip, left knee, and ankle
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Discharge Physical Exam
VS: 98.2 PO 149/66 HR 63 RR 16 ___ 94 Ra
General: Alert and oriented, NAD
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: JVP 6 cm.
CV: Irregularly irregular, no MRG
Lungs: Scattered crackles at bases, no wheezes, normal
respiratory effort
GI: soft, NT/ND
Extremities: warm, well perfused, trace edema on the L ankle,
1+ edema on the RLE
Neuro: No gross motor/coordination abnormalities
Pertinent Results:
Admission Labs
___ 12:45PM BLOOD Glucose-139* UreaN-33* Creat-1.0 Na-135
K-4.1 Cl-100 HCO3-25 AnGap-10
___ 06:30AM BLOOD
WBC-7.9 RBC-2.70* Hgb-7.9* Hct-24.9* MCV-92 MCH-29.3 MCHC-31.7*
RDW-14.9 RDWSD-50.2* Plt ___
___ 05:14AM URINE Hours-RANDOM
UreaN-712 Creat-89 Na-<20
___ 08:30AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM*
Discharge Labs
___ 06:16AM BLOOD WBC-9.9 RBC-2.89* Hgb-8.7* Hct-25.9*
MCV-90 MCH-30.1 MCHC-33.6 RDW-14.9 RDWSD-48.8* Plt ___
___ 06:16AM BLOOD ___ PTT-28.1 ___
___ 06:16AM BLOOD Glucose-110* UreaN-22* Creat-0.7 Na-139
K-3.8 Cl-99 HCO3-28 AnGap-12
___ 06:16AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.9
___ Imaging VENOUS DUP EXT UNI (MAP
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ Imaging KNEE (2 VIEWS) RIGHT
Distal femur fracture. No definite involvement of the
prosthesis
radiographically.
Brief Hospital Course:
Ms. ___ is a ___ w/ HFpEF, afib on apixiban, CAD (60%
LAD in ___, h/o sinus pauses and Mobitz I AVB, HTN, and
hypothyroidism, admitted with R periprosthetic femur fracture
(now s/p ___ ORIF). Course c/b bradycardia (now improved off
carvedilol), CHF and cardiorenal ___ (both improved with
diuresis), and anemia requiring 1u pRBCs.
ACUTE ISSUES ADDRESSED
========================
#R periprosthetic distal femur fracture: The patient was found
to have a right distal femur periprosthetic fracture and was
admitted to the orthopedic surgery service. Given her elevated
Chads2Vasc score, she was bridged from her home apixaban to a
heparin drip for tight control of her anticoagulation status on
the way to the operating room. The patient was taken to the
operating room on ___ for open reduction with internal
fixation, which the patient tolerated well. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and her home
anticoagulation was restarted. She received a blood transfusion
for an asymptomatic low hematocrit which she tolerated without
issue.
Activity restrictions: touch down weight bearing in unlocked
___ knee brace on R side. ___ recommended: discharge to
rehab.
#Acute on chronic diastolic HF exacerbation: Likely ___ IV fluid
administration and holding diuretics post-operatively. On Lasix
40mg BID at home. Admission weight 180lbs. Standing weight was
not trended given patient's activity restriction. She was
treated with IV diuresis with improvement which was transitioned
to PO diuretics at discharge.
___: likely cardiorenal as this developed I/s/o volume
overload. Cr improved with IV diuresis.
#Bradycardia: likely ___ to carvedilol as bradycardia improved
with discontinuation of medication. Patient has history of AVB
2nd degree type ___elay, previously with HR ___ and
pauses on telemetry. The patient continued to have episodes of
HR in ___ that were asymptomatic after discontinuation of
beta blocker. Non-urgent cardiology follow up is recommended for
continued surveillance of her asymptomatic bradycardia.
#Oral bleeding: the patient had hemorrhage from the site of a
recent tooth extraction after resuming her home Eliquis. If this
issue recurs, she should see her outpatient oral surgeon
promptly.
CHRONIC ISSUES:
===============
#Atrial fibrillation - continued home apixaban, stopped
carvedilol as
above
#HTN - continued home amlodipine
#HLD - continued home atorvastatin
#GERD - continued home omeprazole
#Depression - continued home citalopram
#Hypothyroidism - continued home levothyroxine
Transitional Issues
=====================
[] R Distal Femur Periprosthetic Fracture: f/u with orthopedics
team in 2 weeks (contact information listed above)
[] TDWB RLE in unlocked ___ brace until ortho follow up.
[] Consider treatment for presumed osteoporosis with Prolia or a
bisphosphonate (unclear to this author from available records if
she has had a bisphosphonate in the past). She is continued on
vitamin D.
[] Bradycardia: Stopped carvedilol. Because she also has
paroxysmal a-fib, watch for any RVR or palpitations off her beta
blocker.
[] HFpEF: If possible to obtain accurate weights with her
weight-bearing restrictions, please trend daily weights. Please
check BMP in one week. Notify the rehab doctor if creatinine is
1.2 or higher, or if weight changes by five pounds or more.
Titrate PO Lasix pending volume status.
[] Tooth bleeding: Follow-up with surgeon who performed recent
dental extraction PRN
#CODE: Full, presumed
#CONTACT: Name of health care proxy: ___
___ number: ___
Medications on Admission:
1. amLODIPine 5 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Carvedilol 6.25 mg PO BID
4. Citalopram 20 mg PO DAILY
5. Apixaban 5 mg PO BID
6. Furosemide 40 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. PreserVision Lutein (vit C-vit E-copper-zinc-lutein) 226
mg-200 unit -5 mg-0.8 mg oral BID
10. Cholecalciferol ___ IU daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
Do not drink or drive on this medication. Please beware sedation
RX *oxycodone 5 mg 0.5 - 1 tablet(s) by mouth q4hrs Disp #*24
Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
4. Furosemide 80 mg PO DAILY
5. amLODIPine 5 mg PO DAILY
6. Apixaban 5 mg PO BID
7. Atorvastatin 20 mg PO QPM
8. Citalopram 20 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. PreserVision Lutein (vit C-vit E-copper-zinc-lutein) 226
mg-200 unit -5 mg-0.8 mg oral BID
13. Cholecalciferol 1000 IU daily (this was omitted in error by
the discharging resident but was called in to the rehab)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
====================
R Distal Femur Periprosthetic Fracture
Acute on chronic diastolic heart failure exacerbation
SECONDARY DIAGNOSES
===================
Anemia
Constipation
___
Bradycardia
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- 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.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a surgery on your R leg.
- You were treated with diuretics for fluid overload
- You were given a blood transfusion for bleeding.
- You had a kidney injury that improved with diuresis.
- You had slow heart rate that improved with stopping
carvedilol.
- You had tooth bleeding that improved.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
- You also slow heart rate and had volume overload which was
treated with diuresis.
We wish you the best!
Sincerely,
Your ___ Team
ACTIVITY AND WEIGHT BEARING:
- Touchdown weight bearing in the right lower extremity in an
unlocked ___ brace.
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please continue to take your apixaban as you were previously.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
|
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"E039",
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"Y9301",
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"Z6831"
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Allergies: morphine / Penicillins Chief Complaint: R distal femur periprosthetic fx Major Surgical or Invasive Procedure: Surgical fixation (open reduction, internal fixation), R distal femur History of Present Illness: [MASKED] female hx of CHF (EF 65% last TTE [MASKED], A. fib (on Eliquis) who presents after a mechanical fall after slipping on a raw vegetable on the ground at the grocery market. She denied head strike or loss of consciousness. She denied any presyncopal symptoms. She was brought to [MASKED] where her initial evaluation and workup revealed a right periprosthetic distal femur fracture. She states that she last took her Eliquis the morning of her fall. She denies any other complaints including neck pain, chest pain, shortness of breath, pain in the left lower or bilateral upper extremities. She states that she ambulates with a cane and is functionally independent of ADLs and IADLs. Past Medical History: Hypertension CAD CHF Hyperlipidemia Hypothyroidism Atrial fibrillation Social History: [MASKED] Family History: NC Physical Exam: Admission Physical Exam Vitals: AVSS General: Well-appearing female in mild distress due to her right thigh pain Neck: No C-spine tenderness or palpable step-offs, full passive range of motion of the neck Right lower extremity: - Skin intact - No deformity evident, moderate ecchymosis and swelling - Soft, but tender distal thigh and proximal leg - Full, painless ROM at bilateral hip, left knee, and ankle - Fires [MASKED] - SILT S/S/SP/DP/T distributions - 1+ [MASKED] pulses, WWP Discharge Physical Exam VS: 98.2 PO 149/66 HR 63 RR 16 [MASKED] 94 Ra General: Alert and oriented, NAD HEENT: Sclerae anicteric, MMM, oropharynx clear Neck: JVP 6 cm. CV: Irregularly irregular, no MRG Lungs: Scattered crackles at bases, no wheezes, normal respiratory effort GI: soft, NT/ND Extremities: warm, well perfused, trace edema on the L ankle, 1+ edema on the RLE Neuro: No gross motor/coordination abnormalities Pertinent Results: Admission Labs [MASKED] 12:45PM BLOOD Glucose-139* UreaN-33* Creat-1.0 Na-135 K-4.1 Cl-100 HCO3-25 AnGap-10 [MASKED] 06:30AM BLOOD WBC-7.9 RBC-2.70* Hgb-7.9* Hct-24.9* MCV-92 MCH-29.3 MCHC-31.7* RDW-14.9 RDWSD-50.2* Plt [MASKED] [MASKED] 05:14AM URINE Hours-RANDOM UreaN-712 Creat-89 Na-<20 [MASKED] 08:30AM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM* Discharge Labs [MASKED] 06:16AM BLOOD WBC-9.9 RBC-2.89* Hgb-8.7* Hct-25.9* MCV-90 MCH-30.1 MCHC-33.6 RDW-14.9 RDWSD-48.8* Plt [MASKED] [MASKED] 06:16AM BLOOD [MASKED] PTT-28.1 [MASKED] [MASKED] 06:16AM BLOOD Glucose-110* UreaN-22* Creat-0.7 Na-139 K-3.8 Cl-99 HCO3-28 AnGap-12 [MASKED] 06:16AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.9 [MASKED] Imaging VENOUS DUP EXT UNI (MAP No evidence of deep venous thrombosis in the left lower extremity veins. [MASKED] Imaging KNEE (2 VIEWS) RIGHT Distal femur fracture. No definite involvement of the prosthesis radiographically. Brief Hospital Course: Ms. [MASKED] is a [MASKED] w/ HFpEF, afib on apixiban, CAD (60% LAD in [MASKED], h/o sinus pauses and Mobitz I AVB, HTN, and hypothyroidism, admitted with R periprosthetic femur fracture (now s/p [MASKED] ORIF). Course c/b bradycardia (now improved off carvedilol), CHF and cardiorenal [MASKED] (both improved with diuresis), and anemia requiring 1u pRBCs. ACUTE ISSUES ADDRESSED ======================== #R periprosthetic distal femur fracture: The patient was found to have a right distal femur periprosthetic fracture and was admitted to the orthopedic surgery service. Given her elevated Chads2Vasc score, she was bridged from her home apixaban to a heparin drip for tight control of her anticoagulation status on the way to the operating room. The patient was taken to the operating room on [MASKED] for open reduction with internal fixation, which the patient tolerated well. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and her home anticoagulation was restarted. She received a blood transfusion for an asymptomatic low hematocrit which she tolerated without issue. Activity restrictions: touch down weight bearing in unlocked [MASKED] knee brace on R side. [MASKED] recommended: discharge to rehab. #Acute on chronic diastolic HF exacerbation: Likely [MASKED] IV fluid administration and holding diuretics post-operatively. On Lasix 40mg BID at home. Admission weight 180lbs. Standing weight was not trended given patient's activity restriction. She was treated with IV diuresis with improvement which was transitioned to PO diuretics at discharge. [MASKED]: likely cardiorenal as this developed I/s/o volume overload. Cr improved with IV diuresis. #Bradycardia: likely [MASKED] to carvedilol as bradycardia improved with discontinuation of medication. Patient has history of AVB 2nd degree type elay, previously with HR [MASKED] and pauses on telemetry. The patient continued to have episodes of HR in [MASKED] that were asymptomatic after discontinuation of beta blocker. Non-urgent cardiology follow up is recommended for continued surveillance of her asymptomatic bradycardia. #Oral bleeding: the patient had hemorrhage from the site of a recent tooth extraction after resuming her home Eliquis. If this issue recurs, she should see her outpatient oral surgeon promptly. CHRONIC ISSUES: =============== #Atrial fibrillation - continued home apixaban, stopped carvedilol as above #HTN - continued home amlodipine #HLD - continued home atorvastatin #GERD - continued home omeprazole #Depression - continued home citalopram #Hypothyroidism - continued home levothyroxine Transitional Issues ===================== [] R Distal Femur Periprosthetic Fracture: f/u with orthopedics team in 2 weeks (contact information listed above) [] TDWB RLE in unlocked [MASKED] brace until ortho follow up. [] Consider treatment for presumed osteoporosis with Prolia or a bisphosphonate (unclear to this author from available records if she has had a bisphosphonate in the past). She is continued on vitamin D. [] Bradycardia: Stopped carvedilol. Because she also has paroxysmal a-fib, watch for any RVR or palpitations off her beta blocker. [] HFpEF: If possible to obtain accurate weights with her weight-bearing restrictions, please trend daily weights. Please check BMP in one week. Notify the rehab doctor if creatinine is 1.2 or higher, or if weight changes by five pounds or more. Titrate PO Lasix pending volume status. [] Tooth bleeding: Follow-up with surgeon who performed recent dental extraction PRN #CODE: Full, presumed #CONTACT: Name of health care proxy: [MASKED] [MASKED] number: [MASKED] Medications on Admission: 1. amLODIPine 5 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Carvedilol 6.25 mg PO BID 4. Citalopram 20 mg PO DAILY 5. Apixaban 5 mg PO BID 6. Furosemide 40 mg PO DAILY 7. Levothyroxine Sodium 50 mcg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. PreserVision Lutein (vit C-vit E-copper-zinc-lutein) 226 mg-200 unit -5 mg-0.8 mg oral BID 10. Cholecalciferol [MASKED] IU daily Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate Do not drink or drive on this medication. Please beware sedation RX *oxycodone 5 mg 0.5 - 1 tablet(s) by mouth q4hrs Disp #*24 Tablet Refills:*0 3. Polyethylene Glycol 17 g PO DAILY 4. Furosemide 80 mg PO DAILY 5. amLODIPine 5 mg PO DAILY 6. Apixaban 5 mg PO BID 7. Atorvastatin 20 mg PO QPM 8. Citalopram 20 mg PO DAILY 9. Fluticasone Propionate NASAL 1 SPRY NU BID 10. Levothyroxine Sodium 50 mcg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. PreserVision Lutein (vit C-vit E-copper-zinc-lutein) 226 mg-200 unit -5 mg-0.8 mg oral BID 13. Cholecalciferol 1000 IU daily (this was omitted in error by the discharging resident but was called in to the rehab) Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSES ==================== R Distal Femur Periprosthetic Fracture Acute on chronic diastolic heart failure exacerbation SECONDARY DIAGNOSES =================== Anemia Constipation [MASKED] Bradycardia Discharge Condition: Activity Status: Out of Bed with assistance to chair or wheelchair. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? - 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. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had a surgery on your R leg. - You were treated with diuretics for fluid overload - You were given a blood transfusion for bleeding. - You had a kidney injury that improved with diuresis. - You had slow heart rate that improved with stopping carvedilol. - You had tooth bleeding that improved. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. - You also slow heart rate and had volume overload which was treated with diuresis. We wish you the best! Sincerely, Your [MASKED] Team ACTIVITY AND WEIGHT BEARING: - Touchdown weight bearing in the right lower extremity in an unlocked [MASKED] brace. MEDICATIONS: 1) Take Tylenol [MASKED] every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please continue to take your apixaban as you were previously. WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Followup Instructions: [MASKED]
|
[] |
[
"N179",
"D62",
"I110",
"J449",
"E119",
"I480",
"D649",
"K219",
"F329",
"K5900",
"I2510",
"E785",
"E039",
"Z7901"
] |
[
"S72401A: Unspecified fracture of lower end of right femur, initial encounter for closed fracture",
"I5033: Acute on chronic diastolic (congestive) heart failure",
"N179: Acute kidney failure, unspecified",
"M9701XA: Periprosthetic fracture around internal prosthetic right hip joint, initial encounter",
"D62: Acute posthemorrhagic anemia",
"I110: Hypertensive heart disease with heart failure",
"J449: Chronic obstructive pulmonary disease, unspecified",
"I441: Atrioventricular block, second degree",
"E6601: Morbid (severe) obesity due to excess calories",
"E119: Type 2 diabetes mellitus without complications",
"I480: Paroxysmal atrial fibrillation",
"R001: Bradycardia, unspecified",
"D649: Anemia, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"F329: Major depressive disorder, single episode, unspecified",
"K5900: Constipation, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"E785: Hyperlipidemia, unspecified",
"E039: Hypothyroidism, unspecified",
"W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter",
"Y9301: Activity, walking, marching and hiking",
"Y92512: Supermarket, store or market as the place of occurrence of the external cause",
"Z7901: Long term (current) use of anticoagulants",
"Z85828: Personal history of other malignant neoplasm of skin",
"Z6831: Body mass index [BMI] 31.0-31.9, adult"
] |
10,029,468
| 28,440,970
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Amoxicillin / Iodinated Contrast Media - IV Dye / iodine /
Lupron / Lyrica / Migranal / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / Percocet / piroxicam / Salsalate /
Tegretol / Tylenol-Codeine / Ultram / Vicodin / iodoform /
Tegaderm
Attending: ___
Chief Complaint:
motor vehicle accident
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female presenting to ___ after a motor vehicle
accident. She was the restrained driver and was hit on the left
driver's side while traveling at 35 mph. No loss of
consciousness, no airbag deployment. She was seen at an outside
hospital where FAST showed a pericardial effusion. She was
transferred to ___ for further management.
Past Medical History:
PMH
hypothyroidism
PSH
Anterior Fusion cervical spine
Bilateral Salpingoophorectomy
C section
L tendon repair
Occipital nerve stimulator (placed ___- checked ___
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: HR 72, BP 124/72, RR 19, Sat 96% RA
Gen: NAD
Chest/CV: RRR, no tenderness to palpation
Lungs: CTAB
Abdomen: Soft, NT, ND
Spine: Tenderness to palpation at base c-spine, lumbar spine
DISCHARGE PHYSICAL EXAM
Vitals: T97.9 (Tm 97.9), BP: 97/63, HR: 66, RR: 18, O2 sat: 96%,
O2 delivery: Ra
Gen: NAD, AAOx3
HEENT: MMM, tenderness to palpation left neck
CV: RRR
Resp: breaths unlabored, CTAB
Abdomen: soft, nondistended, nontender
Ext: WWP
Pertinent Results:
___ 10:32PM ___ PTT-30.5 ___
___ 10:32PM PLT COUNT-352
___ 10:32PM NEUTS-41.6 ___ MONOS-10.2 EOS-0.9*
BASOS-0.8 IM ___ AbsNeut-3.23 AbsLymp-3.57 AbsMono-0.79
AbsEos-0.07 AbsBaso-0.06
___ 10:32PM WBC-7.8 RBC-3.87* HGB-13.5 HCT-39.8 MCV-103*
MCH-34.9* MCHC-33.9 RDW-12.0 RDWSD-45.2
___ 10:32PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 10:32PM LIPASE-36
___ 10:32PM UREA N-11
___ 10:38PM GLUCOSE-141* LACTATE-0.8 CREAT-0.9 NA+-141
K+-3.6 CL--109* TCO2-23
IMAGING:
Outside Hospital Imaging
1) CT Head
- No acute intracranial abnormality
- Post surgical changes of bilateral mastoid occipital region
noted with what appears to be implantable meshlike material. On
the right, material thickened relative to left. Internal gas
therefore infection cannot be excluded.
- Neurostimulator device is positioned as above
2) CT C spine
- No fracture seen
- S/p anterior fusion at C5-6 with C5-6 disc age
- Disc bulge at C6-7
- Posterior spinal stimulator electrodes
- Bilateral craniotomies with possible infected mesh on right
3) CT Abdomen
- Moderate sized anterior pericardial effusion
-Electronic implanted device possibly a stimulator unit at
posterior right lower thorax
- Mild stranding seen about the paracolic gutters of uncertain
etiology.
___ Imaging
CT Chest:
IMPRESSION: Essentially normal chest CT. No evidence of trauma.
Brief Hospital Course:
Ms ___ was admitted to the Acute Care Surgery service after
being transferred from an outside hospital given concern for
pericardial effusion. She was FAST + in the ED, but
hemodynamically stable. She had no additional injuries on
imaging obtained at the outside hospital.
On the night of admission, she underwent chest CT which showed
an essentially normal chest CT with no evidence of trauma. She
remained hemodynamically stable. She was tolerating a regular
diet and ambulating independently.
She was seen by Neurosurgery given the previous neurosurgical
procedures and concern for possible infection of the right sided
neurostimulator mesh. On their evaluation, there was no evidence
of infection or neurological deficits. She was instructed to
follow up in ___ clinic and to follow up with her PCP.
She was therefore discharged home.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. Topiramate (Topamax) 200 mg PO DAILY
4. BuPROPion XL (Once Daily) 300 mg PO DAILY
5. FLUoxetine 40 mg PO DAILY
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
Discharge Medications:
1. BuPROPion XL (Once Daily) 300 mg PO DAILY
2. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
3. FLUoxetine 40 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Topiramate (Topamax) 200 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
motor vehicle accident, no significant pericardial effusion
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 ___ after a motor vehicle accident due to
concern over fluid around your heart. You had a CT of the chest
which was normal. While in the hospital, you were also seen by
Neurosurgery for your peripheral nerve stimulator. There were no
signs of infection. It is recommended that you follow up with
your neurosurgeon Dr ___ and with your primary care doctor
after discharge. Please continue all of your home medications.
Please come to the Emergency Department if you develop:
* Fever > 101 degrees
* Chills
* Chest pain or shortness of breath
* Dizziness, lightheadedness, or feeling faint
* Any symptoms that concern you
Thank you,
Your ___ Surgery Team
Followup Instructions:
___
|
[
"S2610XA",
"V892XXA",
"Y929",
"Z9689",
"E039"
] |
Allergies: Amoxicillin / Iodinated Contrast Media - IV Dye / iodine / Lupron / Lyrica / Migranal / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Percocet / piroxicam / Salsalate / Tegretol / Tylenol-Codeine / Ultram / Vicodin / iodoform / Tegaderm Chief Complaint: motor vehicle accident Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] year old female presenting to [MASKED] after a motor vehicle accident. She was the restrained driver and was hit on the left driver's side while traveling at 35 mph. No loss of consciousness, no airbag deployment. She was seen at an outside hospital where FAST showed a pericardial effusion. She was transferred to [MASKED] for further management. Past Medical History: PMH hypothyroidism PSH Anterior Fusion cervical spine Bilateral Salpingoophorectomy C section L tendon repair Occipital nerve stimulator (placed [MASKED]- checked [MASKED] Social History: [MASKED] Family History: Non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: HR 72, BP 124/72, RR 19, Sat 96% RA Gen: NAD Chest/CV: RRR, no tenderness to palpation Lungs: CTAB Abdomen: Soft, NT, ND Spine: Tenderness to palpation at base c-spine, lumbar spine DISCHARGE PHYSICAL EXAM Vitals: T97.9 (Tm 97.9), BP: 97/63, HR: 66, RR: 18, O2 sat: 96%, O2 delivery: Ra Gen: NAD, AAOx3 HEENT: MMM, tenderness to palpation left neck CV: RRR Resp: breaths unlabored, CTAB Abdomen: soft, nondistended, nontender Ext: WWP Pertinent Results: [MASKED] 10:32PM [MASKED] PTT-30.5 [MASKED] [MASKED] 10:32PM PLT COUNT-352 [MASKED] 10:32PM NEUTS-41.6 [MASKED] MONOS-10.2 EOS-0.9* BASOS-0.8 IM [MASKED] AbsNeut-3.23 AbsLymp-3.57 AbsMono-0.79 AbsEos-0.07 AbsBaso-0.06 [MASKED] 10:32PM WBC-7.8 RBC-3.87* HGB-13.5 HCT-39.8 MCV-103* MCH-34.9* MCHC-33.9 RDW-12.0 RDWSD-45.2 [MASKED] 10:32PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG tricyclic-NEG [MASKED] 10:32PM LIPASE-36 [MASKED] 10:32PM UREA N-11 [MASKED] 10:38PM GLUCOSE-141* LACTATE-0.8 CREAT-0.9 NA+-141 K+-3.6 CL--109* TCO2-23 IMAGING: Outside Hospital Imaging 1) CT Head - No acute intracranial abnormality - Post surgical changes of bilateral mastoid occipital region noted with what appears to be implantable meshlike material. On the right, material thickened relative to left. Internal gas therefore infection cannot be excluded. - Neurostimulator device is positioned as above 2) CT C spine - No fracture seen - S/p anterior fusion at C5-6 with C5-6 disc age - Disc bulge at C6-7 - Posterior spinal stimulator electrodes - Bilateral craniotomies with possible infected mesh on right 3) CT Abdomen - Moderate sized anterior pericardial effusion -Electronic implanted device possibly a stimulator unit at posterior right lower thorax - Mild stranding seen about the paracolic gutters of uncertain etiology. [MASKED] Imaging CT Chest: IMPRESSION: Essentially normal chest CT. No evidence of trauma. Brief Hospital Course: Ms [MASKED] was admitted to the Acute Care Surgery service after being transferred from an outside hospital given concern for pericardial effusion. She was FAST + in the ED, but hemodynamically stable. She had no additional injuries on imaging obtained at the outside hospital. On the night of admission, she underwent chest CT which showed an essentially normal chest CT with no evidence of trauma. She remained hemodynamically stable. She was tolerating a regular diet and ambulating independently. She was seen by Neurosurgery given the previous neurosurgical procedures and concern for possible infection of the right sided neurostimulator mesh. On their evaluation, there was no evidence of infection or neurological deficits. She was instructed to follow up in [MASKED] clinic and to follow up with her PCP. She was therefore discharged home. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Lisinopril 5 mg PO DAILY 3. Topiramate (Topamax) 200 mg PO DAILY 4. BuPROPion XL (Once Daily) 300 mg PO DAILY 5. FLUoxetine 40 mg PO DAILY 6. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY Discharge Medications: 1. BuPROPion XL (Once Daily) 300 mg PO DAILY 2. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY 3. FLUoxetine 40 mg PO DAILY 4. Levothyroxine Sodium 100 mcg PO DAILY 5. Lisinopril 5 mg PO DAILY 6. Topiramate (Topamax) 200 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: motor vehicle accident, no significant pericardial effusion 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] after a motor vehicle accident due to concern over fluid around your heart. You had a CT of the chest which was normal. While in the hospital, you were also seen by Neurosurgery for your peripheral nerve stimulator. There were no signs of infection. It is recommended that you follow up with your neurosurgeon Dr [MASKED] and with your primary care doctor after discharge. Please continue all of your home medications. Please come to the Emergency Department if you develop: * Fever > 101 degrees * Chills * Chest pain or shortness of breath * Dizziness, lightheadedness, or feeling faint * Any symptoms that concern you Thank you, Your [MASKED] Surgery Team Followup Instructions: [MASKED]
|
[] |
[
"Y929",
"E039"
] |
[
"S2610XA: Unspecified injury of heart without hemopericardium, initial encounter",
"V892XXA: Person injured in unspecified motor-vehicle accident, traffic, initial encounter",
"Y929: Unspecified place or not applicable",
"Z9689: Presence of other specified functional implants",
"E039: Hypothyroidism, unspecified"
] |
10,029,514
| 27,489,281
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right THR failure secondary to fall
Major Surgical or Invasive Procedure:
___: right total hip revision
History of Present Illness:
___ male with a fractured right total hip arthroplasty secondary
to mechanical trip and fall status post right THA in ___ at
___. Transferred to ___ for preoperative optimization and
clearance given his diagnosis of moderate to severe pulmonary
hypertension.
Past Medical History:
Coronary artery disease status post CABG ×4 in ___
Chronic atrial fibrillation
Hypertension
Hyperlipidemia
Type 2 diabetes mellitus
History of right sided CVA with resultant left-sided weakness,
treated with thrombolysis, ___
Prostate cancer
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:
___ 05:40AM BLOOD WBC-5.8 RBC-2.78* Hgb-9.0* Hct-27.7*
MCV-100* MCH-32.4* MCHC-32.5 RDW-14.1 RDWSD-50.7* Plt ___
___ 05:40AM BLOOD WBC-6.2 RBC-2.86* Hgb-9.3* Hct-28.1*
MCV-98 MCH-32.5* MCHC-33.1 RDW-14.1 RDWSD-50.4* Plt ___
___ 05:40AM BLOOD Glucose-113* UreaN-22* Creat-1.0 Na-145
K-4.1 Cl-107 HCO3-26 AnGap-12
___ 05:40AM BLOOD Glucose-103* UreaN-19 Creat-0.9 Na-144
K-4.7 Cl-106 HCO3-27 AnGap-11
___ 05:40AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9
___ 05:40AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.9
___ 02:50AM BLOOD WBC-6.3 RBC-2.75* Hgb-9.1* Hct-26.9*
MCV-98 MCH-33.1* MCHC-33.8 RDW-14.2 RDWSD-50.5* Plt ___
___ 06:05AM BLOOD WBC-7.7 RBC-3.03* Hgb-9.7* Hct-29.7*
MCV-98 MCH-32.0 MCHC-32.7 RDW-14.0 RDWSD-50.4* Plt Ct-94*
___ 06:45AM BLOOD WBC-8.2 RBC-3.16* Hgb-10.1* Hct-31.1*
MCV-98 MCH-32.0 MCHC-32.5 RDW-13.9 RDWSD-49.4* Plt ___
___ 04:26AM BLOOD WBC-8.0 RBC-3.13* Hgb-10.0* Hct-29.9*
MCV-96 MCH-31.9 MCHC-33.4 RDW-13.7 RDWSD-47.8* Plt Ct-96*
___ 08:21PM BLOOD WBC-9.9 RBC-3.87* Hgb-12.5* Hct-38.4*
MCV-99* MCH-32.3* MCHC-32.6 RDW-13.7 RDWSD-49.5* Plt Ct-97*
___ 06:15AM BLOOD WBC-6.3 RBC-3.71* Hgb-11.9* Hct-36.2*
MCV-98 MCH-32.1* MCHC-32.9 RDW-13.9 RDWSD-49.5* Plt ___
___ 02:50AM BLOOD Plt ___
___ 06:05AM BLOOD Plt Ct-94*
___ 06:45AM BLOOD Plt ___
___ 04:26AM BLOOD Plt Ct-96*
___ 08:21PM BLOOD Plt Ct-97*
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD ___
___ 02:50AM BLOOD Glucose-166* UreaN-18 Creat-0.9 Na-141
K-4.0 Cl-104 HCO3-25 AnGap-12
___ 06:05AM BLOOD Glucose-100 UreaN-14 Creat-0.8 Na-145
K-4.1 Cl-107 HCO3-24 AnGap-14
___ 06:45AM BLOOD Glucose-102* UreaN-13 Creat-0.9 Na-142
K-4.3 Cl-106 HCO3-26 AnGap-10
___ 04:26AM BLOOD Glucose-140* UreaN-15 Creat-0.8 Na-142
K-4.3 Cl-107 HCO3-21* AnGap-14
___ 06:15AM BLOOD Glucose-95 UreaN-22* Creat-1.0 Na-147
K-4.0 Cl-111* HCO3-22 AnGap-14
___ 10:15AM BLOOD CK(CPK)-142
___ 02:50AM BLOOD CK(CPK)-162
___ 10:15AM BLOOD CK-MB-2 cTropnT-0.06*
___ 02:50AM BLOOD CK-MB-2 cTropnT-0.06*
___ 02:50AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.0
___ 06:05AM BLOOD Calcium-8.5 Phos-2.3* Mg-2.0
___ 06:45AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.2
___ 04:26AM BLOOD Calcium-8.1* Phos-3.6 Mg-1.6
___ 06:15AM BLOOD Calcium-8.8 Phos-3.1 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.
The patient was transferred to the ___ for post-operative
monitoring.
Postoperative course was remarkable for the following:
___, the patient was extubated and off pressors prior to
arrival to ___. The patient's home Metoprolol and Imdur were
held on admission, but Metoprolol was restarted
post-operatively. His Apixaban was started on POD#1, but at a
lower dose of 2.5 mg x 10 days, then he will increase the dose
to 5 mg twice daily. He otherwise remained stable and was
transferred to the floor later that afternoon.
POD#2, Medicine was consulted to assist with co-management of
the patient. They recommended resuming his Imdur and continuing
to hold his Metformin.
POD#3, his foley was discontinued and he was able to void
independently. Medicine saw the patient and had no new
recommendations. Overnight, the patient reported chest pain and
took Nitroglycerin. EKG was performed and showed no changes
prior to other EKGs. Cardiac enzymes were drawn. Troponin was
0.06 and Medicine recommended that cardiac enzymes be trended.
POD#4, the patient was confused upon awakening. His Gabapentin
was discontinued. Second set of troponins were 0.06 and third
set of troponins were 0.05. Medicine did not feel an additional
work-up was required. They felt he was appropriate for
discharge with outpatient follow-up with his PCP ___
Cardiologist. His mental status had improved in the afternoon.
POD #5, patient had complaint of ongoing sternal pain x 2 days
with complaint of mild intermittent cough. Patient remained
afebrile. A chest x-ray was obtained, which results were
negative for PNA. Patient was not discharged due to observance
of ___.
POD #6, patient had no further issues prior to discharge and
labs remained stable.
Patient to continue Apixaban 2.5mg twice daily x 10 days post-op
(through ___, then may resume home dose 5mg twice daily.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. 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 posterior precautions.
Walker or two crutches, wean as able.
Mr. ___ is discharged to rehab in stable condition.
Medications on Admission:
1. Allopurinol ___ mg PO DAILY
2. Apixaban 5 mg PO BID
3. Atorvastatin 40 mg PO QPM
4. Vitamin D 1000 UNIT PO DAILY
5. Docusate Sodium 100 mg PO BID
6. FLUoxetine 10 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY
8. Magnesium Oxide 400 mg PO DAILY
9. melatonin 5 mg oral QHS
10. MetFORMIN (Glucophage) 500 mg PO BID
11. Metoprolol Succinate XL 12.5 mg PO BID
12. Senna 8.6 mg PO BID
13. Tamsulosin 0.4 mg PO QHS
14. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
3. Allopurinol ___ mg PO QHS
4. Apixaban 2.5 mg PO BID Duration: 10 Days
2.5 mg BID until ___, then 5 mg BID
5. Atorvastatin 80 mg PO QPM
Increased per Cardiology recommendations.
6. Docusate Sodium 100 mg PO BID
7. FLUoxetine 10 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY
9. Magnesium Oxide 400 mg PO DAILY
10. melatonin 5 mg oral QHS
11. MetFORMIN (Glucophage) 500 mg PO BID
12. Metoprolol Succinate XL 12.5 mg PO BID
13. Senna 8.6 mg PO BID
14. Tamsulosin 0.4 mg PO QHS
15. TraZODone 50 mg PO QHS:PRN insomnia
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right THR failure secondary to fall (femoral component
separation of the femoral head from the stem)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
8. ANTICOAGULATION: Please continue your Apixaban 2.5mg twice
daily for 10 days (through ___, then resume 5 mg twice
daily to help prevent deep vein thrombosis (blood clots).
9. WOUND CARE: Please remove Aquacel dressing on POD#7 after
surgery. It is okay to shower after surgery after 5 days but no
tub baths, swimming, or submerging your incision until after
your four (4) week checkup. Please place a dry sterile dressing
on the wound after aqaucel is removed each day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
10. ___ (once at home): Home ___, dressing changes as
instructed, and wound checks.
11. ACTIVITY: Weight bearing as tolerated with walker or 2
crutches. Wean assistive device as able. Posterior
precautions. No strenuous exercise or heavy lifting until follow
up appointment. Mobilize frequently.
Physical Therapy:
WBAT
Posterior hip precautions
Wean assistive device as able
Mobilize frequently
Treatments Frequency:
remove aquacel POD#7 after surgery
apply dry sterile dressing daily if needed after aquacel
dressing is removed
wound checks daily after aquacel removed
Followup Instructions:
___
|
[
"T84010A",
"I69354",
"I5030",
"Y92009",
"I2510",
"Z951",
"E119",
"I482",
"E785",
"F329",
"I110",
"D6959",
"M109",
"N400",
"I2720",
"W1830XA"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: right THR failure secondary to fall Major Surgical or Invasive Procedure: [MASKED]: right total hip revision History of Present Illness: [MASKED] male with a fractured right total hip arthroplasty secondary to mechanical trip and fall status post right THA in [MASKED] at [MASKED]. Transferred to [MASKED] for preoperative optimization and clearance given his diagnosis of moderate to severe pulmonary hypertension. Past Medical History: Coronary artery disease status post CABG ×4 in [MASKED] Chronic atrial fibrillation Hypertension Hyperlipidemia Type 2 diabetes mellitus History of right sided CVA with resultant left-sided weakness, treated with thrombolysis, [MASKED] Prostate cancer 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] 05:40AM BLOOD WBC-5.8 RBC-2.78* Hgb-9.0* Hct-27.7* MCV-100* MCH-32.4* MCHC-32.5 RDW-14.1 RDWSD-50.7* Plt [MASKED] [MASKED] 05:40AM BLOOD WBC-6.2 RBC-2.86* Hgb-9.3* Hct-28.1* MCV-98 MCH-32.5* MCHC-33.1 RDW-14.1 RDWSD-50.4* Plt [MASKED] [MASKED] 05:40AM BLOOD Glucose-113* UreaN-22* Creat-1.0 Na-145 K-4.1 Cl-107 HCO3-26 AnGap-12 [MASKED] 05:40AM BLOOD Glucose-103* UreaN-19 Creat-0.9 Na-144 K-4.7 Cl-106 HCO3-27 AnGap-11 [MASKED] 05:40AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9 [MASKED] 05:40AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.9 [MASKED] 02:50AM BLOOD WBC-6.3 RBC-2.75* Hgb-9.1* Hct-26.9* MCV-98 MCH-33.1* MCHC-33.8 RDW-14.2 RDWSD-50.5* Plt [MASKED] [MASKED] 06:05AM BLOOD WBC-7.7 RBC-3.03* Hgb-9.7* Hct-29.7* MCV-98 MCH-32.0 MCHC-32.7 RDW-14.0 RDWSD-50.4* Plt Ct-94* [MASKED] 06:45AM BLOOD WBC-8.2 RBC-3.16* Hgb-10.1* Hct-31.1* MCV-98 MCH-32.0 MCHC-32.5 RDW-13.9 RDWSD-49.4* Plt [MASKED] [MASKED] 04:26AM BLOOD WBC-8.0 RBC-3.13* Hgb-10.0* Hct-29.9* MCV-96 MCH-31.9 MCHC-33.4 RDW-13.7 RDWSD-47.8* Plt Ct-96* [MASKED] 08:21PM BLOOD WBC-9.9 RBC-3.87* Hgb-12.5* Hct-38.4* MCV-99* MCH-32.3* MCHC-32.6 RDW-13.7 RDWSD-49.5* Plt Ct-97* [MASKED] 06:15AM BLOOD WBC-6.3 RBC-3.71* Hgb-11.9* Hct-36.2* MCV-98 MCH-32.1* MCHC-32.9 RDW-13.9 RDWSD-49.5* Plt [MASKED] [MASKED] 02:50AM BLOOD Plt [MASKED] [MASKED] 06:05AM BLOOD Plt Ct-94* [MASKED] 06:45AM BLOOD Plt [MASKED] [MASKED] 04:26AM BLOOD Plt Ct-96* [MASKED] 08:21PM BLOOD Plt Ct-97* [MASKED] 06:15AM BLOOD Plt [MASKED] [MASKED] 06:15AM BLOOD [MASKED] [MASKED] 02:50AM BLOOD Glucose-166* UreaN-18 Creat-0.9 Na-141 K-4.0 Cl-104 HCO3-25 AnGap-12 [MASKED] 06:05AM BLOOD Glucose-100 UreaN-14 Creat-0.8 Na-145 K-4.1 Cl-107 HCO3-24 AnGap-14 [MASKED] 06:45AM BLOOD Glucose-102* UreaN-13 Creat-0.9 Na-142 K-4.3 Cl-106 HCO3-26 AnGap-10 [MASKED] 04:26AM BLOOD Glucose-140* UreaN-15 Creat-0.8 Na-142 K-4.3 Cl-107 HCO3-21* AnGap-14 [MASKED] 06:15AM BLOOD Glucose-95 UreaN-22* Creat-1.0 Na-147 K-4.0 Cl-111* HCO3-22 AnGap-14 [MASKED] 10:15AM BLOOD CK(CPK)-142 [MASKED] 02:50AM BLOOD CK(CPK)-162 [MASKED] 10:15AM BLOOD CK-MB-2 cTropnT-0.06* [MASKED] 02:50AM BLOOD CK-MB-2 cTropnT-0.06* [MASKED] 02:50AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.0 [MASKED] 06:05AM BLOOD Calcium-8.5 Phos-2.3* Mg-2.0 [MASKED] 06:45AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.2 [MASKED] 04:26AM BLOOD Calcium-8.1* Phos-3.6 Mg-1.6 [MASKED] 06:15AM BLOOD Calcium-8.8 Phos-3.1 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. The patient was transferred to the [MASKED] for post-operative monitoring. Postoperative course was remarkable for the following: [MASKED], the patient was extubated and off pressors prior to arrival to [MASKED]. The patient's home Metoprolol and Imdur were held on admission, but Metoprolol was restarted post-operatively. His Apixaban was started on POD#1, but at a lower dose of 2.5 mg x 10 days, then he will increase the dose to 5 mg twice daily. He otherwise remained stable and was transferred to the floor later that afternoon. POD#2, Medicine was consulted to assist with co-management of the patient. They recommended resuming his Imdur and continuing to hold his Metformin. POD#3, his foley was discontinued and he was able to void independently. Medicine saw the patient and had no new recommendations. Overnight, the patient reported chest pain and took Nitroglycerin. EKG was performed and showed no changes prior to other EKGs. Cardiac enzymes were drawn. Troponin was 0.06 and Medicine recommended that cardiac enzymes be trended. POD#4, the patient was confused upon awakening. His Gabapentin was discontinued. Second set of troponins were 0.06 and third set of troponins were 0.05. Medicine did not feel an additional work-up was required. They felt he was appropriate for discharge with outpatient follow-up with his PCP [MASKED] Cardiologist. His mental status had improved in the afternoon. POD #5, patient had complaint of ongoing sternal pain x 2 days with complaint of mild intermittent cough. Patient remained afebrile. A chest x-ray was obtained, which results were negative for PNA. Patient was not discharged due to observance of [MASKED]. POD #6, patient had no further issues prior to discharge and labs remained stable. Patient to continue Apixaban 2.5mg twice daily x 10 days post-op (through [MASKED], then may resume home dose 5mg twice daily. Otherwise, pain was controlled with a combination of IV and oral pain medications. 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 posterior precautions. Walker or two crutches, wean as able. Mr. [MASKED] is discharged to rehab in stable condition. Medications on Admission: 1. Allopurinol [MASKED] mg PO DAILY 2. Apixaban 5 mg PO BID 3. Atorvastatin 40 mg PO QPM 4. Vitamin D 1000 UNIT PO DAILY 5. Docusate Sodium 100 mg PO BID 6. FLUoxetine 10 mg PO DAILY 7. Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY 8. Magnesium Oxide 400 mg PO DAILY 9. melatonin 5 mg oral QHS 10. MetFORMIN (Glucophage) 500 mg PO BID 11. Metoprolol Succinate XL 12.5 mg PO BID 12. Senna 8.6 mg PO BID 13. Tamsulosin 0.4 mg PO QHS 14. TraZODone 50 mg PO QHS:PRN insomnia Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain 3. Allopurinol [MASKED] mg PO QHS 4. Apixaban 2.5 mg PO BID Duration: 10 Days 2.5 mg BID until [MASKED], then 5 mg BID 5. Atorvastatin 80 mg PO QPM Increased per Cardiology recommendations. 6. Docusate Sodium 100 mg PO BID 7. FLUoxetine 10 mg PO DAILY 8. Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY 9. Magnesium Oxide 400 mg PO DAILY 10. melatonin 5 mg oral QHS 11. MetFORMIN (Glucophage) 500 mg PO BID 12. Metoprolol Succinate XL 12.5 mg PO BID 13. Senna 8.6 mg PO BID 14. Tamsulosin 0.4 mg PO QHS 15. TraZODone 50 mg PO QHS:PRN insomnia 16. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: right THR failure secondary to fall (femoral component separation of the femoral head from the stem) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Apixaban 2.5mg twice daily for 10 days (through [MASKED], then resume 5 mg twice daily to help prevent deep vein thrombosis (blood clots). 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated with walker or 2 crutches. Wean assistive device as able. Posterior precautions. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. Physical Therapy: WBAT Posterior hip precautions Wean assistive device as able Mobilize frequently Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed Followup Instructions: [MASKED]
|
[] |
[
"I2510",
"Z951",
"E119",
"E785",
"F329",
"I110",
"M109",
"N400"
] |
[
"T84010A: Broken internal right hip prosthesis, initial encounter",
"I69354: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side",
"I5030: Unspecified diastolic (congestive) heart failure",
"Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z951: Presence of aortocoronary bypass graft",
"E119: Type 2 diabetes mellitus without complications",
"I482: Chronic atrial fibrillation",
"E785: Hyperlipidemia, unspecified",
"F329: Major depressive disorder, single episode, unspecified",
"I110: Hypertensive heart disease with heart failure",
"D6959: Other secondary thrombocytopenia",
"M109: Gout, unspecified",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"I2720: Pulmonary hypertension, unspecified",
"W1830XA: Fall on same level, unspecified, initial encounter"
] |
10,029,644
| 22,084,015
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
R foot ulcer
Major Surgical or Invasive Procedure:
___: R ___ digit arthroplasty
History of Present Illness:
This patient is a ___ year old male with PMH significant for
uncontrolled type II diabetes and hypertension with a right
fourth to infection. Patient recalls doing yard work on ___
when he dropped a heavy object on his foot. He then travelled to
___ for a business trip and a on ___ noticed an
ulcer with increasing redness and drainage on his right fourth
toe. He presented to an emergency room in ___, where he was
admitted for IV antibiotics. Surgical intervention was discussed
during his admission, but an infectious disease physician
recommended he fly home to ___ and be seen immediately. He
was discharged on a course of Augmentin which he has been taking
and states some of the redness has improved. Patients admits to
being diabetic and that his blood sugars have been under poor
control. His most recent HbA1c was 12.3%. He denies any recent
nausea, vomiting, fever, chills, shortness of breath, or chest
pain.
Past Medical History:
HTN, DMII
Social History:
___
Family History:
Significant for diabetes and heart disease
Physical Exam:
Admission Physical Examination
General: Awake, alert, oriented x3. No acute distress
HEENT: MMM, neck supple, NTAC
Cardiac: extremities well perfused
Lungs: No respiratory distress
Abd: Soft, non-tender, non-distended
Lower extremity exam: ___ pulses palpable b/l. Capillary
refill time < 3 seconds to the digits b/l. Skin temperature warm
to cool from proximal tibia to distal digits bilaterally.
Protective sensation diminished b/l. Ulcer noted to the lateral
aspect of the fourth digit that probes deeply. Scant amount of
purulent drainage expressed from the fourth digit ulcer. Right
fourth digit appear erythematous and edematous with sloughing
skin. Erythema note to the right fourth toe extending to the
right dorsal foot, outline by previous hospital. Distal aspect
of the fourth digit appears dusky in color without capillary
refill. Mild tenderness with palpation of the right fourth
digit.
Discharge Physical Exam:
Pertinent Results:
___ 09:29PM BLOOD WBC-7.3 RBC-4.15* Hgb-12.5* Hct-35.7*
MCV-86 MCH-30.1 MCHC-35.0 RDW-11.5 RDWSD-36.1 Plt ___
___ 09:29PM BLOOD Neuts-58.1 ___ Monos-9.2 Eos-1.8
Baso-0.1 Im ___ AbsNeut-4.25 AbsLymp-2.23 AbsMono-0.67
AbsEos-0.13 AbsBaso-0.01
___ 09:29PM BLOOD Plt ___
___ 09:29PM BLOOD Glucose-286* UreaN-17 Creat-0.8 Na-136
K-4.1 Cl-99 HCO3-24 AnGap-17
___ 09:29PM BLOOD Calcium-9.2 Phos-2.7 Mg-1.8
___ 09:29PM BLOOD CRP-18.7*
Right foot radiograph ___:
FINDINGS:
Soft tissue swelling at the fourth toe is present. No overt
bone destruction
or periosteal reaction.
Mild degenerative changes are seen at the first MTP joint,
fourth TMT joint, first TMT joint. Plantar and posterior
calcaneal spurs are seen. Bipartite lateral sesamoid at first
MTP.
IMPRESSION:
Soft tissue swelling at the fourth toe. No overt evidence of
osteomyelitis. Additional findings as above.
Brief Hospital Course:
The patient was admitted to the podiatric surgery service from
clinic on ___ for a R foot infection. On admission, he was
started on broad spectrum antibiotics. The patient was brought
to the operating room on ___ for a Right ___ digit
arthoplasty, which the patient tolerated well. For full details
of the procedure, please see the separately dictated operative
report. The patient was taken to the PACU in stable condition
and was transferred back to the floor after satisfactory
recovery from anesthesia.
Throughout his hospital stay, the patient remained afebrile with
stable vital signs; pain was well controlled oral pain
medication on a PRN basis. The patient remained stable from
both a cardiovascular and pulmonary standpoint. He was placed on
broad spectrum antibiotics while hospitalized and discharged
with oral antibiotics. His intake and output were closely
monitored and noted to be adequate. The patient received
subcutaneous heparin throughout admission; early and frequent
ambulation were strongly encouraged. The patient had
hyperglycemia throughout his stay, and was seen by a member of
the ___ Diabetes Team and his blood glucose levels improved.
The patient was subsequently discharged to home on POD 2 with
vital signs stable and vascular status intact to right foot. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
1. Metformin 1000mg BID
2. Lisinopril 40mg
3. Simvastatin 40mg
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
3. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
4. Glargine 30 Units Dinner
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR
30 Units before DINR; Disp #*1 Syringe Refills:*0
5. Lisinopril 40 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
R foot ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service for your right foot surgery.
You were given IV antibiotics while here. You are being
discharged home with the following instructions:
ACTIVITY:
There are restrictions on activity. Please remain weight bearing
to your R heel in a surgical shoe until your follow up
appointment. You should keep this site elevated when ever
possible (above the level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking in a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
Followup Instructions:
___
|
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"E1165",
"L97519",
"I10",
"Z794",
"E11621",
"S97121A",
"W208XXA",
"Y92096"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: R foot ulcer Major Surgical or Invasive Procedure: [MASKED]: R [MASKED] digit arthroplasty History of Present Illness: This patient is a [MASKED] year old male with PMH significant for uncontrolled type II diabetes and hypertension with a right fourth to infection. Patient recalls doing yard work on [MASKED] when he dropped a heavy object on his foot. He then travelled to [MASKED] for a business trip and a on [MASKED] noticed an ulcer with increasing redness and drainage on his right fourth toe. He presented to an emergency room in [MASKED], where he was admitted for IV antibiotics. Surgical intervention was discussed during his admission, but an infectious disease physician recommended he fly home to [MASKED] and be seen immediately. He was discharged on a course of Augmentin which he has been taking and states some of the redness has improved. Patients admits to being diabetic and that his blood sugars have been under poor control. His most recent HbA1c was 12.3%. He denies any recent nausea, vomiting, fever, chills, shortness of breath, or chest pain. Past Medical History: HTN, DMII Social History: [MASKED] Family History: Significant for diabetes and heart disease Physical Exam: Admission Physical Examination General: Awake, alert, oriented x3. No acute distress HEENT: MMM, neck supple, NTAC Cardiac: extremities well perfused Lungs: No respiratory distress Abd: Soft, non-tender, non-distended Lower extremity exam: [MASKED] pulses palpable b/l. Capillary refill time < 3 seconds to the digits b/l. Skin temperature warm to cool from proximal tibia to distal digits bilaterally. Protective sensation diminished b/l. Ulcer noted to the lateral aspect of the fourth digit that probes deeply. Scant amount of purulent drainage expressed from the fourth digit ulcer. Right fourth digit appear erythematous and edematous with sloughing skin. Erythema note to the right fourth toe extending to the right dorsal foot, outline by previous hospital. Distal aspect of the fourth digit appears dusky in color without capillary refill. Mild tenderness with palpation of the right fourth digit. Discharge Physical Exam: Pertinent Results: [MASKED] 09:29PM BLOOD WBC-7.3 RBC-4.15* Hgb-12.5* Hct-35.7* MCV-86 MCH-30.1 MCHC-35.0 RDW-11.5 RDWSD-36.1 Plt [MASKED] [MASKED] 09:29PM BLOOD Neuts-58.1 [MASKED] Monos-9.2 Eos-1.8 Baso-0.1 Im [MASKED] AbsNeut-4.25 AbsLymp-2.23 AbsMono-0.67 AbsEos-0.13 AbsBaso-0.01 [MASKED] 09:29PM BLOOD Plt [MASKED] [MASKED] 09:29PM BLOOD Glucose-286* UreaN-17 Creat-0.8 Na-136 K-4.1 Cl-99 HCO3-24 AnGap-17 [MASKED] 09:29PM BLOOD Calcium-9.2 Phos-2.7 Mg-1.8 [MASKED] 09:29PM BLOOD CRP-18.7* Right foot radiograph [MASKED]: FINDINGS: Soft tissue swelling at the fourth toe is present. No overt bone destruction or periosteal reaction. Mild degenerative changes are seen at the first MTP joint, fourth TMT joint, first TMT joint. Plantar and posterior calcaneal spurs are seen. Bipartite lateral sesamoid at first MTP. IMPRESSION: Soft tissue swelling at the fourth toe. No overt evidence of osteomyelitis. Additional findings as above. Brief Hospital Course: The patient was admitted to the podiatric surgery service from clinic on [MASKED] for a R foot infection. On admission, he was started on broad spectrum antibiotics. The patient was brought to the operating room on [MASKED] for a Right [MASKED] digit arthoplasty, which the patient tolerated well. For full details of the procedure, please see the separately dictated operative report. The patient was taken to the PACU in stable condition and was transferred back to the floor after satisfactory recovery from anesthesia. Throughout his hospital stay, the patient remained afebrile with stable vital signs; pain was well controlled oral pain medication on a PRN basis. The patient remained stable from both a cardiovascular and pulmonary standpoint. He was placed on broad spectrum antibiotics while hospitalized and discharged with oral antibiotics. His intake and output were closely monitored and noted to be adequate. The patient received subcutaneous heparin throughout admission; early and frequent ambulation were strongly encouraged. The patient had hyperglycemia throughout his stay, and was seen by a member of the [MASKED] Diabetes Team and his blood glucose levels improved. The patient was subsequently discharged to home on POD 2 with vital signs stable and vascular status intact to right foot. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. Metformin 1000mg BID 2. Lisinopril 40mg 3. Simvastatin 40mg Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 750 mg PO Q12H RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 3. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 4. Glargine 30 Units Dinner Humalog 8 Units Breakfast Humalog 8 Units Lunch Humalog 8 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR 30 Units before DINR; Disp #*1 Syringe Refills:*0 5. Lisinopril 40 mg PO DAILY 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Simvastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: R foot ulcer 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 at [MASKED]. You were admitted to the Podiatric Surgery service for your right foot surgery. You were given IV antibiotics while here. You are being discharged home with the following instructions: ACTIVITY: There are restrictions on activity. Please remain weight bearing to your R heel in a surgical shoe until your follow up appointment. You should keep this site elevated when ever possible (above the level of the heart!) No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 6 weeks. No heavy lifting greater than 20 pounds for the next [MASKED] days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home, but you must keep your dressing CLEAN, DRY and INTACT. You can use a shower bag taped around your ankle/leg or hang your foot/leg outside of the bathtub. Avoid taking a tub bath, swimming, or soaking in a hot tub for 4 weeks after surgery or until cleared by your physician. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is not unusual for several weeks and small, frequent meals may be preferred. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. If a follow up appointment was not made prior to your discharge, please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are [MASKED] through [MASKED]. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: [MASKED]
|
[] |
[
"E1165",
"I10",
"Z794"
] |
[
"E1169: Type 2 diabetes mellitus with other specified complication",
"M86171: Other acute osteomyelitis, right ankle and foot",
"E1165: Type 2 diabetes mellitus with hyperglycemia",
"L97519: Non-pressure chronic ulcer of other part of right foot with unspecified severity",
"I10: Essential (primary) hypertension",
"Z794: Long term (current) use of insulin",
"E11621: Type 2 diabetes mellitus with foot ulcer",
"S97121A: Crushing injury of right lesser toe(s), initial encounter",
"W208XXA: Other cause of strike by thrown, projected or falling object, initial encounter",
"Y92096: Garden or yard of other non-institutional residence as the place of occurrence of the external cause"
] |
10,029,649
| 25,577,737
|
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 don't feel like I can do anything anymore."
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of chronic
anxiety and dysthymia who is brought to the emergency department
by EMS due to worsening symptoms of depression, irritability,
and expressed suicidal ideation. On initial and subsequent
interviews, patient is unable to describe fully her current
symptoms, nor precipitants for current symptoms. Although she
endorses fatigue and diminished motivation, she is unable to
cite specific stressors or precipitants for decline in mood or
functioning. Stated, "I feel frustrated and exhausted."
Explained that she currently lives with her sister and
step-grandmother in her step-grandmother's home; described
living arrangements as "cramped" (e.g. "I don't have space to do
what I want to do"), adding that she has "anxiety about wanting
to get organized." Has been self-employed as a ___ for
the past ___ years, working four days per week; describes work as
"tiring" but "it's the only thing [she knows] how to do for
work." Also cited intermittent conflict with boyfriend as
contributing to low mood. Explained, "It feels like I'm losing
control in these situations. One little thing, and it's like the
last straw. In those moments I don't know what to do." However,
patient describes her relationship with her boyfriend as
supportive; two have been dating for ___ year (met eachother ___
years ago). [Should be noted that patient's boyfriend called EMS
and reported to Dr. ___ patient had not been eating or
sleeping, and endorsed suicidal ideation]. Regarding thoughts of
suicide, patient was not able to elaborate further beyond "vague
thoughts of death." However, affirmed that she feels safe on
this unit, and would be capable of approaching staff if
thoughts/urges of self-harm intensified.
Past Medical History:
Past psychiatric history notable for previous diagnoses of
depression and anxiety. No previous hospitalizations. Has
therapist ___ ___, no consistent
psychiatrist. Reported previous medication trials of several
antidepressants (Prozac, Cymbalta, Celexa), none with
significant improvement in symptoms. Of noted, patient reported
that "citalopram ___ years ago led to significant weight gain and
feeling numb, not helpful. Duloxetine ___ to help with
chronic pain, led to severe exhaustion and did not help." Denies
previous suicide attempts or self-injurious behavior.
Past medical history:
- myofacial pain syndrome in neck
- recurrent UTIs
- asthma
- chronic pelvic pain
Allergies: NKDA; pollen and shellfish
Social History:
___
Family History:
Family psychiatric history notable for several family members
with depression and anxiety; siblings with chronic SI, no known
suicide attempts
Physical Exam:
PHYSICAL EXAMINATION:
VS: ___ 2252 Temp:97.7 BP:117/80 HR:74 RR:16 O2:98%
General: NAD, sitting up in chair.
HEENT: PERRL, MMM.
Neck: Supple. No adenopathy or thyromegaly.
Lungs: CTAB; no crackles or wheezes.
CV: RRR; no m/r/g
Abdomen: Soft, NT, ND.
Extremities: No clubbing, cyanosis, or edema.
Skin: Warm and dry, no cyanosis or erythema. No rash.
NEUROLOGICAL EXAM:
CN: PERRL, EOMI, smile symmetric, shoulder shrug intact
Motor: strength ___ in all four ext b/l
*Deep tendon Reflexes: Patellar: 1+
Gait/Romberg: gait wnl, Romberg not assessed
MENTAL STATUS EXAM:
-Appearance: ___ year old woman who appears younger than stated
age, sitting up in chair in NAD
-Behavior: Calm and cooperative with interview, makes
appropriate eye contact, answers questions appropriately
-Mood and Affect: "tired", affect constricted, fatigued,
dysphoric
-Thought process: linear, goal-directed, no loose associations,
no tangentiality, no circumstantiality
-Thought Content: Denies SI/HI/AVH, does not appear to be
responding to internal stimuli
-Judgment and Insight: impaired/impaired
COGNITIVE EXAM:
*Attention, *orientation, and executive function: has difficulty
attending to some aspects of interview, able to state DOTWB;
fully oriented to person, ___, and date; executive function
not formally tested
*Memory: intact to recent events on interview
*Fund of knowledge: Accurately states last three ___ presidents.
*Speech: normal amount, volume and tone normal, rhythm normal
*Language: fluent, native ___ speaker
Pertinent Results:
___ 02:10PM URINE HOURS-RANDOM
___ 02:10PM URINE UCG-NEGATIVE
___ 02:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 02:10PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:10PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 02:10PM URINE RBC-<1 WBC-1 BACTERIA-FEW* YEAST-NONE
EPI-1
___ 02:10PM URINE MUCOUS-OCC*
___ 12:46PM GLUCOSE-85 UREA N-11 CREAT-0.6 SODIUM-142
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-22 ANION GAP-15
___ 12:46PM CALCIUM-9.1 PHOSPHATE-2.2* MAGNESIUM-2.3
___ 12:46PM WBC-7.0 RBC-4.50 HGB-13.0 HCT-40.2 MCV-89
MCH-28.9 MCHC-32.3 RDW-14.0 RDWSD-45.6
___ 12:46PM NEUTS-74.4* LYMPHS-18.5* MONOS-5.1 EOS-0.9*
BASOS-0.7 IM ___ AbsNeut-5.24 AbsLymp-1.30 AbsMono-0.36
AbsEos-0.06 AbsBaso-0.05
___ 12:46PM PLT COUNT-354
Brief Hospital Course:
Mr. ___ is a ___ year old woman with a history of chronic
anxiety and dysthymia who is brought to the emergency department
by EMS due to worsening symptoms of depression, irritability,
and expressed suicidal ideation.
1. LEGAL & SAFETY:
On admission, the patient signed a conditional voluntary
agreement (Section 10 & 11) and remained on that level
throughout their admission. She was also placed on 15 minute
checks status on admission and remained on that level of
observation throughout while being unit restricted.
2. PSYCHIATRIC
#Major Depressive Disorder
At the time of presentation, the patient had difficulty fully
describing her current mood state, almost to the point of
alexithymia. She did endorse recent fatigue, poor sleep, poor
appetite, anhedonia, decreased motivation, diminished
concentration, and passive suicidal thoughts. While she denied
suicidal plan or intent, she did note that she had recently felt
worried that she may lose control and do something unsafe.
Collateral from her boyfriend, in addition to patient's
appraisal of her own functioning, was concerning for recent
deterioration and heightened irritability and depressed mood. On
initial exam, she had a restricted affect and made minimal eye
contact with interviewers.
Her presentation appeared most consistent with major depressive
disorder, but there was additionally an element of
trauma-related symptoms contributing to her presentation.
Patient has a history of sexual assault and also described
arguments with boyfriend evoking memories from childhood when
she observed her mother/stepfather arguing.
She reported previous medication trials of fluoxetine,
citalopram, and duloxetine which were discontinued either due to
ineffectiveness or side effects. She was started on Wellbutrin
XR 150mg daily and Hydroxyzine 25mg BID:PRN anxiety/insomnia.
She reported feeling jittery, anxious, with racing heart on
Wellbutrin XR 150mg so was transitioned to Wellbutrin SR 100mg.
She tolerated this well with no reported side effects. Over the
course of her admission, she engaged in treatment, including
individual therapy as well as groups focused on coping. She
reported improvement in her mood and energy level. She denied
any suicidal ideation, reporting that she was no longer in a
dark place. She had a less constricted affect and was brighter
and more reactive. At the time of discharge, she was
future-oriented, looking forward to getting back to work.
3. MEDICAL
#Chronic pelvic pain: Patient reported intermittent right-sided
pelvic pain exacerbated by urination, bowel movements, and
intercourse. She denied heavy or irregular menstrual bleeding
and stated that she usually does not take anything for the pain,
as ibuprofen and Tylenol have never seemed to help. Patient has
had discussions about endometriosis with doctors in the past but
has never been definitively diagnosed. She reports that her
symptoms are currently at baseline and tolerable. She declined
offer for PRN pain medication during this admission.
4. SUBSTANCE USE: Patient reported intermittent marijuana use.
She was provided with counseling regarding marijuana use and
possible negative impact substance use has on her anxiety/mood.
5. PSYCHOSOCIAL
#) GROUPS/MILIEU:
The patient was encouraged to participate in the various groups
and milieu therapy opportunities offered by the unit. The
patient often attended these groups that focused on teaching
patients various coping skills. She was also noted to be social
with her peers in the milieu and pleasant with staff members.
#) COLLATERAL CONTACTS & FAMILY INVOLVEMENT:
Patient provided verbal permission to contact her outpatient
therapist ___ ___ and her
outpatient PCP (Dr. ___ ___. Providers were
contacted for collateral information and for discharge planning.
Patient also gave verbal permission to contact her boyfriend
___ who provided the primary team with
collateral information.
INFORMED CONSENT: The team discussed the indications for,
intended benefits of, and possible side effects and risks of
starting Wellbutrin and Hydroxyzine, and risks and benefits of
possible alternatives, including not taking the medications,
with this patient. We discussed the patient's right to decide
whether to take this medication as well as the importance of the
patient's actively participating in the treatment and discussing
any questions about medications with the treatment team, and I
answered the patient's questions. The patient appeared able to
understand and consented to begin the medication.
RISK ASSESSMENT
On presentation, the patient was evaluated and felt to be at an
increased risk of harm to herself and/or others based upon
worsening functioning with passive suicidal ideation, fears of
losing control and doing something unsafe. Her static factors
noted at that time include history of trauma and abuse, chronic
mental illness, chronic pain (fibromyalgia, myofascial pain
syndrome, chronic pelvic pain) . The modifiable risk factors,
which included lack of outpatient treaters, passive suicidal
ideation, acute mood episode, and medication noncompliance
(history of discontinuing several antidepressants due to side
effects) were also addressed at that time. The patient engaged
in individual and group therapy focusing on coping skills during
her admission; she was also started on Wellbutrin which she
tolerated well and outpatient follow up was scheduled. Finally,
the patient is being discharged with many protective factors,
including future-oriented thinking, willingness to seek help,
and sense of responsibility to family. Overall, based on the
totality of our assessment at this time, the patient is not at
an acutely elevated risk of self-harm nor danger to others.
Medications on Admission:
None
Discharge Medications:
1. BuPROPion (Sustained Release) 100 mg PO QAM
RX *bupropion HCl [Wellbutrin SR] 100 mg 1 tablet by mouth daily
Disp #*14 Tablet Refills:*0
2. HydrOXYzine 25 mg PO BID:PRN insomnia/anxiety
RX *hydroxyzine HCl 25 mg 1 tablet by mouth daily PRN Disp #*14
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Major depressive disorder
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status:
-Appearance: ___ year old woman, appearing her stated age, well
groomed, wearing casual home clothing
-Behavior: sitting up in a chair, making appropriate eye
contact with interviewers, no psychomotor agitation or
retardation
-Attitude: calm and cooperative with the interview, easily
engaged
-Mood and Affect: 'fine'; bright, appropriately reactive
affect smiling several times throughout interview appropriately;
less anxious appearing than previous
-Speech: normal volume, rate, tone
-Thought process: linear, no loose associations, organized
-Thought content: denies SI and is future oriented, looking
forward to getting back to work, did not endorse HI or AVH, does
not appear to be responding to internal stimuli, no evidence of
paranoia or delusions
-Judgment and Insight: good
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:
___
|
[
"F329",
"R102",
"R45851"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "I don't feel like I can do anything anymore." Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old woman with a history of chronic anxiety and dysthymia who is brought to the emergency department by EMS due to worsening symptoms of depression, irritability, and expressed suicidal ideation. On initial and subsequent interviews, patient is unable to describe fully her current symptoms, nor precipitants for current symptoms. Although she endorses fatigue and diminished motivation, she is unable to cite specific stressors or precipitants for decline in mood or functioning. Stated, "I feel frustrated and exhausted." Explained that she currently lives with her sister and step-grandmother in her step-grandmother's home; described living arrangements as "cramped" (e.g. "I don't have space to do what I want to do"), adding that she has "anxiety about wanting to get organized." Has been self-employed as a [MASKED] for the past [MASKED] years, working four days per week; describes work as "tiring" but "it's the only thing [she knows] how to do for work." Also cited intermittent conflict with boyfriend as contributing to low mood. Explained, "It feels like I'm losing control in these situations. One little thing, and it's like the last straw. In those moments I don't know what to do." However, patient describes her relationship with her boyfriend as supportive; two have been dating for [MASKED] year (met eachother [MASKED] years ago). [Should be noted that patient's boyfriend called EMS and reported to Dr. [MASKED] patient had not been eating or sleeping, and endorsed suicidal ideation]. Regarding thoughts of suicide, patient was not able to elaborate further beyond "vague thoughts of death." However, affirmed that she feels safe on this unit, and would be capable of approaching staff if thoughts/urges of self-harm intensified. Past Medical History: Past psychiatric history notable for previous diagnoses of depression and anxiety. No previous hospitalizations. Has therapist [MASKED] [MASKED], no consistent psychiatrist. Reported previous medication trials of several antidepressants (Prozac, Cymbalta, Celexa), none with significant improvement in symptoms. Of noted, patient reported that "citalopram [MASKED] years ago led to significant weight gain and feeling numb, not helpful. Duloxetine [MASKED] to help with chronic pain, led to severe exhaustion and did not help." Denies previous suicide attempts or self-injurious behavior. Past medical history: - myofacial pain syndrome in neck - recurrent UTIs - asthma - chronic pelvic pain Allergies: NKDA; pollen and shellfish Social History: [MASKED] Family History: Family psychiatric history notable for several family members with depression and anxiety; siblings with chronic SI, no known suicide attempts Physical Exam: PHYSICAL EXAMINATION: VS: [MASKED] 2252 Temp:97.7 BP:117/80 HR:74 RR:16 O2:98% General: NAD, sitting up in chair. HEENT: PERRL, MMM. Neck: Supple. No adenopathy or thyromegaly. Lungs: CTAB; no crackles or wheezes. CV: RRR; no m/r/g Abdomen: Soft, NT, ND. Extremities: No clubbing, cyanosis, or edema. Skin: Warm and dry, no cyanosis or erythema. No rash. NEUROLOGICAL EXAM: CN: PERRL, EOMI, smile symmetric, shoulder shrug intact Motor: strength [MASKED] in all four ext b/l *Deep tendon Reflexes: Patellar: 1+ Gait/Romberg: gait wnl, Romberg not assessed MENTAL STATUS EXAM: -Appearance: [MASKED] year old woman who appears younger than stated age, sitting up in chair in NAD -Behavior: Calm and cooperative with interview, makes appropriate eye contact, answers questions appropriately -Mood and Affect: "tired", affect constricted, fatigued, dysphoric -Thought process: linear, goal-directed, no loose associations, no tangentiality, no circumstantiality -Thought Content: Denies SI/HI/AVH, does not appear to be responding to internal stimuli -Judgment and Insight: impaired/impaired COGNITIVE EXAM: *Attention, *orientation, and executive function: has difficulty attending to some aspects of interview, able to state DOTWB; fully oriented to person, [MASKED], and date; executive function not formally tested *Memory: intact to recent events on interview *Fund of knowledge: Accurately states last three [MASKED] presidents. *Speech: normal amount, volume and tone normal, rhythm normal *Language: fluent, native [MASKED] speaker Pertinent Results: [MASKED] 02:10PM URINE HOURS-RANDOM [MASKED] 02:10PM URINE UCG-NEGATIVE [MASKED] 02:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG [MASKED] 02:10PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 02:10PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [MASKED] 02:10PM URINE RBC-<1 WBC-1 BACTERIA-FEW* YEAST-NONE EPI-1 [MASKED] 02:10PM URINE MUCOUS-OCC* [MASKED] 12:46PM GLUCOSE-85 UREA N-11 CREAT-0.6 SODIUM-142 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-22 ANION GAP-15 [MASKED] 12:46PM CALCIUM-9.1 PHOSPHATE-2.2* MAGNESIUM-2.3 [MASKED] 12:46PM WBC-7.0 RBC-4.50 HGB-13.0 HCT-40.2 MCV-89 MCH-28.9 MCHC-32.3 RDW-14.0 RDWSD-45.6 [MASKED] 12:46PM NEUTS-74.4* LYMPHS-18.5* MONOS-5.1 EOS-0.9* BASOS-0.7 IM [MASKED] AbsNeut-5.24 AbsLymp-1.30 AbsMono-0.36 AbsEos-0.06 AbsBaso-0.05 [MASKED] 12:46PM PLT COUNT-354 Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old woman with a history of chronic anxiety and dysthymia who is brought to the emergency department by EMS due to worsening symptoms of depression, irritability, and expressed suicidal ideation. 1. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) and remained on that level throughout their admission. She was also placed on 15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. 2. PSYCHIATRIC #Major Depressive Disorder At the time of presentation, the patient had difficulty fully describing her current mood state, almost to the point of alexithymia. She did endorse recent fatigue, poor sleep, poor appetite, anhedonia, decreased motivation, diminished concentration, and passive suicidal thoughts. While she denied suicidal plan or intent, she did note that she had recently felt worried that she may lose control and do something unsafe. Collateral from her boyfriend, in addition to patient's appraisal of her own functioning, was concerning for recent deterioration and heightened irritability and depressed mood. On initial exam, she had a restricted affect and made minimal eye contact with interviewers. Her presentation appeared most consistent with major depressive disorder, but there was additionally an element of trauma-related symptoms contributing to her presentation. Patient has a history of sexual assault and also described arguments with boyfriend evoking memories from childhood when she observed her mother/stepfather arguing. She reported previous medication trials of fluoxetine, citalopram, and duloxetine which were discontinued either due to ineffectiveness or side effects. She was started on Wellbutrin XR 150mg daily and Hydroxyzine 25mg BID:PRN anxiety/insomnia. She reported feeling jittery, anxious, with racing heart on Wellbutrin XR 150mg so was transitioned to Wellbutrin SR 100mg. She tolerated this well with no reported side effects. Over the course of her admission, she engaged in treatment, including individual therapy as well as groups focused on coping. She reported improvement in her mood and energy level. She denied any suicidal ideation, reporting that she was no longer in a dark place. She had a less constricted affect and was brighter and more reactive. At the time of discharge, she was future-oriented, looking forward to getting back to work. 3. MEDICAL #Chronic pelvic pain: Patient reported intermittent right-sided pelvic pain exacerbated by urination, bowel movements, and intercourse. She denied heavy or irregular menstrual bleeding and stated that she usually does not take anything for the pain, as ibuprofen and Tylenol have never seemed to help. Patient has had discussions about endometriosis with doctors in the past but has never been definitively diagnosed. She reports that her symptoms are currently at baseline and tolerable. She declined offer for PRN pain medication during this admission. 4. SUBSTANCE USE: Patient reported intermittent marijuana use. She was provided with counseling regarding marijuana use and possible negative impact substance use has on her anxiety/mood. 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The patient often attended these groups that focused on teaching patients various coping skills. She was also noted to be social with her peers in the milieu and pleasant with staff members. #) COLLATERAL CONTACTS & FAMILY INVOLVEMENT: Patient provided verbal permission to contact her outpatient therapist [MASKED] [MASKED] and her outpatient PCP (Dr. [MASKED] [MASKED]. Providers were contacted for collateral information and for discharge planning. Patient also gave verbal permission to contact her boyfriend [MASKED] who provided the primary team with collateral information. INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of starting Wellbutrin and Hydroxyzine, and risks and benefits of possible alternatives, including not taking the medications, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team, and I answered the patient's questions. The patient appeared able to understand and consented to begin the medication. RISK ASSESSMENT On presentation, the patient was evaluated and felt to be at an increased risk of harm to herself and/or others based upon worsening functioning with passive suicidal ideation, fears of losing control and doing something unsafe. Her static factors noted at that time include history of trauma and abuse, chronic mental illness, chronic pain (fibromyalgia, myofascial pain syndrome, chronic pelvic pain) . The modifiable risk factors, which included lack of outpatient treaters, passive suicidal ideation, acute mood episode, and medication noncompliance (history of discontinuing several antidepressants due to side effects) were also addressed at that time. The patient engaged in individual and group therapy focusing on coping skills during her admission; she was also started on Wellbutrin which she tolerated well and outpatient follow up was scheduled. Finally, the patient is being discharged with many protective factors, including future-oriented thinking, willingness to seek help, and sense of responsibility to family. Overall, based on the totality of our assessment at this time, the patient is not at an acutely elevated risk of self-harm nor danger to others. Medications on Admission: None Discharge Medications: 1. BuPROPion (Sustained Release) 100 mg PO QAM RX *bupropion HCl [Wellbutrin SR] 100 mg 1 tablet by mouth daily Disp #*14 Tablet Refills:*0 2. HydrOXYzine 25 mg PO BID:PRN insomnia/anxiety RX *hydroxyzine HCl 25 mg 1 tablet by mouth daily PRN Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Major depressive disorder Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: -Appearance: [MASKED] year old woman, appearing her stated age, well groomed, wearing casual home clothing -Behavior: sitting up in a chair, making appropriate eye contact with interviewers, no psychomotor agitation or retardation -Attitude: calm and cooperative with the interview, easily engaged -Mood and Affect: 'fine'; bright, appropriately reactive affect smiling several times throughout interview appropriately; less anxious appearing than previous -Speech: normal volume, rate, tone -Thought process: linear, no loose associations, organized -Thought content: denies SI and is future oriented, looking forward to getting back to work, did not endorse HI or AVH, does not appear to be responding to internal stimuli, no evidence of paranoia or delusions -Judgment and Insight: good 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]
|
[] |
[
"F329"
] |
[
"F329: Major depressive disorder, single episode, unspecified",
"R102: Pelvic and perineal pain",
"R45851: Suicidal ideations"
] |
10,029,874
| 27,592,458
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Darvon / Penicillins / Codeine / Motrin
Attending: ___.
Chief Complaint:
Left Parietal stroke in the setting of Left Carotid Artery
Stenosis
Major Surgical or Invasive Procedure:
___: Left Carotid Endarterectomy
History of Present Illness:
Mr. ___ presents for evaluation
of his symptomatic left carotid stenosis. Two weeks ago, on
___, he was noted to have abnormal speech and some
right-sided weakness. He was evaluated at ___
where he underwent evaluation by CTA of the head and neck. This
demonstrated a subacute left parietal stroke as well as 80%
narrowing of the left internal carotid artery. He presents
today
for management recommendations as he preferred to have his
treatment here.
Today, he is not able to communicate well due to an expressive
aphasia. Through a series of yes and no questions, he informed
me that he does have some persistent right hand weakness. He
also has persistent inability to communicate since his stroke
two
weeks ago. He has not had any increasing focal motor weakness or
numbness. He has not experienced transient monocular blindness
or deterioration in his speech since the initial event.
Past Medical History:
Depression
? mild dementia
HIV on HAART
Hepatitis C, reportedly s/p interferon treatment
self-administered for ___ year
Hypertension
Lumbar Stenosis s/p spinal fusion in ___ for back pain
Sciatica
BPH
urinary retention
anxiety
B12 deficiency
Social History:
___
Family History:
Father was an alcoholic and died of complications, unsure of how
mother died
Physical ___:
VITAL SIGNS:
97.8 59 127/49 16 96% RA
GENERAL: Aphasic, but understands well. In NAD.
NECK: Left CEA incision with some yellowish drainage, tender to
palpation, mild redness around incision.
ABDOMEN: Soft, NT, ND.
CHEST: Clear without wheezes or crackles. Breathing comfortably
on RA.
HEART: Has a regular rate and rhythm without murmurs.
EXTREMITIES: The upper extremity pulses are symmetric. Moving
all extremities. RUE strength ___. LUE strength ___. ___ strength
___ bilaterally.
NEUROLOGIC: He has dorsi and plantar flexion of the feet.
Facial movement poor bilaterally. PERRLA, EOMI, assymetric face
with facial droop left. Tongue midline.
Pertinent Results:
___ 06:45AM BLOOD WBC-8.9 RBC-3.23* Hgb-9.0* Hct-28.0*
MCV-87 MCH-27.9 MCHC-32.1 RDW-14.8 RDWSD-46.6* Plt ___
___ 01:20AM BLOOD Glucose-95 UreaN-9 Creat-1.0 Na-140 K-3.8
Cl-103 HCO3-24 AnGap-17
___ 11:38PM BLOOD ALT-15 AST-19 AlkPhos-68 TotBili-0.4
___ 01:20AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.1
___ 05:05AM BLOOD ___ pO2-157* pCO2-50* pH-7.37
calTCO2-30 Base XS-2
Brief Hospital Course:
Mr. ___ presented to the pre-op holding area at ___ on
___. He underwent L CEA on ___. Intra-operatively, he
received about 1500cc of fluids, and he had low urine output
postoperatively. He was again given 500cc bolus x 2 for low
urine output on the floor, with a good response. In the post
operative period he was noted to have facial droop which was
new. In addition he has had increasing difficulty swallowing
after his procedure. He was given water when he was noted to
have aspiration by nursing, then developing respiratory distress
and hypoxia and decision was made to transfer to the ICU on
___. Upon admission to ICU, he was saturating in low ___ on
RA, and low ___ on 4LNC. He was given one dose of 10mg IV Lasix
for diuresis with no results followed by 20mg of Lasix with no
significant change in diuresis. A foley catheter was placed for
monitoring of urine output. He was further started on
vanc/cefepime/flagyl, which was d/c'd on ___ as his
respiratory distress was due to Atelectasis. He was started on
CPAP q4H, which was continued until he was transferred to the
floor on ___. Speech and swallow cleared him for nectar
thickened/pureed solids, crushed meds, supervised. His left neck
incision was noted to be oozing yellowish fluid on ___ and
was painful on palpation, so he was started on IV Vancomycin,
which was switched to PO Minocycline at discharge.
His Foley catheter stayed in place until ___. The
rehabilitation facility will replace his foley catheter if he
fails to void.
At the time of discharge, he was doing well, afebrile with
stable vital signs. He was tolerating the diet suggested by
speech and swallow, ambulating, was due to void, and his pain
was well controlled on oral medications. He was deemed ready for
discharge (the rehab facility agreed to replace his foley if
necessary), and was given the appropriate discharge and
follow-up instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 50 mg PO QHS
2. TraZODone 25 mg PO Q6H:PRN agitation
3. Senna 17.2 mg PO DAILY:PRN constipation
4. RiTONAvir 100 mg PO BID
5. Raltegravir 400 mg PO BID
6. Paroxetine 40 mg PO QHS
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
8. Omeprazole 20 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Heparin 5000 UNIT SC TID
12. Gabapentin 300 mg PO TID
13. Finasteride 5 mg PO DAILY
14. Emtricitabine 200 mg PO Q24H
15. Docusate Sodium 100 mg PO BID:PRN constipation
16. Darunavir 600 mg PO BID
17. cyanocobalamin (vitamin B-12) 1,000 mcg sublingual DAILY
18. Atorvastatin 10 mg PO QHS
19. Aspirin Childrens (aspirin) 81 mg oral DAILY
20. Amlodipine 10 mg PO DAILY
21. ___ (alum-mag hydroxide-simeth) 30 mL oral Q6H:PRN
stomach upset
22. Acyclovir 400 mg PO Q24H
23. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Medications:
1. Acyclovir 400 mg PO Q24H
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 10 mg PO QHS
4. Darunavir 600 mg PO BID
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Emtricitabine 200 mg PO Q24H
7. Finasteride 5 mg PO DAILY
8. Heparin 5000 UNIT SC TID
9. Paroxetine 40 mg PO QHS
10. Raltegravir 400 mg PO BID
11. RiTONAvir 100 mg PO BID
12. Senna 17.2 mg PO DAILY:PRN constipation
13. TraZODone 50 mg PO QHS
14. TraZODone 25 mg PO Q6H:PRN agitation
15. Acetaminophen 650 mg PO Q6H:PRN pain
16. Aspirin Childrens (aspirin) 81 mg oral DAILY
17. cyanocobalamin (vitamin B-12) 1,000 mcg sublingual DAILY
18. Gabapentin 300 mg PO TID
19. ___ (alum-mag hydroxide-simeth) 30 mL oral Q6H:PRN
stomach upset
20. Metoprolol Succinate XL 100 mg PO DAILY
21. Multivitamins W/minerals 1 TAB PO DAILY
22. Omeprazole 20 mg PO DAILY
23. Minocycline 100 mg PO BID Duration: 7 Days
RX *minocycline [Minocin] 100 mg 1 capsule(s) by mouth twice a
day Disp #*14 Capsule Refills:*0
24. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Please take with food. Do not drink or drive when taking.
RX *oxycodone 5 mg/5 mL ___ solution(s) by mouth Q4
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Symptomatic Carotid Stenosis
Discharge Condition:
Mental Status: Clear and coherent- although aphasic, understands
appropriately, but cannot speak.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Please follow up with speech and swallow for clearance to eat
solid foods.
Currently, you are allowed to eat pureed foods, nectar
prethickened liquids. Please also supplement with Ensure at
breakfast, lunch, dinner
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
CEA
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
WHAT TO EXPECT:
1. Surgical Incision:
It is normal to have some swelling and feel a firm ridge along
the incision
Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
Try ibuprofen, acetaminophen, or your discharge pain
medication
If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call vascular surgeons office
4. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
5. It is normal to have a decreased appetite, your appetite
will return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Take all of your medications as prescribed in your discharge
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area
CALL THE OFFICE at ___ FOR:
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Temperature greater than 101.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
___
|
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Allergies: Darvon / Penicillins / Codeine / Motrin Chief Complaint: Left Parietal stroke in the setting of Left Carotid Artery Stenosis Major Surgical or Invasive Procedure: [MASKED]: Left Carotid Endarterectomy History of Present Illness: Mr. [MASKED] presents for evaluation of his symptomatic left carotid stenosis. Two weeks ago, on [MASKED], he was noted to have abnormal speech and some right-sided weakness. He was evaluated at [MASKED] where he underwent evaluation by CTA of the head and neck. This demonstrated a subacute left parietal stroke as well as 80% narrowing of the left internal carotid artery. He presents today for management recommendations as he preferred to have his treatment here. Today, he is not able to communicate well due to an expressive aphasia. Through a series of yes and no questions, he informed me that he does have some persistent right hand weakness. He also has persistent inability to communicate since his stroke two weeks ago. He has not had any increasing focal motor weakness or numbness. He has not experienced transient monocular blindness or deterioration in his speech since the initial event. Past Medical History: Depression ? mild dementia HIV on HAART Hepatitis C, reportedly s/p interferon treatment self-administered for [MASKED] year Hypertension Lumbar Stenosis s/p spinal fusion in [MASKED] for back pain Sciatica BPH urinary retention anxiety B12 deficiency Social History: [MASKED] Family History: Father was an alcoholic and died of complications, unsure of how mother died Physical [MASKED]: VITAL SIGNS: 97.8 59 127/49 16 96% RA GENERAL: Aphasic, but understands well. In NAD. NECK: Left CEA incision with some yellowish drainage, tender to palpation, mild redness around incision. ABDOMEN: Soft, NT, ND. CHEST: Clear without wheezes or crackles. Breathing comfortably on RA. HEART: Has a regular rate and rhythm without murmurs. EXTREMITIES: The upper extremity pulses are symmetric. Moving all extremities. RUE strength [MASKED]. LUE strength [MASKED]. [MASKED] strength [MASKED] bilaterally. NEUROLOGIC: He has dorsi and plantar flexion of the feet. Facial movement poor bilaterally. PERRLA, EOMI, assymetric face with facial droop left. Tongue midline. Pertinent Results: [MASKED] 06:45AM BLOOD WBC-8.9 RBC-3.23* Hgb-9.0* Hct-28.0* MCV-87 MCH-27.9 MCHC-32.1 RDW-14.8 RDWSD-46.6* Plt [MASKED] [MASKED] 01:20AM BLOOD Glucose-95 UreaN-9 Creat-1.0 Na-140 K-3.8 Cl-103 HCO3-24 AnGap-17 [MASKED] 11:38PM BLOOD ALT-15 AST-19 AlkPhos-68 TotBili-0.4 [MASKED] 01:20AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.1 [MASKED] 05:05AM BLOOD [MASKED] pO2-157* pCO2-50* pH-7.37 calTCO2-30 Base XS-2 Brief Hospital Course: Mr. [MASKED] presented to the pre-op holding area at [MASKED] on [MASKED]. He underwent L CEA on [MASKED]. Intra-operatively, he received about 1500cc of fluids, and he had low urine output postoperatively. He was again given 500cc bolus x 2 for low urine output on the floor, with a good response. In the post operative period he was noted to have facial droop which was new. In addition he has had increasing difficulty swallowing after his procedure. He was given water when he was noted to have aspiration by nursing, then developing respiratory distress and hypoxia and decision was made to transfer to the ICU on [MASKED]. Upon admission to ICU, he was saturating in low [MASKED] on RA, and low [MASKED] on 4LNC. He was given one dose of 10mg IV Lasix for diuresis with no results followed by 20mg of Lasix with no significant change in diuresis. A foley catheter was placed for monitoring of urine output. He was further started on vanc/cefepime/flagyl, which was d/c'd on [MASKED] as his respiratory distress was due to Atelectasis. He was started on CPAP q4H, which was continued until he was transferred to the floor on [MASKED]. Speech and swallow cleared him for nectar thickened/pureed solids, crushed meds, supervised. His left neck incision was noted to be oozing yellowish fluid on [MASKED] and was painful on palpation, so he was started on IV Vancomycin, which was switched to PO Minocycline at discharge. His Foley catheter stayed in place until [MASKED]. The rehabilitation facility will replace his foley catheter if he fails to void. At the time of discharge, he was doing well, afebrile with stable vital signs. He was tolerating the diet suggested by speech and swallow, ambulating, was due to void, and his pain was well controlled on oral medications. He was deemed ready for discharge (the rehab facility agreed to replace his foley if necessary), and was given the appropriate discharge and follow-up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. TraZODone 50 mg PO QHS 2. TraZODone 25 mg PO Q6H:PRN agitation 3. Senna 17.2 mg PO DAILY:PRN constipation 4. RiTONAvir 100 mg PO BID 5. Raltegravir 400 mg PO BID 6. Paroxetine 40 mg PO QHS 7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 8. Omeprazole 20 mg PO DAILY 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Metoprolol Succinate XL 100 mg PO DAILY 11. Heparin 5000 UNIT SC TID 12. Gabapentin 300 mg PO TID 13. Finasteride 5 mg PO DAILY 14. Emtricitabine 200 mg PO Q24H 15. Docusate Sodium 100 mg PO BID:PRN constipation 16. Darunavir 600 mg PO BID 17. cyanocobalamin (vitamin B-12) 1,000 mcg sublingual DAILY 18. Atorvastatin 10 mg PO QHS 19. Aspirin Childrens (aspirin) 81 mg oral DAILY 20. Amlodipine 10 mg PO DAILY 21. [MASKED] (alum-mag hydroxide-simeth) 30 mL oral Q6H:PRN stomach upset 22. Acyclovir 400 mg PO Q24H 23. Acetaminophen 650 mg PO Q6H:PRN pain Discharge Medications: 1. Acyclovir 400 mg PO Q24H 2. Amlodipine 10 mg PO DAILY 3. Atorvastatin 10 mg PO QHS 4. Darunavir 600 mg PO BID 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Emtricitabine 200 mg PO Q24H 7. Finasteride 5 mg PO DAILY 8. Heparin 5000 UNIT SC TID 9. Paroxetine 40 mg PO QHS 10. Raltegravir 400 mg PO BID 11. RiTONAvir 100 mg PO BID 12. Senna 17.2 mg PO DAILY:PRN constipation 13. TraZODone 50 mg PO QHS 14. TraZODone 25 mg PO Q6H:PRN agitation 15. Acetaminophen 650 mg PO Q6H:PRN pain 16. Aspirin Childrens (aspirin) 81 mg oral DAILY 17. cyanocobalamin (vitamin B-12) 1,000 mcg sublingual DAILY 18. Gabapentin 300 mg PO TID 19. [MASKED] (alum-mag hydroxide-simeth) 30 mL oral Q6H:PRN stomach upset 20. Metoprolol Succinate XL 100 mg PO DAILY 21. Multivitamins W/minerals 1 TAB PO DAILY 22. Omeprazole 20 mg PO DAILY 23. Minocycline 100 mg PO BID Duration: 7 Days RX *minocycline [Minocin] 100 mg 1 capsule(s) by mouth twice a day Disp #*14 Capsule Refills:*0 24. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain Please take with food. Do not drink or drive when taking. RX *oxycodone 5 mg/5 mL [MASKED] solution(s) by mouth Q4 Refills:*0 Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary: Symptomatic Carotid Stenosis Discharge Condition: Mental Status: Clear and coherent- although aphasic, understands appropriately, but cannot speak. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Please follow up with speech and swallow for clearance to eat solid foods. Currently, you are allowed to eat pureed foods, nectar prethickened liquids. Please also supplement with Ensure at breakfast, lunch, dinner = = = = = = = = = = = = = = = = = ================================================================ CEA = = = = = = = = = = = = = = = = = ================================================================ WHAT TO EXPECT: 1. Surgical Incision: It is normal to have some swelling and feel a firm ridge along the incision Your incision may be slightly red and raised, it may feel irritated from the staples 2. You may have a sore throat and/or mild hoarseness Try warm tea, throat lozenges or cool/cold beverages 3. You may have a mild headache, especially on the side of your surgery Try ibuprofen, acetaminophen, or your discharge pain medication If headache worsens, is associated with visual changes or lasts longer than 2 hours- call vascular surgeons office 4. It is normal to feel tired, this will last for [MASKED] weeks You should get up out of bed every day and gradually increase your activity each day You may walk and you may go up and down stairs Increase your activities as you can tolerate- do not do too much right away! 5. It is normal to have a decreased appetite, your appetite will return with time You will probably lose your taste for food and lose some weight Eat small frequent meals It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication MEDICATION: Take all of your medications as prescribed in your discharge ACTIVITIES: No driving until post-op visit and you are no longer taking pain medications No excessive head turning, lifting, pushing or pulling (greater than 5 lbs) until your post op visit You may shower (no direct spray on incision, let the soapy water run over incision, rinse and pat dry) Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area CALL THE OFFICE at [MASKED] FOR: Changes in vision (loss of vision, blurring, double vision, half vision) Slurring of speech or difficulty finding correct words to use Severe headache or worsening headache not controlled by pain medication A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg Trouble swallowing, breathing, or talking Temperature greater than 101.5F for 24 hours Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: [MASKED]
|
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[
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] |
[
"I6523: Occlusion and stenosis of bilateral carotid arteries",
"J9601: Acute respiratory failure with hypoxia",
"J9811: Atelectasis",
"I69351: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side",
"I69320: Aphasia following cerebral infarction",
"E785: Hyperlipidemia, unspecified",
"Z981: Arthrodesis status",
"Z21: Asymptomatic human immunodeficiency virus [HIV] infection status",
"F329: Major depressive disorder, single episode, unspecified",
"F419: Anxiety disorder, unspecified",
"Z8619: Personal history of other infectious and parasitic diseases",
"Z9842: Cataract extraction status, left eye",
"Z9841: Cataract extraction status, right eye",
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"R1310: Dysphagia, unspecified",
"Z7901: Long term (current) use of anticoagulants",
"Z7982: Long term (current) use of aspirin",
"I10: Essential (primary) hypertension"
] |
10,030,549
| 21,292,378
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
isoniazid
Attending: ___
Chief Complaint:
Encounter for chemotherapy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of T2DM, Metastatic Penile squamous cell carcinoma
presented for cycle 2 of TIP
Pt reported that he tolerated his first cycle without incident
and noted that he gets his neulasta dosed in clinic as he is not
a huge fan of needles.
He noted that he is presently in his baseline state of health,
denied fever, chills, nausea, vomiting, abdominal pain. Noted
that he has been eating, drinking, voiding, stooling without
issue.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Per last outpatient f/u note:
- ___: reported penile pain and bleeding to his PCP present
for about 2 months
- ___: CT torso showing no clear metastatic disease
- ___: Distal partial penectomy, path showing poorly
differentiated squamous cell carcinoma with sarcomatoid and
acantholytic features, pT3. Dr. ___ inguinal
___
on ___ but patient had some difficult social circumstances as he
was primary caretaker for his wife.
- ___: At follow-up visit, he had a new 2x2 cm lesion in the
left groin.
- ___: CT pelvis showing extensive new retroperitoneal
lymphadenopathy and new rim enhancing metastasis in the
pre-pubic
fat to the left of midline.
- ___: Initial med onc evaluation, planned to complete
restaging and begin palliative TIP, for which patient consented.
- ___: C1D1 TIP
PAST MEDICAL HISTORY:
-Metastatic Penile SCC with sarcomatoid and acantholytic
features
-Rheumatoid arthritis previously treated with Plaquenil, MTX,
sulfasalaine, leflunomide
-Type 2 diabetes mellitus
-Asthma
-+PPD and +Quantiferon, s/p 3 months of INH but complicated by
LFT
abnormalities, then s/p full course of rifampin
-Osteoarthritis
-Right bundle branch block
-Ventral hernia
-Hypertension
-Hyperlipidemia
Social History:
___
Family History:
Father had blood cancer, no history of colon, lung or prostate
ca, no history of stroke or MI
Physical Exam:
DISCHARGE PHYSICAL EXAM:
Vitals:
___ 0726 Temp: 97.8 PO BP: 106/51 R Lying HR: 86 RR: 18 O2
sat: 97% O2 delivery: Room Air
GENERAL: Sitting in bed, appears comfortable, no acute distress
HEENT: Pupils round, scleara anicteric. Oropharynx clear, moist
mucous membranes.
NECK: Supple, normal range of motion
LUNGS: Clear to auscultation bilaterally no wheezes rales or
rhonchi, normal respiratory rate
CV: Regular rate and rhythm, normal distal perfusion no edema
ABD: Soft, nontender, nondistended, normoactive bowel sounds
GENITOURINARY: No Foley or suprapubic tenderness
EXT: Warm, normal muscle bulk, no deformity
SKIN: Warm dry, no rash
NEURO: Alert and oriented x3, fluent speech
ACCESS: Port dressing clean/dry/intact
Pertinent Results:
Discharge labs:
___ 06:00AM BLOOD WBC-9.8 RBC-3.24* Hgb-9.9* Hct-29.7*
MCV-92 MCH-30.6 MCHC-33.3 RDW-17.1* RDWSD-55.9* Plt ___
___ 06:00AM BLOOD Neuts-82.0* Lymphs-14.8* Monos-2.5*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-8.02* AbsLymp-1.45
AbsMono-0.24 AbsEos-0.01* AbsBaso-0.02
___ 06:00AM BLOOD ___ PTT-39.9* ___
___ 06:00AM BLOOD Glucose-237* UreaN-11 Creat-0.8 Na-142
K-4.7 Cl-107 HCO3-26 AnGap-9*
___ 06:00AM BLOOD ALT-11 AST-12 AlkPhos-132* TotBili-0.3
___ 06:00AM BLOOD Calcium-9.5 Phos-3.0 Mg-1.8
___ 06:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-300* Ketone-10* Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG*
___ 06:00AM URINE Color-Straw Appear-Clear Sp ___ PMH of Metastatic Penile squamous cell carcinoma presented
for cycle 2 of TIP
#Metastatic Penile squamous cell carcinoma.
Now s/p cycle 2 of TIP without acute complications. He tolerated
cycle 1 without incident.
-C2D1 ___
-s/p Taxol, Ifosfamide, Cisplatin, Mesna with appropriate
pre-meds as per Dr. ___ for neulasta administration ___ 9AM
#T2DM
-Hold metformin/glipizide, resume on discharge
-___ while inpatient
#HTN
-Continue lisinopril
#HLD
-Held statin during stay, restart on discharge
#RA: on prn oxy
Transitional issues:
- will follow up for neulasta injection on ___
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. Albuterol Inhaler 2 PUFF IH TID:PRN dyspnea
2. Docusate Sodium 100 mg PO BID
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. OxyCODONE (Immediate Release) 2.5 mg PO DAILY:PRN Pain -
Moderate
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. GlipiZIDE XL 5 mg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
11. Vitamin D 1000 UNIT PO DAILY
12. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
13. Dexamethasone 4 mg PO ASDIR
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH TID:PRN dyspnea
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Dexamethasone 4 mg PO ASDIR
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. GlipiZIDE XL 5 mg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
11. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
12. OxyCODONE (Immediate Release) 2.5 mg PO DAILY:PRN Pain -
Moderate
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Encounter for chemotherapy
Penile Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure to care for you at ___.
You came to the hospital for chemotherapy.
WHAT HAPPENED IN THE HOSPITAL?
-you received your chemotherapy and tolerated it well
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- follow up closely with oncology tomorrow ___ for an
injection to support your blood counts
We wish you all the best!
Sincerely,
Your care team at ___
Followup Instructions:
___
|
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"I10",
"C609",
"K5900",
"G8929",
"M25562",
"E785",
"Z8611",
"Z7982",
"Z9079"
] |
Allergies: isoniazid Chief Complaint: Encounter for chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] PMH of T2DM, Metastatic Penile squamous cell carcinoma presented for cycle 2 of TIP Pt reported that he tolerated his first cycle without incident and noted that he gets his neulasta dosed in clinic as he is not a huge fan of needles. He noted that he is presently in his baseline state of health, denied fever, chills, nausea, vomiting, abdominal pain. Noted that he has been eating, drinking, voiding, stooling without issue. Past Medical History: PAST ONCOLOGIC HISTORY: Per last outpatient f/u note: - [MASKED]: reported penile pain and bleeding to his PCP present for about 2 months - [MASKED]: CT torso showing no clear metastatic disease - [MASKED]: Distal partial penectomy, path showing poorly differentiated squamous cell carcinoma with sarcomatoid and acantholytic features, pT3. Dr. [MASKED] inguinal [MASKED] on [MASKED] but patient had some difficult social circumstances as he was primary caretaker for his wife. - [MASKED]: At follow-up visit, he had a new 2x2 cm lesion in the left groin. - [MASKED]: CT pelvis showing extensive new retroperitoneal lymphadenopathy and new rim enhancing metastasis in the pre-pubic fat to the left of midline. - [MASKED]: Initial med onc evaluation, planned to complete restaging and begin palliative TIP, for which patient consented. - [MASKED]: C1D1 TIP PAST MEDICAL HISTORY: -Metastatic Penile SCC with sarcomatoid and acantholytic features -Rheumatoid arthritis previously treated with Plaquenil, MTX, sulfasalaine, leflunomide -Type 2 diabetes mellitus -Asthma -+PPD and +Quantiferon, s/p 3 months of INH but complicated by LFT abnormalities, then s/p full course of rifampin -Osteoarthritis -Right bundle branch block -Ventral hernia -Hypertension -Hyperlipidemia Social History: [MASKED] Family History: Father had blood cancer, no history of colon, lung or prostate ca, no history of stroke or MI Physical Exam: DISCHARGE PHYSICAL EXAM: Vitals: [MASKED] 0726 Temp: 97.8 PO BP: 106/51 R Lying HR: 86 RR: 18 O2 sat: 97% O2 delivery: Room Air GENERAL: Sitting in bed, appears comfortable, no acute distress HEENT: Pupils round, scleara anicteric. Oropharynx clear, moist mucous membranes. NECK: Supple, normal range of motion LUNGS: Clear to auscultation bilaterally no wheezes rales or rhonchi, normal respiratory rate CV: Regular rate and rhythm, normal distal perfusion no edema ABD: Soft, nontender, nondistended, normoactive bowel sounds GENITOURINARY: No Foley or suprapubic tenderness EXT: Warm, normal muscle bulk, no deformity SKIN: Warm dry, no rash NEURO: Alert and oriented x3, fluent speech ACCESS: Port dressing clean/dry/intact Pertinent Results: Discharge labs: [MASKED] 06:00AM BLOOD WBC-9.8 RBC-3.24* Hgb-9.9* Hct-29.7* MCV-92 MCH-30.6 MCHC-33.3 RDW-17.1* RDWSD-55.9* Plt [MASKED] [MASKED] 06:00AM BLOOD Neuts-82.0* Lymphs-14.8* Monos-2.5* Eos-0.1* Baso-0.2 Im [MASKED] AbsNeut-8.02* AbsLymp-1.45 AbsMono-0.24 AbsEos-0.01* AbsBaso-0.02 [MASKED] 06:00AM BLOOD [MASKED] PTT-39.9* [MASKED] [MASKED] 06:00AM BLOOD Glucose-237* UreaN-11 Creat-0.8 Na-142 K-4.7 Cl-107 HCO3-26 AnGap-9* [MASKED] 06:00AM BLOOD ALT-11 AST-12 AlkPhos-132* TotBili-0.3 [MASKED] 06:00AM BLOOD Calcium-9.5 Phos-3.0 Mg-1.8 [MASKED] 06:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-300* Ketone-10* Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG* [MASKED] 06:00AM URINE Color-Straw Appear-Clear Sp [MASKED] PMH of Metastatic Penile squamous cell carcinoma presented for cycle 2 of TIP #Metastatic Penile squamous cell carcinoma. Now s/p cycle 2 of TIP without acute complications. He tolerated cycle 1 without incident. -C2D1 [MASKED] -s/p Taxol, Ifosfamide, Cisplatin, Mesna with appropriate pre-meds as per Dr. [MASKED] for neulasta administration [MASKED] 9AM #T2DM -Hold metformin/glipizide, resume on discharge -[MASKED] while inpatient #HTN -Continue lisinopril #HLD -Held statin during stay, restart on discharge #RA: on prn oxy Transitional issues: - will follow up for neulasta injection on [MASKED] This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH TID:PRN dyspnea 2. Docusate Sodium 100 mg PO BID 3. Fluticasone Propionate NASAL 1 SPRY NU BID 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. OxyCODONE (Immediate Release) 2.5 mg PO DAILY:PRN Pain - Moderate 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. GlipiZIDE XL 5 mg PO DAILY 9. Lisinopril 10 mg PO DAILY 10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 11. Vitamin D 1000 UNIT PO DAILY 12. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 13. Dexamethasone 4 mg PO ASDIR Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH TID:PRN dyspnea 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Dexamethasone 4 mg PO ASDIR 5. Docusate Sodium 100 mg PO BID 6. Fluticasone Propionate NASAL 1 SPRY NU BID 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 8. GlipiZIDE XL 5 mg PO DAILY 9. Lisinopril 10 mg PO DAILY 10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 11. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 12. OxyCODONE (Immediate Release) 2.5 mg PO DAILY:PRN Pain - Moderate 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Encounter for chemotherapy Penile Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was our pleasure to care for you at [MASKED]. You came to the hospital for chemotherapy. WHAT HAPPENED IN THE HOSPITAL? -you received your chemotherapy and tolerated it well WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? - follow up closely with oncology tomorrow [MASKED] for an injection to support your blood counts We wish you all the best! Sincerely, Your care team at [MASKED] Followup Instructions: [MASKED]
|
[] |
[
"E119",
"J45909",
"I10",
"K5900",
"G8929",
"E785"
] |
[
"Z5111: Encounter for antineoplastic chemotherapy",
"C7989: Secondary malignant neoplasm of other specified sites",
"C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes",
"E119: Type 2 diabetes mellitus without complications",
"M069: Rheumatoid arthritis, unspecified",
"J45909: Unspecified asthma, uncomplicated",
"M1990: Unspecified osteoarthritis, unspecified site",
"I10: Essential (primary) hypertension",
"C609: Malignant neoplasm of penis, unspecified",
"K5900: Constipation, unspecified",
"G8929: Other chronic pain",
"M25562: Pain in left knee",
"E785: Hyperlipidemia, unspecified",
"Z8611: Personal history of tuberculosis",
"Z7982: Long term (current) use of aspirin",
"Z9079: Acquired absence of other genital organ(s)"
] |
10,030,549
| 25,268,104
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Scheduled Chemotherapy
Major Surgical or Invasive Procedure:
None this hospitalization.
History of Present Illness:
Mr. ___ is a ___ male with poorly
differentiated penile squamous cell carcinoma s/p partial
penectomy in ___ with rapid metastatic recurrence to soft
tissue and RP nodes who presents for cycle 3 of TIP.
He is feeling well. He notes occasional dizziness and mild
numbness in his fingers. He denies fevers/chills, headache,
vision changes, weakness, shortness of breath, cough,
hemoptysis, chest pain, palpitations, abdominal pain,
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, hematuria, and new rashes.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: reported penile pain and bleeding to his PCP present
for about 2 months.
- ___: CT torso showing no clear metastatic disease.
- ___: Distal partial penectomy, path showing poorly
differentiated squamous cell carcinoma with sarcomatoid and
acantholytic features, pT3. Dr. ___ inguinal
___ on ___ but patient had some difficult social circumstances
as he was primary caretaker for his wife.
- ___: At follow-up visit, he had a new 2x2 cm lesion in the
left groin.
- ___: CT pelvis showing extensive new retroperitoneal
lymphadenopathy and new rim enhancing metastasis in the
pre-pubic fat to the left of midline.
- ___: Initial med onc evaluation, planned to complete
restaging and begin palliative TIP, for which patient consented.
- ___: C1D1 TIP
- ___: C2D1 TIP
PAST MEDICAL HISTORY:
- Metastatic Penile SCC with sarcomatoid and acantholytic
features, as above
- Rheumatoid Arthritis previously treated with Plaquenil, MTX,
sulfasalaine, leflunomide
- Type 2 Diabetes Mellitus
- Asthma
- +PPD and +Quantiferon, s/p 3 months of INH but complicated by
LFT abnormalities, then s/p full course of rifampin
- Osteoarthritis
- Right Bundle Branch Block
- Ventral Hernia
- Hypertension
- Hyperlipidemia
Social History:
___
Family History:
Mother deceased at ___. Father deceased at ___ from blood cancer.
No family history of colon, lung, or prostate cancer.
Physical Exam:
========================
Discharge Physical Exam:
========================
VITAL SIGNS: ___ 0807 Temp: 98.2 PO BP: 121/68 HR: 66 RR:
18
O2 sat: 100% O2 delivery: ra
General: NAD
HEENT: MMM
CV: RR, NL S1S2 no S3S4, no MRG
PULM: CTAB, respirations unlabored
ABD: BS+ SNT/ND
LIMBS: No ___, WWP
SKIN: No rashes on extremities
NEURO: Speech fluent, strength grossly intact, ambulating in
hallway well
PSYCH: thought process logical, linear, future oriented
ACCESS: chest port site intact w/o erythema, accessed and
dressing C/D/I
Pertinent Results:
===============
Admission Labs:
===============
___ 02:03PM BLOOD WBC-9.2 RBC-3.14* Hgb-9.5* Hct-29.2*
MCV-93 MCH-30.3 MCHC-32.5 RDW-18.0* RDWSD-60.0* Plt ___
___ 02:03PM BLOOD Neuts-70.0 ___ Monos-6.8 Eos-1.5
Baso-0.8 Im ___ AbsNeut-6.45* AbsLymp-1.91 AbsMono-0.63
AbsEos-0.14 AbsBaso-0.07
___ 02:03PM BLOOD ___ PTT-31.5 ___
___ 02:03PM BLOOD Glucose-174* UreaN-12 Creat-0.9 Na-139
K-4.8 Cl-100 HCO3-28 AnGap-11
___ 02:03PM BLOOD ALT-12 AST-18 AlkPhos-157* TotBili-<0.2
___ 02:03PM BLOOD Calcium-9.6 Phos-3.5 Mg-1.7
___ 03:38AM BLOOD WBC-11.3* RBC-2.97* Hgb-9.0* Hct-27.6*
MCV-93 MCH-30.3 MCHC-32.6 RDW-19.1* RDWSD-64.3* Plt ___
___ 03:38AM BLOOD Glucose-188* UreaN-9 Creat-0.8 Na-142
K-4.6 Cl-110* HCO3-23 AnGap-9*
___ 03:38AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.9
___ 03:38AM BLOOD ALT-11 AST-___ w/ HTN, DL, Asthma, T2DM, RA, and poorly differentiated
penile SCC s/p partial penectomy ___ now w/ rapid metastatic
recurrence presenting for C3 TIP
# Metastatic Penile Squamous Cell Carcinoma
Unfortunately his high risk localized disease has rapidly
progressed to at least soft tissue and RP nodes. He is being
treated with TIP with palliative intent ___ JCO ___.
He tolerated it well other than fatigue and decreased appetite.
- required 2L NS boluses to maintain ___ ___
- clinic appointment scheduled for neulasta tomorrow
- restaging imaging tomorrow
# T2DM
We hold home antihyperglycemics and required about 10U insulin
despite dex. In concern for potential hypoglycemia at home, we
downtitrated his home regimen
- stopped glipizide as has poor po intake
- decreased home metformin from 1000 bid to qd and only w/ food
- he will keep a log of sugars and review w/ his outpatient
oncologist
# Asthma: quiescent, cont advair/flonase, albuterol prn
# HTN: cont ACEI and ASA
# DL: held statin while actively receiving chemo
# RA: on prn oxy, a refill for 14 day supply given
FEN: Regular diet
DVT PROPH: Enoxaparin inpatient
ACCESS: PORT
CODE STATUS: Full code, presumed
DISPO: Home today w/o services
BILLING: >30 min spent coordinating care for discharge
________________
___, D.O.
Heme/Onc Hospitalist
p: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH TID:PRN shortness of
breath/wheezing
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Lisinopril 10 mg PO DAILY
6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
7. Vitamin D 1000 UNIT PO DAILY
8. Atorvastatin 40 mg PO QPM
9. GlipiZIDE XL 5 mg PO DAILY
10. Dexamethasone 4 mg PO ASDIR
11. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
12. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
13. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal
congestion
Discharge Medications:
1. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
take ONLY once a day if you are eating meals. do not take if not
feeling well and not eating much
2. Albuterol Inhaler 2 PUFF IH TID:PRN shortness of
breath/wheezing
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Dexamethasone 4 mg PO ASDIR
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal
congestion
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Lisinopril 10 mg PO DAILY
10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
11. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 2.5-5 mg by mouth q4hrs prn Disp #*28 Tablet
Refills:*0
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Encounter for Chemotherapy
- Metastatic Squamous Cell Carcinoma of the Penis
- Secondary Neoplasm of Soft Tissue
- Secondary Neoplasm of Lymph Nodes
- DMII
- Hypertension
- Hyperlipidemia
- Asthma
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 follow up with your
oncology team as instructed.
You needed a small amount of insulin despite receiving steroids.
You may not need a lot of diabetes medications as you have in
the past. Keep a log of your sugars at home and review them with
your oncologist in clinic. We decreased your metformin to once a
day and stopped your glipizide. You should talk to your
oncologist about whether you need to take atorvastatin.
Followup Instructions:
___
|
[
"Z5111",
"C772",
"C7989",
"C609",
"J45909",
"I10",
"E785",
"M069"
] |
Allergies: [MASKED] Chief Complaint: Scheduled Chemotherapy Major Surgical or Invasive Procedure: None this hospitalization. History of Present Illness: Mr. [MASKED] is a [MASKED] male with poorly differentiated penile squamous cell carcinoma s/p partial penectomy in [MASKED] with rapid metastatic recurrence to soft tissue and RP nodes who presents for cycle 3 of TIP. He is feeling well. He notes occasional dizziness and mild numbness in his fingers. He denies fevers/chills, headache, vision changes, weakness, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. Past Medical History: PAST ONCOLOGIC HISTORY: - [MASKED]: reported penile pain and bleeding to his PCP present for about 2 months. - [MASKED]: CT torso showing no clear metastatic disease. - [MASKED]: Distal partial penectomy, path showing poorly differentiated squamous cell carcinoma with sarcomatoid and acantholytic features, pT3. Dr. [MASKED] inguinal [MASKED] on [MASKED] but patient had some difficult social circumstances as he was primary caretaker for his wife. - [MASKED]: At follow-up visit, he had a new 2x2 cm lesion in the left groin. - [MASKED]: CT pelvis showing extensive new retroperitoneal lymphadenopathy and new rim enhancing metastasis in the pre-pubic fat to the left of midline. - [MASKED]: Initial med onc evaluation, planned to complete restaging and begin palliative TIP, for which patient consented. - [MASKED]: C1D1 TIP - [MASKED]: C2D1 TIP PAST MEDICAL HISTORY: - Metastatic Penile SCC with sarcomatoid and acantholytic features, as above - Rheumatoid Arthritis previously treated with Plaquenil, MTX, sulfasalaine, leflunomide - Type 2 Diabetes Mellitus - Asthma - +PPD and +Quantiferon, s/p 3 months of INH but complicated by LFT abnormalities, then s/p full course of rifampin - Osteoarthritis - Right Bundle Branch Block - Ventral Hernia - Hypertension - Hyperlipidemia Social History: [MASKED] Family History: Mother deceased at [MASKED]. Father deceased at [MASKED] from blood cancer. No family history of colon, lung, or prostate cancer. Physical Exam: ======================== Discharge Physical Exam: ======================== VITAL SIGNS: [MASKED] 0807 Temp: 98.2 PO BP: 121/68 HR: 66 RR: 18 O2 sat: 100% O2 delivery: ra General: NAD HEENT: MMM CV: RR, NL S1S2 no S3S4, no MRG PULM: CTAB, respirations unlabored ABD: BS+ SNT/ND LIMBS: No [MASKED], WWP SKIN: No rashes on extremities NEURO: Speech fluent, strength grossly intact, ambulating in hallway well PSYCH: thought process logical, linear, future oriented ACCESS: chest port site intact w/o erythema, accessed and dressing C/D/I Pertinent Results: =============== Admission Labs: =============== [MASKED] 02:03PM BLOOD WBC-9.2 RBC-3.14* Hgb-9.5* Hct-29.2* MCV-93 MCH-30.3 MCHC-32.5 RDW-18.0* RDWSD-60.0* Plt [MASKED] [MASKED] 02:03PM BLOOD Neuts-70.0 [MASKED] Monos-6.8 Eos-1.5 Baso-0.8 Im [MASKED] AbsNeut-6.45* AbsLymp-1.91 AbsMono-0.63 AbsEos-0.14 AbsBaso-0.07 [MASKED] 02:03PM BLOOD [MASKED] PTT-31.5 [MASKED] [MASKED] 02:03PM BLOOD Glucose-174* UreaN-12 Creat-0.9 Na-139 K-4.8 Cl-100 HCO3-28 AnGap-11 [MASKED] 02:03PM BLOOD ALT-12 AST-18 AlkPhos-157* TotBili-<0.2 [MASKED] 02:03PM BLOOD Calcium-9.6 Phos-3.5 Mg-1.7 [MASKED] 03:38AM BLOOD WBC-11.3* RBC-2.97* Hgb-9.0* Hct-27.6* MCV-93 MCH-30.3 MCHC-32.6 RDW-19.1* RDWSD-64.3* Plt [MASKED] [MASKED] 03:38AM BLOOD Glucose-188* UreaN-9 Creat-0.8 Na-142 K-4.6 Cl-110* HCO3-23 AnGap-9* [MASKED] 03:38AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.9 [MASKED] 03:38AM BLOOD ALT-11 AST-[MASKED] w/ HTN, DL, Asthma, T2DM, RA, and poorly differentiated penile SCC s/p partial penectomy [MASKED] now w/ rapid metastatic recurrence presenting for C3 TIP # Metastatic Penile Squamous Cell Carcinoma Unfortunately his high risk localized disease has rapidly progressed to at least soft tissue and RP nodes. He is being treated with TIP with palliative intent [MASKED] JCO [MASKED]. He tolerated it well other than fatigue and decreased appetite. - required 2L NS boluses to maintain [MASKED] [MASKED] - clinic appointment scheduled for neulasta tomorrow - restaging imaging tomorrow # T2DM We hold home antihyperglycemics and required about 10U insulin despite dex. In concern for potential hypoglycemia at home, we downtitrated his home regimen - stopped glipizide as has poor po intake - decreased home metformin from 1000 bid to qd and only w/ food - he will keep a log of sugars and review w/ his outpatient oncologist # Asthma: quiescent, cont advair/flonase, albuterol prn # HTN: cont ACEI and ASA # DL: held statin while actively receiving chemo # RA: on prn oxy, a refill for 14 day supply given FEN: Regular diet DVT PROPH: Enoxaparin inpatient ACCESS: PORT CODE STATUS: Full code, presumed DISPO: Home today w/o services BILLING: >30 min spent coordinating care for discharge [MASKED] [MASKED], D.O. Heme/Onc Hospitalist p: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH TID:PRN shortness of breath/wheezing 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Lisinopril 10 mg PO DAILY 6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate 7. Vitamin D 1000 UNIT PO DAILY 8. Atorvastatin 40 mg PO QPM 9. GlipiZIDE XL 5 mg PO DAILY 10. Dexamethasone 4 mg PO ASDIR 11. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 12. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 13. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal congestion Discharge Medications: 1. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY take ONLY once a day if you are eating meals. do not take if not feeling well and not eating much 2. Albuterol Inhaler 2 PUFF IH TID:PRN shortness of breath/wheezing 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Dexamethasone 4 mg PO ASDIR 6. Docusate Sodium 100 mg PO BID:PRN constipation 7. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal congestion 8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 9. Lisinopril 10 mg PO DAILY 10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 11. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 2.5-5 mg by mouth q4hrs prn Disp #*28 Tablet Refills:*0 12. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Encounter for Chemotherapy - Metastatic Squamous Cell Carcinoma of the Penis - Secondary Neoplasm of Soft Tissue - Secondary Neoplasm of Lymph Nodes - DMII - Hypertension - Hyperlipidemia - Asthma 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 follow up with your oncology team as instructed. You needed a small amount of insulin despite receiving steroids. You may not need a lot of diabetes medications as you have in the past. Keep a log of your sugars at home and review them with your oncologist in clinic. We decreased your metformin to once a day and stopped your glipizide. You should talk to your oncologist about whether you need to take atorvastatin. Followup Instructions: [MASKED]
|
[] |
[
"J45909",
"I10",
"E785"
] |
[
"Z5111: Encounter for antineoplastic chemotherapy",
"C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes",
"C7989: Secondary malignant neoplasm of other specified sites",
"C609: Malignant neoplasm of penis, unspecified",
"J45909: Unspecified asthma, uncomplicated",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"M069: Rheumatoid arthritis, unspecified"
] |
10,030,549
| 28,978,916
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
isoniazid
Attending: ___.
Chief Complaint:
Right upper and lower limb weakness
Major Surgical or Invasive Procedure:
Cyber Knife to brain lesion
History of Present Illness:
Mr. ___ is a pleasant ___ HTN, DL, Asthma, T2DM, RA, and
poorly
differentiated penile SCC s/p partial penectomy ___ w/ rapid
met recurrence s/p C3 TIP ___ who p/w RLE weakness x ___ days.
He acutely developed RUE weakness while walking up the stairs at
6PM tonight and fell back and hit his head. He called EMS and
code-stroked by EMS. In the ED he was noted to have RUE and RLE
weakness although subjectively improved. He was seen by
neurology
and found to have preserved strenght in the RUE but RLE weakness
w/ R foot drop and sensory changes. NCHCT revaled a large
hypodensity in the L frontoparietal region w/ c/f mass. He was
seen by ___ who advised dex and no AEDs. He denied any
headache,
changes to vision, no N/V, no other acute complaints.
REVIEW OF SYSTEMS:
12 point ROS reviewed in detail and negative except for what is
mentioned above in HPI
Past Medical History:
Metastatic Penile SCC with sarcomatoid and acantholytic features
Rheumatoid arthritis previously treated with Plaquenil, MTX,
sulfasalaine, leflunomide
Type 2 diabetes mellitus
Asthma
+PPD and +Quantiferon, s/p 3 months of INH but complicated by
LFT
abnormalities, then s/p full course of rifampin
Osteoarthritis
Right bundle branch block
Ventral hernia
Hypertension
Hyperlipidemia
Social History:
___
Family History:
Mother ___ ___
Father ___ ___ blood cancer
NO history of colon, lung or prostate cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITAL SIGNS: 98.2 PO 120/70 7620 99 ra
General: NAD, Resting in bed comfortably
HEENT: MMM, no OP lesions NCAT
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no peritoneal signs
LIMBS: WWP, no ___, no tremors
SKIN: No notable rashes on trunk nor extremities
NEURO: CN III-XII intact, strength ___ LUE, ___ RUE/RLE with
paresthesias RLE, ___ R ___, + R dysmetria , speech intermittent
difficulty to understand due to aphasia, AOx3
PSYCH: Thought process logical, linear, future oriented but
seems
to have intermittent aphasia, off baseline from when i've met
him
before
ACCESS: Chest port site intact w/o overlying erythema, PIV
DISCHARGE PHYSICAL EXAM
=======================
Vitals: ___ 2347 Temp: 97.9 PO BP: 112/59 HR: 59 RR: 18 O2
sat: 100% O2 delivery: Ra
GENERAL: NAD, lying comfortably in bed, sits up independently,
fully cooperative with exam.
HEENT: AT/NC, EOMI, PERLLA, MMM
NECK: Supple, No LAD
CV: RRR, S1/S2, no murmurs
PULM: CTAB, breathing comfortably without use of accessory
muscles, no wheezes, rales or crackles.
ABD: Bowel sounds appreciated, abdomen soft, nondistended
EXT: WWP. Chronic RA changes to BUE, mostly right hand. 2+
pulses
appreciated in four limbs.
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
NEURO: AOx3, Fluent speech, CN II-XII grossly intact. RUE with
4+/5 strength, no difference in sensation to light touch, stable
from previous exam. RLE with ___ strength, mostly decreased in
right foot plantar flexion but improved from baseline (and
stable), reduced sensation to light touch throughout RLE.
ACCESS: Port, no erythema, no skin breakdown, no tenderness.
PIV.
Pertinent Results:
IMAGING
=======
EEG (___) impression:
This was normal continuous EEG recording. There were no
epileptiform discharges or electrographic seizures. Single
channel ecg showed an irregular heart rhythm.
CT Head and Neck (___) impression:
ECG (___) impression:
Sinus rhythm
Ventricular premature complex
Right bundle branch block
repolarization abnormality- nonspecific
MRI Head w&w/o contrast (___) impression:
1. 1 cm ovoid enhancing lesion in the posterior with aspect of
the left superior frontal gyrus with surrounding moderate
vasogenic edema, raises
concern for metastatic disease. Primary brain malignancy is
also differential consideration.
2. No additional intraparenchymal lesions are identified.
3. There is T1 hypointensity in the C4 and C5 vertebral bodies
which is incompletely assessed on this examination but can
reflect osseous metastatic disease. Consider dedicated imaging
of the cervical spine.
4. No acute infarct or hemorrhage.
5. Cerebellar tonsils are pointed and protrude below the foramen
magnum by approximately 1 cm, which can reflect Chiari type
configuration in the appropriate setting.
Chest CT w/contrast (___) impression:
No good evidence for intrathoracic malignancy. 3 mm solid
nodule left lung apex is indeterminate but more likely a scar
than a solitary metastasis. Recommendations for such incidental
findings provided below.
Benign air-filled cyst, right lower lobe.
CT Abdomen and Pelvis w/Contrast (___) impression:
1. Lucent lesion in the T11 vertebral body with associated soft
tissue, better characterized on the same day thoracic spine MRI,
likely a metastasis.
2. Same date chest CT is reported separately.
MRI Spine w&w/o contrast (___) impression:
1. Enhancing lesion involving the T11 vertebral body, raises
concern for
metastatic disease. No additional lesions are identified in the
spine.
2. Severe bilateral neural foraminal narrowing at L3-L4, L4-L5
and L5-S1.
3. Severe spinal canal narrowing at L4-5 due to degenerative
disease.
4. Additional multilevel multifactorial cervical and lumbar
spondylosis as
described above.
CYTOLOGY
========
SPECIMEN(S) SUBMITTED: CEREBROSPINAL FLUID
DIAGNOSIS:
CEREBROSPINAL FLUID:
NEGATIVE FOR MALIGNANT CELLS.
Lymphocytes and monocytes.
MICROBIOLOGY
============
___ 8:35 pm URINE STROKE.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
LABS
====
___ 04:52AM BLOOD WBC-5.8 RBC-3.71* Hgb-11.6* Hct-34.4*
MCV-93 MCH-31.3 MCHC-33.7 RDW-13.4 RDWSD-46.3 Plt ___
___ 04:29AM BLOOD WBC-5.8 RBC-3.68* Hgb-11.6* Hct-34.1*
MCV-93 MCH-31.5 MCHC-34.0 RDW-13.5 RDWSD-46.4* Plt ___
___ 05:20AM BLOOD WBC-5.9 RBC-3.75* Hgb-11.6* Hct-35.3*
MCV-94 MCH-30.9 MCHC-32.9 RDW-13.7 RDWSD-46.9* Plt ___
___ 05:24AM BLOOD WBC-5.3 RBC-3.85* Hgb-12.0* Hct-36.3*
MCV-94 MCH-31.2 MCHC-33.1 RDW-13.7 RDWSD-47.6* Plt ___
___ 05:55AM BLOOD WBC-3.8* RBC-3.88* Hgb-12.1* Hct-36.4*
MCV-94 MCH-31.2 MCHC-33.2 RDW-13.7 RDWSD-47.5* Plt ___
___ 06:06AM BLOOD WBC-4.3 RBC-3.81* Hgb-11.8* Hct-35.7*
MCV-94 MCH-31.0 MCHC-33.1 RDW-14.0 RDWSD-47.8* Plt ___
___ 04:11AM BLOOD WBC-4.2 RBC-3.67* Hgb-11.6* Hct-34.5*
MCV-94 MCH-31.6 MCHC-33.6 RDW-13.8 RDWSD-47.4* Plt ___
___ 04:15AM BLOOD WBC-4.8 RBC-3.73* Hgb-11.6* Hct-35.1*
MCV-94 MCH-31.1 MCHC-33.0 RDW-13.8 RDWSD-47.1* Plt ___
___ 05:20AM BLOOD WBC-4.7 RBC-3.68* Hgb-11.5* Hct-34.3*
MCV-93 MCH-31.3 MCHC-33.5 RDW-13.8 RDWSD-47.8* Plt ___
___ 05:30AM BLOOD WBC-5.3 RBC-3.78* Hgb-11.8* Hct-35.7*
MCV-94 MCH-31.2 MCHC-33.1 RDW-14.2 RDWSD-49.7* Plt ___
___ 05:00AM BLOOD WBC-4.9 RBC-3.77* Hgb-11.6* Hct-35.1*
MCV-93 MCH-30.8 MCHC-33.0 RDW-14.1 RDWSD-48.1* Plt ___
___ 05:10AM BLOOD WBC-5.1 RBC-3.59* Hgb-11.2* Hct-33.8*
MCV-94 MCH-31.2 MCHC-33.1 RDW-14.4 RDWSD-49.9* Plt ___
___ 06:04AM BLOOD WBC-6.5 RBC-3.42* Hgb-10.5* Hct-32.1*
MCV-94 MCH-30.7 MCHC-32.7 RDW-14.6 RDWSD-50.7* Plt ___
___ 04:52AM BLOOD WBC-6.3 RBC-3.39* Hgb-10.6* Hct-32.1*
MCV-95 MCH-31.3 MCHC-33.0 RDW-14.9 RDWSD-52.1* Plt ___
___ 05:04AM BLOOD WBC-4.2 RBC-3.62* Hgb-11.2* Hct-34.3*
MCV-95 MCH-30.9 MCHC-32.7 RDW-14.6 RDWSD-51.3* Plt ___
___ 07:25PM BLOOD WBC-6.4 RBC-3.45* Hgb-10.8* Hct-33.5*
MCV-97 MCH-31.3 MCHC-32.2 RDW-15.4 RDWSD-55.3* Plt ___
___ 04:29AM BLOOD Neuts-72.9* ___ Monos-4.1*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-4.25 AbsLymp-1.32
AbsMono-0.24 AbsEos-0.00* AbsBaso-0.01
___ 07:25PM BLOOD Neuts-51.4 ___ Monos-7.4 Eos-5.2
Baso-1.1* Im ___ AbsNeut-3.26 AbsLymp-2.20 AbsMono-0.47
AbsEos-0.33 AbsBaso-0.07
___ 04:52AM BLOOD ___ PTT-27.3 ___
___ 04:29AM BLOOD ___ PTT-52.9* ___
___ 05:20AM BLOOD ___ PTT-25.5 ___
___ 05:00AM BLOOD ___ PTT-25.6 ___
___ 07:25PM BLOOD ___ PTT-29.1 ___
___ 04:52AM BLOOD Glucose-180* UreaN-17 Creat-0.9 Na-133*
K-4.7 Cl-94* HCO3-27 AnGap-12
___ 04:29AM BLOOD Glucose-146* UreaN-14 Creat-0.9 Na-132*
K-4.7 Cl-94* HCO3-26 AnGap-12
___ 05:20AM BLOOD Glucose-215* UreaN-15 Creat-0.8 Na-134*
K-5.0 Cl-96 HCO3-25 AnGap-13
___ 05:24AM BLOOD Glucose-175* UreaN-18 Creat-0.8 Na-135
K-4.8 Cl-98 HCO3-25 AnGap-12
___ 05:55AM BLOOD Glucose-164* UreaN-22* Creat-1.0 Na-133*
K-4.6 Cl-96 HCO3-24 AnGap-13
___ 06:06AM BLOOD Glucose-112* UreaN-19 Creat-0.8 Na-133*
K-4.8 Cl-96 HCO3-24 AnGap-13
___ 04:11AM BLOOD Glucose-149* UreaN-22* Creat-1.1 Na-132*
K-5.0 Cl-93* HCO3-24 AnGap-15
___ 05:45PM BLOOD Glucose-258* UreaN-23* Creat-1.1 Na-133*
K-4.6 Cl-95* HCO3-25 AnGap-13
___ 04:15AM BLOOD Glucose-173* UreaN-22* Creat-1.1 Na-131*
K-5.0 Cl-95* HCO3-24 AnGap-12
___ 05:29PM BLOOD Glucose-225* UreaN-27* Creat-1.2 Na-129*
K-5.5* Cl-92* HCO3-25 AnGap-12
___ 05:20AM BLOOD Glucose-213* UreaN-20 Creat-1.0 Na-131*
K-5.1 Cl-94* HCO3-25 AnGap-12
___ 03:44PM BLOOD Glucose-158* UreaN-22* Creat-1.2 Na-131*
K-5.7* Cl-92* HCO3-22 AnGap-17
___ 05:30AM BLOOD Glucose-158* UreaN-22* Creat-1.1 Na-131*
K-5.4 Cl-94* HCO3-26 AnGap-11
___ 05:00AM BLOOD Glucose-227* UreaN-18 Creat-1.0 Na-133*
K-5.1 Cl-97 HCO3-25 AnGap-11
___ 05:10AM BLOOD Glucose-290* UreaN-18 Creat-1.0 Na-134*
K-5.1 Cl-97 HCO3-26 AnGap-11
___ 06:04AM BLOOD Glucose-239* UreaN-18 Creat-0.9 Na-138
K-4.8 Cl-101 HCO3-24 AnGap-13
___ 04:52AM BLOOD Glucose-201* UreaN-18 Creat-0.9 Na-137
K-4.5 Cl-98 HCO3-25 AnGap-14
___ 07:25PM BLOOD UreaN-10
___ 04:29AM BLOOD ALT-32 AST-19 AlkPhos-95 TotBili-0.4
___ 05:00AM BLOOD ALT-25 AST-24 LD(LDH)-167 AlkPhos-99
TotBili-0.3
___ 07:25PM BLOOD ALT-12 AST-25 AlkPhos-123 TotBili-0.3
___ 07:25PM BLOOD cTropnT-<0.01
___ 04:52AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.9
___ 04:29AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.8
___ 05:20AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.8
___ 05:24AM BLOOD Calcium-9.6 Phos-3.3 Mg-1.8
___ 05:55AM BLOOD Calcium-9.9 Phos-3.9 Mg-1.9
___ 06:06AM BLOOD Calcium-9.6 Phos-4.2 Mg-1.9
___ 04:11AM BLOOD Calcium-9.9 Phos-4.0 Mg-1.9
___ 05:45PM BLOOD Calcium-9.6 Phos-4.0 Mg-1.9
___ 04:15AM BLOOD Calcium-9.6 Phos-4.2 Mg-1.9
___ 05:29PM BLOOD Calcium-9.9 Phos-4.1 Mg-2.1
___ 05:20AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.0
___ 05:30AM BLOOD Calcium-9.6 Phos-3.9 Mg-2.1
___ 05:00AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.8 Mg-2.1
Iron-93
___ 05:10AM BLOOD Calcium-9.8 Phos-3.5 Mg-2.1
___ 06:04AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.0
___ 04:52AM BLOOD Calcium-9.9 Phos-4.9* Mg-2.0
___ 07:25PM BLOOD Albumin-4.5
___ 05:00AM BLOOD calTIBC-321 Ferritn-59 TRF-247
___ 05:00AM BLOOD %HbA1c-8.4* eAG-194*
___ 05:45PM BLOOD Osmolal-286
___ 03:44PM BLOOD Osmolal-285
___ 05:20AM BLOOD TSH-1.8
___ 05:00AM BLOOD 25VitD-37
___ 07:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 08:02PM BLOOD Glucose-150* Creat-0.9 Na-139 K-4.0 Cl-99
calHCO3-29
___ 08:35PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 08:35PM URINE Blood-NEG Nitrite-POS* Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 08:35PM URINE RBC-1 WBC-172* Bacteri-FEW* Yeast-NONE
Epi-0
___ 08:35PM URINE Mucous-RARE*
___ 06:07AM URINE Hours-RANDOM UreaN-736 Creat-78 Na-86
K-61 Cl-84 HCO3-2
___ 07:09PM URINE Hours-RANDOM Na-91
___ 03:44PM URINE Hours-RANDOM UreaN-563 Creat-47 Na-65
K-34 Cl-55 HCO3-2
___ 06:07AM URINE Osmolal-557
___ 07:09PM URINE Osmolal-654
___ 03:44PM URINE Osmolal-441
___ 08:35PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG
___ 12:50PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-29* Polys-7
___ ___ 12:50PM CEREBROSPINAL FLUID (CSF) TNC-2 RBC-12* Polys-0
___ ___ 12:50PM CEREBROSPINAL FLUID (CSF) TotProt-34
Glucose-156 LD(LDH)-40
___ 06:10AM BLOOD WBC-4.8 RBC-3.79* Hgb-12.1* Hct-35.2*
MCV-93 MCH-31.9 MCHC-34.4 RDW-13.6 RDWSD-46.2 Plt ___
___ 06:10AM BLOOD ___ PTT-25.1 ___
___ 06:10AM BLOOD Glucose-194* UreaN-18 Creat-0.9 Na-134*
K-4.7 Cl-94* HCO3-28 AnGap-12
___ 06:10AM BLOOD Calcium-10.0 Phos-3.6 Mg-1.8
Brief Hospital Course:
Mr. ___ is a ___ HTN, DL, Asthma, T2DM, RA, and poorly
differentiated penile SCC s/p partial penectomy ___ w/ rapid
met recurrence s/p C3 TIP ___ who p/w RLE/RUE weakness and a
fall, found to have new brain lesion, concerning for metastatic
disease or second primary tumor.
TRANSITIONAL ISSUES
===================
[ ] Continue dexamethasone 4 mg BID until follow up with
neuro-oncology. This was tapered from TID as of ___
evening. His insulin needs will fluctuate with this taper. His
insulin is being decreased by 30% to accommodate this change,
but will likely need further adjustment in insulin based on his
sliding scale needs.
[ ] Discharge diabetes regimen:
- Continue Lantus 25 units QHS
- Continue Humalog 12 units AC breakfast, Humalog 10 units AC
lunch and Humalog 8 units AC supper
- Continue sliding scale to start at 200 mg/dL 2 units+2
units/50mg/dl
- Metformin 1000 mg daily
[ ] Continue PPI and Bactrim for prophylaxis while on steroids.
[ ] Recommend slow dexamethasone taper when indicated given
prolonged course. Would recommend transition to hydrocortisone
to complete taper before stopping completely.
[ ] Continue Keppra for seizure prophylaxis.
[ ] Recommend rechecking electrolytes in 1 week to assess
hyponatremia.
[ ] Continue outpatient follow up with primary oncologist, neuro
oncologist and radiation oncology.
#New left frontoparietal brain lesion
His R hemiplegia is most likely from the new brain lesion. MRI
demonstrated a 1 cm lesion with vasogenic edema. There is a
question of whether this is a metastatic lesion vs new primary.
Total spine MRI without additional lesions. S/p LP with CSF
Cytology, CEA, immunofixation and Beta2 macroglobulin negative.
More likely metastasis from penile Ca > new primary (e.g. GBM).
Was seen by Neurosurgery, but patient denied surgery or biopsy.
With the caveat that a GBM would do poorly with radiation,
patient elected to start Cyber Knife treatments to lesion.
Started Stereotactic XRT for brain lesion, and completed three
fractions (___). Received dexamethasone before and
during radiation for reduction of vasogenic edema with good
response and significant return of strength to RUE and RLE. His
dexamethasone was tapered from 4 mg QID to TID, then to BID on
discharge.
#T2DM
#Increasing insulin requirements
T2DM background, on home metformin, held as inpatient. Required
large amounts of short acting insulin with metformin held and
Dexamethasone treatment. Had been started on Glargine nightly
and
humolog with meals. The ___ has been
consulted and followed along, insulin scales adjusted as needed,
insulin teaching was provided prior to discharge. While on
dexamethasone 4 mg TID he was stabilized on insulin regimen of
glargine 35 U QHS, Humalog 17 U breakfast/14 U lunch/12 U dinner
with sliding scale.
His insulin was decreased by 30% on day of discharge given the
plan to taper his dexamethasone. His metformin was held during
the admission and restarted on discharge.
#Hypointensity in the C4 and C5 vertebral bodies
Dedicated C-spine MRI negative for spinal mets per Neuro Onc.
T11 lesion identified by CT Torso and T-Spine MRI has been
stable since ___ and unlikely represented new progression of
disease.
#RUE, RLE weakness
Secondary to new brain lesion as above. As per neuro oncology,
less likely that RLE will recover. Radiation planned. ___
consulted and are following, able to walk for short distances
daily. Will be discharged to ___ rehab.
#UTI / Asymptomatic Bacteuria
ED UA reflexed to ___ and found to have bacteria in urine. Was
started on Ceftriaxone for empiric care, final culture grew
ENTEROBACTER CLOACAE COMPLEX, and so therapy was escalated to IV
Cefepime and then changed to PO Bactrim. Assymptomatic and may
be colonized, however chose to complete a course of seven days.
#Hyponatremia
Sodium trending low with nadir of 131 (baseline 141 on
admission). Clinically euvolemic. Normal blood osmolality, urine
Na=65 and urine osmolality=441 raise concern for SIADH in the
presence of known brain lesion, which was communicated to care
team. Hyponatremia asymptomatic. Stable at 131 with water
restriction, but seems dry by kidney function. Sodium up to 133
after 500ml NS, but urine more concentrated (sodium 90, Osm
~600). Sodium stable at 133 with further hydration and
resolution of renal function to baseline, supporting
hypovolemia. TSH wnl. Sodium stable after gentle hydration.
Electrolytes were trended as needed.
#Met Penile Squamous Cell Ca
Unfortunately his high risk localized disease has rapidly
progressed to at least soft tissue and RP nodes. He is being
treated with TIP with palliative intent ___ ___ ___
w/near CR. He completed TIP therapy ___ and has close f/u
with oncology. Given negative LP and scans, planned for
surveillance as outpatient with follow up imaging at 8 weeks
with therapy reserved in case of progression of disease.
#Asthma: quiescent
- Continued advair/flonase, albuterol prn
#HTN:
- Held ACEI and remained normotensive so was not continued on
discharge. Held aspirin indefinitely given brain lesion.
#Dyslipidemia:
- Continued statin
#RA:
- Continued prn oxy
#CODE STATUS: FULL CODE (Confirmed ___ with patient)
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. Albuterol Inhaler 2 PUFF IH TID:PRN shortness of
breath/wheezing
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Lisinopril 10 mg PO DAILY
6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
7. Vitamin D 1000 UNIT PO DAILY
8. Dexamethasone 4 mg PO ASDIR
9. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal
congestion
10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
11. Atorvastatin 40 mg PO QPM
12. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
13. diclofenac sodium ___ grams topical BID
Discharge Medications:
1. Glargine 25 Units Bedtime
Humalog 12 Units Breakfast
Humalog 10 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. LevETIRAcetam 1000 mg PO Q12H
3. Omeprazole 20 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 8.6 mg PO DAILY:PRN Constipation - Second Line
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. Dexamethasone 4 mg PO BID
Continue BID dosing until follow up with his neuro-oncologist
8. Albuterol Inhaler 2 PUFF IH TID:PRN shortness of
breath/wheezing
9. Atorvastatin 40 mg PO QPM
10. Docusate Sodium 100 mg PO BID:PRN constipation
11. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal
congestion
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
13. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
Do Not Crush
14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
15. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
16. Vitamin D 1000 UNIT PO DAILY
17. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you follow you with the ___
___ clinic
18. HELD- diclofenac sodium ___ grams topical BID This
medication was held. Do not restart diclofenac sodium until you
follow up with the ___ clinic
19. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until You follow up with your PCP and
your blood pressure is evaluated.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic Penile Squamous Cell Carcinoma
New Brain Lesion, most likely ___ metastasis
Hyperglycemia
Type II 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. ___,
It was a pleasure to care for you at ___
___!
Why was I here?
- You came to the hospital because you noticed weakness in your
right leg and right arm.
What was done while I was here?
- You had a scan of your head which showed a mass.
- This mass was thought to be causing your symptoms and looked
consistent with a cancer.
- You had a spinal tap which did not show any cancer cells.
- You were started on steroids which helped with your weakness.
- You had radiation therapy to your brain.
- You were seen by physical therapy who recommended discharge to
an acute rehab facility to help you gain your strength back.
What should I do when I get home?
- Please take all of your medications as prescribed and go to
all of your follow up appointments as listed below.
We wish you the best!
- Your ___ Team
Followup Instructions:
___
|
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] |
Allergies: isoniazid Chief Complaint: Right upper and lower limb weakness Major Surgical or Invasive Procedure: Cyber Knife to brain lesion History of Present Illness: Mr. [MASKED] is a pleasant [MASKED] HTN, DL, Asthma, T2DM, RA, and poorly differentiated penile SCC s/p partial penectomy [MASKED] w/ rapid met recurrence s/p C3 TIP [MASKED] who p/w RLE weakness x [MASKED] days. He acutely developed RUE weakness while walking up the stairs at 6PM tonight and fell back and hit his head. He called EMS and code-stroked by EMS. In the ED he was noted to have RUE and RLE weakness although subjectively improved. He was seen by neurology and found to have preserved strenght in the RUE but RLE weakness w/ R foot drop and sensory changes. NCHCT revaled a large hypodensity in the L frontoparietal region w/ c/f mass. He was seen by [MASKED] who advised dex and no AEDs. He denied any headache, changes to vision, no N/V, no other acute complaints. REVIEW OF SYSTEMS: 12 point ROS reviewed in detail and negative except for what is mentioned above in HPI Past Medical History: Metastatic Penile SCC with sarcomatoid and acantholytic features Rheumatoid arthritis previously treated with Plaquenil, MTX, sulfasalaine, leflunomide Type 2 diabetes mellitus Asthma +PPD and +Quantiferon, s/p 3 months of INH but complicated by LFT abnormalities, then s/p full course of rifampin Osteoarthritis Right bundle branch block Ventral hernia Hypertension Hyperlipidemia Social History: [MASKED] Family History: Mother [MASKED] [MASKED] Father [MASKED] [MASKED] blood cancer NO history of colon, lung or prostate cancer Physical Exam: ADMISSION PHYSICAL EXAM ======================= VITAL SIGNS: 98.2 PO 120/70 7620 99 ra General: NAD, Resting in bed comfortably HEENT: MMM, no OP lesions NCAT CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no peritoneal signs LIMBS: WWP, no [MASKED], no tremors SKIN: No notable rashes on trunk nor extremities NEURO: CN III-XII intact, strength [MASKED] LUE, [MASKED] RUE/RLE with paresthesias RLE, [MASKED] R [MASKED], + R dysmetria , speech intermittent difficulty to understand due to aphasia, AOx3 PSYCH: Thought process logical, linear, future oriented but seems to have intermittent aphasia, off baseline from when i've met him before ACCESS: Chest port site intact w/o overlying erythema, PIV DISCHARGE PHYSICAL EXAM ======================= Vitals: [MASKED] 2347 Temp: 97.9 PO BP: 112/59 HR: 59 RR: 18 O2 sat: 100% O2 delivery: Ra GENERAL: NAD, lying comfortably in bed, sits up independently, fully cooperative with exam. HEENT: AT/NC, EOMI, PERLLA, MMM NECK: Supple, No LAD CV: RRR, S1/S2, no murmurs PULM: CTAB, breathing comfortably without use of accessory muscles, no wheezes, rales or crackles. ABD: Bowel sounds appreciated, abdomen soft, nondistended EXT: WWP. Chronic RA changes to BUE, mostly right hand. 2+ pulses appreciated in four limbs. SKIN: Warm and well perfused, no excoriations or lesions, no rashes NEURO: AOx3, Fluent speech, CN II-XII grossly intact. RUE with 4+/5 strength, no difference in sensation to light touch, stable from previous exam. RLE with [MASKED] strength, mostly decreased in right foot plantar flexion but improved from baseline (and stable), reduced sensation to light touch throughout RLE. ACCESS: Port, no erythema, no skin breakdown, no tenderness. PIV. Pertinent Results: IMAGING ======= EEG ([MASKED]) impression: This was normal continuous EEG recording. There were no epileptiform discharges or electrographic seizures. Single channel ecg showed an irregular heart rhythm. CT Head and Neck ([MASKED]) impression: ECG ([MASKED]) impression: Sinus rhythm Ventricular premature complex Right bundle branch block repolarization abnormality- nonspecific MRI Head w&w/o contrast ([MASKED]) impression: 1. 1 cm ovoid enhancing lesion in the posterior with aspect of the left superior frontal gyrus with surrounding moderate vasogenic edema, raises concern for metastatic disease. Primary brain malignancy is also differential consideration. 2. No additional intraparenchymal lesions are identified. 3. There is T1 hypointensity in the C4 and C5 vertebral bodies which is incompletely assessed on this examination but can reflect osseous metastatic disease. Consider dedicated imaging of the cervical spine. 4. No acute infarct or hemorrhage. 5. Cerebellar tonsils are pointed and protrude below the foramen magnum by approximately 1 cm, which can reflect Chiari type configuration in the appropriate setting. Chest CT w/contrast ([MASKED]) impression: No good evidence for intrathoracic malignancy. 3 mm solid nodule left lung apex is indeterminate but more likely a scar than a solitary metastasis. Recommendations for such incidental findings provided below. Benign air-filled cyst, right lower lobe. CT Abdomen and Pelvis w/Contrast ([MASKED]) impression: 1. Lucent lesion in the T11 vertebral body with associated soft tissue, better characterized on the same day thoracic spine MRI, likely a metastasis. 2. Same date chest CT is reported separately. MRI Spine w&w/o contrast ([MASKED]) impression: 1. Enhancing lesion involving the T11 vertebral body, raises concern for metastatic disease. No additional lesions are identified in the spine. 2. Severe bilateral neural foraminal narrowing at L3-L4, L4-L5 and L5-S1. 3. Severe spinal canal narrowing at L4-5 due to degenerative disease. 4. Additional multilevel multifactorial cervical and lumbar spondylosis as described above. CYTOLOGY ======== SPECIMEN(S) SUBMITTED: CEREBROSPINAL FLUID DIAGNOSIS: CEREBROSPINAL FLUID: NEGATIVE FOR MALIGNANT CELLS. Lymphocytes and monocytes. MICROBIOLOGY ============ [MASKED] 8:35 pm URINE STROKE. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROBACTER CLOACAE COMPLEX | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S LABS ==== [MASKED] 04:52AM BLOOD WBC-5.8 RBC-3.71* Hgb-11.6* Hct-34.4* MCV-93 MCH-31.3 MCHC-33.7 RDW-13.4 RDWSD-46.3 Plt [MASKED] [MASKED] 04:29AM BLOOD WBC-5.8 RBC-3.68* Hgb-11.6* Hct-34.1* MCV-93 MCH-31.5 MCHC-34.0 RDW-13.5 RDWSD-46.4* Plt [MASKED] [MASKED] 05:20AM BLOOD WBC-5.9 RBC-3.75* Hgb-11.6* Hct-35.3* MCV-94 MCH-30.9 MCHC-32.9 RDW-13.7 RDWSD-46.9* Plt [MASKED] [MASKED] 05:24AM BLOOD WBC-5.3 RBC-3.85* Hgb-12.0* Hct-36.3* MCV-94 MCH-31.2 MCHC-33.1 RDW-13.7 RDWSD-47.6* Plt [MASKED] [MASKED] 05:55AM BLOOD WBC-3.8* RBC-3.88* Hgb-12.1* Hct-36.4* MCV-94 MCH-31.2 MCHC-33.2 RDW-13.7 RDWSD-47.5* Plt [MASKED] [MASKED] 06:06AM BLOOD WBC-4.3 RBC-3.81* Hgb-11.8* Hct-35.7* MCV-94 MCH-31.0 MCHC-33.1 RDW-14.0 RDWSD-47.8* Plt [MASKED] [MASKED] 04:11AM BLOOD WBC-4.2 RBC-3.67* Hgb-11.6* Hct-34.5* MCV-94 MCH-31.6 MCHC-33.6 RDW-13.8 RDWSD-47.4* Plt [MASKED] [MASKED] 04:15AM BLOOD WBC-4.8 RBC-3.73* Hgb-11.6* Hct-35.1* MCV-94 MCH-31.1 MCHC-33.0 RDW-13.8 RDWSD-47.1* Plt [MASKED] [MASKED] 05:20AM BLOOD WBC-4.7 RBC-3.68* Hgb-11.5* Hct-34.3* MCV-93 MCH-31.3 MCHC-33.5 RDW-13.8 RDWSD-47.8* Plt [MASKED] [MASKED] 05:30AM BLOOD WBC-5.3 RBC-3.78* Hgb-11.8* Hct-35.7* MCV-94 MCH-31.2 MCHC-33.1 RDW-14.2 RDWSD-49.7* Plt [MASKED] [MASKED] 05:00AM BLOOD WBC-4.9 RBC-3.77* Hgb-11.6* Hct-35.1* MCV-93 MCH-30.8 MCHC-33.0 RDW-14.1 RDWSD-48.1* Plt [MASKED] [MASKED] 05:10AM BLOOD WBC-5.1 RBC-3.59* Hgb-11.2* Hct-33.8* MCV-94 MCH-31.2 MCHC-33.1 RDW-14.4 RDWSD-49.9* Plt [MASKED] [MASKED] 06:04AM BLOOD WBC-6.5 RBC-3.42* Hgb-10.5* Hct-32.1* MCV-94 MCH-30.7 MCHC-32.7 RDW-14.6 RDWSD-50.7* Plt [MASKED] [MASKED] 04:52AM BLOOD WBC-6.3 RBC-3.39* Hgb-10.6* Hct-32.1* MCV-95 MCH-31.3 MCHC-33.0 RDW-14.9 RDWSD-52.1* Plt [MASKED] [MASKED] 05:04AM BLOOD WBC-4.2 RBC-3.62* Hgb-11.2* Hct-34.3* MCV-95 MCH-30.9 MCHC-32.7 RDW-14.6 RDWSD-51.3* Plt [MASKED] [MASKED] 07:25PM BLOOD WBC-6.4 RBC-3.45* Hgb-10.8* Hct-33.5* MCV-97 MCH-31.3 MCHC-32.2 RDW-15.4 RDWSD-55.3* Plt [MASKED] [MASKED] 04:29AM BLOOD Neuts-72.9* [MASKED] Monos-4.1* Eos-0.0* Baso-0.2 Im [MASKED] AbsNeut-4.25 AbsLymp-1.32 AbsMono-0.24 AbsEos-0.00* AbsBaso-0.01 [MASKED] 07:25PM BLOOD Neuts-51.4 [MASKED] Monos-7.4 Eos-5.2 Baso-1.1* Im [MASKED] AbsNeut-3.26 AbsLymp-2.20 AbsMono-0.47 AbsEos-0.33 AbsBaso-0.07 [MASKED] 04:52AM BLOOD [MASKED] PTT-27.3 [MASKED] [MASKED] 04:29AM BLOOD [MASKED] PTT-52.9* [MASKED] [MASKED] 05:20AM BLOOD [MASKED] PTT-25.5 [MASKED] [MASKED] 05:00AM BLOOD [MASKED] PTT-25.6 [MASKED] [MASKED] 07:25PM BLOOD [MASKED] PTT-29.1 [MASKED] [MASKED] 04:52AM BLOOD Glucose-180* UreaN-17 Creat-0.9 Na-133* K-4.7 Cl-94* HCO3-27 AnGap-12 [MASKED] 04:29AM BLOOD Glucose-146* UreaN-14 Creat-0.9 Na-132* K-4.7 Cl-94* HCO3-26 AnGap-12 [MASKED] 05:20AM BLOOD Glucose-215* UreaN-15 Creat-0.8 Na-134* K-5.0 Cl-96 HCO3-25 AnGap-13 [MASKED] 05:24AM BLOOD Glucose-175* UreaN-18 Creat-0.8 Na-135 K-4.8 Cl-98 HCO3-25 AnGap-12 [MASKED] 05:55AM BLOOD Glucose-164* UreaN-22* Creat-1.0 Na-133* K-4.6 Cl-96 HCO3-24 AnGap-13 [MASKED] 06:06AM BLOOD Glucose-112* UreaN-19 Creat-0.8 Na-133* K-4.8 Cl-96 HCO3-24 AnGap-13 [MASKED] 04:11AM BLOOD Glucose-149* UreaN-22* Creat-1.1 Na-132* K-5.0 Cl-93* HCO3-24 AnGap-15 [MASKED] 05:45PM BLOOD Glucose-258* UreaN-23* Creat-1.1 Na-133* K-4.6 Cl-95* HCO3-25 AnGap-13 [MASKED] 04:15AM BLOOD Glucose-173* UreaN-22* Creat-1.1 Na-131* K-5.0 Cl-95* HCO3-24 AnGap-12 [MASKED] 05:29PM BLOOD Glucose-225* UreaN-27* Creat-1.2 Na-129* K-5.5* Cl-92* HCO3-25 AnGap-12 [MASKED] 05:20AM BLOOD Glucose-213* UreaN-20 Creat-1.0 Na-131* K-5.1 Cl-94* HCO3-25 AnGap-12 [MASKED] 03:44PM BLOOD Glucose-158* UreaN-22* Creat-1.2 Na-131* K-5.7* Cl-92* HCO3-22 AnGap-17 [MASKED] 05:30AM BLOOD Glucose-158* UreaN-22* Creat-1.1 Na-131* K-5.4 Cl-94* HCO3-26 AnGap-11 [MASKED] 05:00AM BLOOD Glucose-227* UreaN-18 Creat-1.0 Na-133* K-5.1 Cl-97 HCO3-25 AnGap-11 [MASKED] 05:10AM BLOOD Glucose-290* UreaN-18 Creat-1.0 Na-134* K-5.1 Cl-97 HCO3-26 AnGap-11 [MASKED] 06:04AM BLOOD Glucose-239* UreaN-18 Creat-0.9 Na-138 K-4.8 Cl-101 HCO3-24 AnGap-13 [MASKED] 04:52AM BLOOD Glucose-201* UreaN-18 Creat-0.9 Na-137 K-4.5 Cl-98 HCO3-25 AnGap-14 [MASKED] 07:25PM BLOOD UreaN-10 [MASKED] 04:29AM BLOOD ALT-32 AST-19 AlkPhos-95 TotBili-0.4 [MASKED] 05:00AM BLOOD ALT-25 AST-24 LD(LDH)-167 AlkPhos-99 TotBili-0.3 [MASKED] 07:25PM BLOOD ALT-12 AST-25 AlkPhos-123 TotBili-0.3 [MASKED] 07:25PM BLOOD cTropnT-<0.01 [MASKED] 04:52AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.9 [MASKED] 04:29AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.8 [MASKED] 05:20AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.8 [MASKED] 05:24AM BLOOD Calcium-9.6 Phos-3.3 Mg-1.8 [MASKED] 05:55AM BLOOD Calcium-9.9 Phos-3.9 Mg-1.9 [MASKED] 06:06AM BLOOD Calcium-9.6 Phos-4.2 Mg-1.9 [MASKED] 04:11AM BLOOD Calcium-9.9 Phos-4.0 Mg-1.9 [MASKED] 05:45PM BLOOD Calcium-9.6 Phos-4.0 Mg-1.9 [MASKED] 04:15AM BLOOD Calcium-9.6 Phos-4.2 Mg-1.9 [MASKED] 05:29PM BLOOD Calcium-9.9 Phos-4.1 Mg-2.1 [MASKED] 05:20AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.0 [MASKED] 05:30AM BLOOD Calcium-9.6 Phos-3.9 Mg-2.1 [MASKED] 05:00AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.8 Mg-2.1 Iron-93 [MASKED] 05:10AM BLOOD Calcium-9.8 Phos-3.5 Mg-2.1 [MASKED] 06:04AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.0 [MASKED] 04:52AM BLOOD Calcium-9.9 Phos-4.9* Mg-2.0 [MASKED] 07:25PM BLOOD Albumin-4.5 [MASKED] 05:00AM BLOOD calTIBC-321 Ferritn-59 TRF-247 [MASKED] 05:00AM BLOOD %HbA1c-8.4* eAG-194* [MASKED] 05:45PM BLOOD Osmolal-286 [MASKED] 03:44PM BLOOD Osmolal-285 [MASKED] 05:20AM BLOOD TSH-1.8 [MASKED] 05:00AM BLOOD 25VitD-37 [MASKED] 07:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 08:02PM BLOOD Glucose-150* Creat-0.9 Na-139 K-4.0 Cl-99 calHCO3-29 [MASKED] 08:35PM URINE Color-Yellow Appear-Hazy* Sp [MASKED] [MASKED] 08:35PM URINE Blood-NEG Nitrite-POS* Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG* [MASKED] 08:35PM URINE RBC-1 WBC-172* Bacteri-FEW* Yeast-NONE Epi-0 [MASKED] 08:35PM URINE Mucous-RARE* [MASKED] 06:07AM URINE Hours-RANDOM UreaN-736 Creat-78 Na-86 K-61 Cl-84 HCO3-2 [MASKED] 07:09PM URINE Hours-RANDOM Na-91 [MASKED] 03:44PM URINE Hours-RANDOM UreaN-563 Creat-47 Na-65 K-34 Cl-55 HCO3-2 [MASKED] 06:07AM URINE Osmolal-557 [MASKED] 07:09PM URINE Osmolal-654 [MASKED] 03:44PM URINE Osmolal-441 [MASKED] 08:35PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG [MASKED] 12:50PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-29* Polys-7 [MASKED] [MASKED] 12:50PM CEREBROSPINAL FLUID (CSF) TNC-2 RBC-12* Polys-0 [MASKED] [MASKED] 12:50PM CEREBROSPINAL FLUID (CSF) TotProt-34 Glucose-156 LD(LDH)-40 [MASKED] 06:10AM BLOOD WBC-4.8 RBC-3.79* Hgb-12.1* Hct-35.2* MCV-93 MCH-31.9 MCHC-34.4 RDW-13.6 RDWSD-46.2 Plt [MASKED] [MASKED] 06:10AM BLOOD [MASKED] PTT-25.1 [MASKED] [MASKED] 06:10AM BLOOD Glucose-194* UreaN-18 Creat-0.9 Na-134* K-4.7 Cl-94* HCO3-28 AnGap-12 [MASKED] 06:10AM BLOOD Calcium-10.0 Phos-3.6 Mg-1.8 Brief Hospital Course: Mr. [MASKED] is a [MASKED] HTN, DL, Asthma, T2DM, RA, and poorly differentiated penile SCC s/p partial penectomy [MASKED] w/ rapid met recurrence s/p C3 TIP [MASKED] who p/w RLE/RUE weakness and a fall, found to have new brain lesion, concerning for metastatic disease or second primary tumor. TRANSITIONAL ISSUES =================== [ ] Continue dexamethasone 4 mg BID until follow up with neuro-oncology. This was tapered from TID as of [MASKED] evening. His insulin needs will fluctuate with this taper. His insulin is being decreased by 30% to accommodate this change, but will likely need further adjustment in insulin based on his sliding scale needs. [ ] Discharge diabetes regimen: - Continue Lantus 25 units QHS - Continue Humalog 12 units AC breakfast, Humalog 10 units AC lunch and Humalog 8 units AC supper - Continue sliding scale to start at 200 mg/dL 2 units+2 units/50mg/dl - Metformin 1000 mg daily [ ] Continue PPI and Bactrim for prophylaxis while on steroids. [ ] Recommend slow dexamethasone taper when indicated given prolonged course. Would recommend transition to hydrocortisone to complete taper before stopping completely. [ ] Continue Keppra for seizure prophylaxis. [ ] Recommend rechecking electrolytes in 1 week to assess hyponatremia. [ ] Continue outpatient follow up with primary oncologist, neuro oncologist and radiation oncology. #New left frontoparietal brain lesion His R hemiplegia is most likely from the new brain lesion. MRI demonstrated a 1 cm lesion with vasogenic edema. There is a question of whether this is a metastatic lesion vs new primary. Total spine MRI without additional lesions. S/p LP with CSF Cytology, CEA, immunofixation and Beta2 macroglobulin negative. More likely metastasis from penile Ca > new primary (e.g. GBM). Was seen by Neurosurgery, but patient denied surgery or biopsy. With the caveat that a GBM would do poorly with radiation, patient elected to start Cyber Knife treatments to lesion. Started Stereotactic XRT for brain lesion, and completed three fractions ([MASKED]). Received dexamethasone before and during radiation for reduction of vasogenic edema with good response and significant return of strength to RUE and RLE. His dexamethasone was tapered from 4 mg QID to TID, then to BID on discharge. #T2DM #Increasing insulin requirements T2DM background, on home metformin, held as inpatient. Required large amounts of short acting insulin with metformin held and Dexamethasone treatment. Had been started on Glargine nightly and humolog with meals. The [MASKED] has been consulted and followed along, insulin scales adjusted as needed, insulin teaching was provided prior to discharge. While on dexamethasone 4 mg TID he was stabilized on insulin regimen of glargine 35 U QHS, Humalog 17 U breakfast/14 U lunch/12 U dinner with sliding scale. His insulin was decreased by 30% on day of discharge given the plan to taper his dexamethasone. His metformin was held during the admission and restarted on discharge. #Hypointensity in the C4 and C5 vertebral bodies Dedicated C-spine MRI negative for spinal mets per Neuro Onc. T11 lesion identified by CT Torso and T-Spine MRI has been stable since [MASKED] and unlikely represented new progression of disease. #RUE, RLE weakness Secondary to new brain lesion as above. As per neuro oncology, less likely that RLE will recover. Radiation planned. [MASKED] consulted and are following, able to walk for short distances daily. Will be discharged to [MASKED] rehab. #UTI / Asymptomatic Bacteuria ED UA reflexed to [MASKED] and found to have bacteria in urine. Was started on Ceftriaxone for empiric care, final culture grew ENTEROBACTER CLOACAE COMPLEX, and so therapy was escalated to IV Cefepime and then changed to PO Bactrim. Assymptomatic and may be colonized, however chose to complete a course of seven days. #Hyponatremia Sodium trending low with nadir of 131 (baseline 141 on admission). Clinically euvolemic. Normal blood osmolality, urine Na=65 and urine osmolality=441 raise concern for SIADH in the presence of known brain lesion, which was communicated to care team. Hyponatremia asymptomatic. Stable at 131 with water restriction, but seems dry by kidney function. Sodium up to 133 after 500ml NS, but urine more concentrated (sodium 90, Osm ~600). Sodium stable at 133 with further hydration and resolution of renal function to baseline, supporting hypovolemia. TSH wnl. Sodium stable after gentle hydration. Electrolytes were trended as needed. #Met Penile Squamous Cell Ca Unfortunately his high risk localized disease has rapidly progressed to at least soft tissue and RP nodes. He is being treated with TIP with palliative intent [MASKED] [MASKED] [MASKED] w/near CR. He completed TIP therapy [MASKED] and has close f/u with oncology. Given negative LP and scans, planned for surveillance as outpatient with follow up imaging at 8 weeks with therapy reserved in case of progression of disease. #Asthma: quiescent - Continued advair/flonase, albuterol prn #HTN: - Held ACEI and remained normotensive so was not continued on discharge. Held aspirin indefinitely given brain lesion. #Dyslipidemia: - Continued statin #RA: - Continued prn oxy #CODE STATUS: FULL CODE (Confirmed [MASKED] with patient) 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. Albuterol Inhaler 2 PUFF IH TID:PRN shortness of breath/wheezing 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Lisinopril 10 mg PO DAILY 6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate 7. Vitamin D 1000 UNIT PO DAILY 8. Dexamethasone 4 mg PO ASDIR 9. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal congestion 10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 11. Atorvastatin 40 mg PO QPM 12. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 13. diclofenac sodium [MASKED] grams topical BID Discharge Medications: 1. Glargine 25 Units Bedtime Humalog 12 Units Breakfast Humalog 10 Units Lunch Humalog 8 Units Dinner Insulin SC Sliding Scale using HUM Insulin 2. LevETIRAcetam 1000 mg PO Q12H 3. Omeprazole 20 mg PO DAILY 4. Polyethylene Glycol 17 g PO DAILY 5. Senna 8.6 mg PO DAILY:PRN Constipation - Second Line 6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 7. Dexamethasone 4 mg PO BID Continue BID dosing until follow up with his neuro-oncologist 8. Albuterol Inhaler 2 PUFF IH TID:PRN shortness of breath/wheezing 9. Atorvastatin 40 mg PO QPM 10. Docusate Sodium 100 mg PO BID:PRN constipation 11. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN nasal congestion 12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 13. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY Do Not Crush 14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 15. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 16. Vitamin D 1000 UNIT PO DAILY 17. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until you follow you with the [MASKED] [MASKED] clinic 18. HELD- diclofenac sodium [MASKED] grams topical BID This medication was held. Do not restart diclofenac sodium until you follow up with the [MASKED] clinic 19. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until You follow up with your PCP and your blood pressure is evaluated. Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Metastatic Penile Squamous Cell Carcinoma New Brain Lesion, most likely [MASKED] metastasis Hyperglycemia Type II 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], It was a pleasure to care for you at [MASKED] [MASKED]! Why was I here? - You came to the hospital because you noticed weakness in your right leg and right arm. What was done while I was here? - You had a scan of your head which showed a mass. - This mass was thought to be causing your symptoms and looked consistent with a cancer. - You had a spinal tap which did not show any cancer cells. - You were started on steroids which helped with your weakness. - You had radiation therapy to your brain. - You were seen by physical therapy who recommended discharge to an acute rehab facility to help you gain your strength back. What should I do when I get home? - Please take all of your medications as prescribed and go to all of your follow up appointments as listed below. We wish you the best! - Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"N390",
"E871",
"E1165",
"J45909",
"I10",
"Z515",
"Z66",
"Z794",
"E785"
] |
[
"C7931: Secondary malignant neoplasm of brain",
"G936: Cerebral edema",
"C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes",
"C7989: Secondary malignant neoplasm of other specified sites",
"N390: Urinary tract infection, site not specified",
"E871: Hypo-osmolality and hyponatremia",
"R4701: Aphasia",
"G8194: Hemiplegia, unspecified affecting left nondominant side",
"R531: Weakness",
"E1165: Type 2 diabetes mellitus with hyperglycemia",
"B9689: Other specified bacterial agents as the cause of diseases classified elsewhere",
"Z8549: Personal history of malignant neoplasm of other male genital organs",
"E861: Hypovolemia",
"J45909: Unspecified asthma, uncomplicated",
"I10: Essential (primary) hypertension",
"Z515: Encounter for palliative care",
"Z66: Do not resuscitate",
"Z7984: Long term (current) use of oral hypoglycemic drugs",
"Z794: Long term (current) use of insulin",
"T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter",
"R948: Abnormal results of function studies of other organs and systems",
"Y92239: Unspecified place in hospital as the place of occurrence of the external cause",
"E785: Hyperlipidemia, unspecified",
"M069: Rheumatoid arthritis, unspecified"
] |
10,030,549
| 29,784,292
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Encounter for chemotherapy
Major Surgical or Invasive Procedure:
Port Placement ___
History of Present Illness:
Mr. ___ is a pleasant ___ w/ HTN, DL, Asthma, T2DM, Rheumatoid
arthritis, and poorly differentiated squamous cell carcinoma s/p
partial penectomy in ___ (pT3, sarcomatoid and acantholytic
features), now with rapid metastatic recurrence to at least soft
tissue and RP nodes who is presenting for a PORT placement
followed by chemo. He states he has been doing otherwise well
w/o
any F/C, no N/V, no CP/SOB. He had pain at the surgical incision
in his penis but that has resolved. He has pain in his low back
for which he takes oxycodone prn.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
-___: CT torso showing no clear metastatic idsease
-___: Distal partial penectomy, path showing poorly
differentiated squamous cell carcinoma with sarcomatoid and
acantholytic features, pT3. Dr. ___ inguinal
___
on ___ but patient had some difficult social circumstances as he
was primary caretaker for his wife.
-___: At follow-up visit, he had a new 2x2 cm lesion in the
left groin.
-___: CT pelvis showing extensive new retroperitoneal
lymphadenopathy and new rim enhancing metastasis in the
pre-pubic
fat to the left of midline.
-___: Initial med onc evaluation, planned to complete
restaging and begin palliative TIP, for which patient consented.
PAST MEDICAL HISTORY (per OMR):
ASTHMA
DIABETES TYPE II
PPD POSITIVE
RHEUMATOID ARTHRITIS previously treated with Plaquenil, MTX,
sulfasalaine, leflunomide.
+PPD and +Quantiferon, s/p 3 months of INH but complicated by
LFT
abnormalities, then s/p full course of rifampin
Osteoarthritis in left knee
RIGHT BUNDLE BRANCH BLOCK
VENTRAL HERNIA
NORMOCYTIC ANEMIA
HYPERTENSION
HYPERLIPIDEMIA
PENILE CANCER
Social History:
___
Family History:
Father had blood cancer, no history of colon, lung or prostate
ca, no history of stroke or MI
Physical Exam:
VITALS: ___ 1154 Temp: 98.2 PO BP: 113/68 HR: 77 RR: 18 O2
sat: 99% O2 delivery: RA
General: NAD, resting in bed comfortably
HEENT: MMM, no OP lesions
CV: RRR, +S1S2 no S3S4, no m/r/g
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no peritoneal signs, no suprapubic
tenderness, no CVAT
LIMBS: WWP, no ___, no tremors
SKIN: port site dressing C/D/I
NEURO: CN III-XII intact, strength b/l ___ intact
PSYCH: Thought process logical, linear, future oriented
ACCESS: R chest port
Pertinent Results:
Admission Labs:
___ 08:15PM BLOOD WBC-8.1 RBC-3.73* Hgb-11.1* Hct-34.0*
MCV-91 MCH-29.8 MCHC-32.6 RDW-13.9 RDWSD-46.3 Plt ___
___ 08:15PM BLOOD Neuts-57.9 ___ Monos-5.3 Eos-4.0
Baso-0.9 Im ___ AbsNeut-4.68 AbsLymp-2.56 AbsMono-0.43
AbsEos-0.32 AbsBaso-0.07
___ 08:15PM BLOOD Glucose-100 UreaN-10 Creat-0.8 Na-139
K-4.5 Cl-101 HCO3-27 AnGap-11
___ 08:15PM BLOOD Albumin-4.0 Calcium-10.1 Phos-3.4 Mg-1.9
Labs at time of discharge:
___ 05:38AM BLOOD WBC-6.6 RBC-3.34* Hgb-9.8* Hct-30.2*
MCV-90 MCH-29.3 MCHC-32.5 RDW-14.4 RDWSD-47.1* Plt ___
___ 05:38AM BLOOD Neuts-64.4 ___ Monos-2.3*
Eos-0.6* Baso-0.2 Im ___ AbsNeut-4.26 AbsLymp-2.11
AbsMono-0.15* AbsEos-0.04 AbsBaso-0.01
___ 05:38AM BLOOD Glucose-110* UreaN-9 Creat-0.8 Na-140
K-4.1 Cl-106 HCO3-26 AnGap-8*
___ 05:38AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.8
Micro:
Urine Cx (___):
REFLEX URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 CFU/mL.
Brief Hospital Course:
___ w/ HTN, DL, Asthma, T2DM, RA, and poorly differentiated
penile SCC s/p partial penectomy ___ now w/ rapid metastatic
recurrence presenting for PORT placement and chemo. Patient
underwent port placement on ___ and started his first cycle
of chemotherapy as an inpatient which was well tolerated.
Patient was instructed to follow up in ___ clinic for
continued monitoring.
# Metastatic Penile Squamous Cell Carcinoma
Met to at least soft tissue and RP nodes. Started TIP chemo as
follows:
- ___
- Taxol 175 mg/m2 over 3 hours on D1
- Ifosfamide 1200 mg/m2 on D ___ w/ mesna
- Cisplatin 25 mg/m2 on D1-3
- received IVF 500cc boluses pre/post cisplatin
- cont oxy prn w/ colace
- plan for neulasta as outpatient on ___
- discharged with 4 days of dexamethasone 4mg BID given
possibility of significant nausea with this regimen, will also
send with PRN Zofran
# Asympatomatic Bacturia
- UCx with >100k GNR on routine screening UA
- patient without symptoms at time of discharge and as such will
not treat
- advised with strict return precautions if patient develops
symptoms of UTI
# T2DM: held home antihyperglycemics, ISS, resume on discharge
# Asthma: quiescent, cont advair/flonase, albuterol prn
# HTN: held ACEI while on chemo, as well as ASA
# DL: held statin while on chemo
# RA: on prn oxy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH TID:PRN dyspnea
2. Atorvastatin 40 mg PO QPM
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. GlipiZIDE XL 5 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
8. OxyCODONE (Immediate Release) 2.5 mg PO DAILY:PRN Pain -
Moderate
9. Aspirin 81 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Dexamethasone 4 mg PO Q12H Duration: 4 Days
take after chemo
RX *dexamethasone 4 mg 1 tablet(s) by mouth twice a day Disp #*8
Tablet Refills:*0
2. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*12 Tablet Refills:*0
3. Albuterol Inhaler 2 PUFF IH TID:PRN dyspnea
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Docusate Sodium 100 mg PO BID
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. GlipiZIDE XL 5 mg PO DAILY
10. Lisinopril 10 mg PO DAILY
11. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
12. OxyCODONE (Immediate Release) 2.5 mg PO DAILY:PRN Pain -
Moderate
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every eight
(8) hours Disp #*12 Tablet Refills:*0
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Encounter for chemotherapy
Penile Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure to care for you at ___.
You came to the hospital to start chemotherapy for your cancer.
WHAT HAPPENED IN THE HOSPITAL?
- you had a port placed in your chest to allow easy access for
chemotherapy
- you started your first cycle of chemotherapy which you
tolerated well
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- follow up closely with oncology tomorrow ___ for an
injection to support your blood counts
We wish you all the best!
Sincerely,
Your care team at ___
Followup Instructions:
___
|
[
"Z5111",
"C772",
"C7989",
"C609",
"I10",
"E785",
"E119",
"J45909",
"M069"
] |
Allergies: [MASKED] Chief Complaint: Encounter for chemotherapy Major Surgical or Invasive Procedure: Port Placement [MASKED] History of Present Illness: Mr. [MASKED] is a pleasant [MASKED] w/ HTN, DL, Asthma, T2DM, Rheumatoid arthritis, and poorly differentiated squamous cell carcinoma s/p partial penectomy in [MASKED] (pT3, sarcomatoid and acantholytic features), now with rapid metastatic recurrence to at least soft tissue and RP nodes who is presenting for a PORT placement followed by chemo. He states he has been doing otherwise well w/o any F/C, no N/V, no CP/SOB. He had pain at the surgical incision in his penis but that has resolved. He has pain in his low back for which he takes oxycodone prn. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): -[MASKED]: CT torso showing no clear metastatic idsease -[MASKED]: Distal partial penectomy, path showing poorly differentiated squamous cell carcinoma with sarcomatoid and acantholytic features, pT3. Dr. [MASKED] inguinal [MASKED] on [MASKED] but patient had some difficult social circumstances as he was primary caretaker for his wife. -[MASKED]: At follow-up visit, he had a new 2x2 cm lesion in the left groin. -[MASKED]: CT pelvis showing extensive new retroperitoneal lymphadenopathy and new rim enhancing metastasis in the pre-pubic fat to the left of midline. -[MASKED]: Initial med onc evaluation, planned to complete restaging and begin palliative TIP, for which patient consented. PAST MEDICAL HISTORY (per OMR): ASTHMA DIABETES TYPE II PPD POSITIVE RHEUMATOID ARTHRITIS previously treated with Plaquenil, MTX, sulfasalaine, leflunomide. +PPD and +Quantiferon, s/p 3 months of INH but complicated by LFT abnormalities, then s/p full course of rifampin Osteoarthritis in left knee RIGHT BUNDLE BRANCH BLOCK VENTRAL HERNIA NORMOCYTIC ANEMIA HYPERTENSION HYPERLIPIDEMIA PENILE CANCER Social History: [MASKED] Family History: Father had blood cancer, no history of colon, lung or prostate ca, no history of stroke or MI Physical Exam: VITALS: [MASKED] 1154 Temp: 98.2 PO BP: 113/68 HR: 77 RR: 18 O2 sat: 99% O2 delivery: RA General: NAD, resting in bed comfortably HEENT: MMM, no OP lesions CV: RRR, +S1S2 no S3S4, no m/r/g PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no peritoneal signs, no suprapubic tenderness, no CVAT LIMBS: WWP, no [MASKED], no tremors SKIN: port site dressing C/D/I NEURO: CN III-XII intact, strength b/l [MASKED] intact PSYCH: Thought process logical, linear, future oriented ACCESS: R chest port Pertinent Results: Admission Labs: [MASKED] 08:15PM BLOOD WBC-8.1 RBC-3.73* Hgb-11.1* Hct-34.0* MCV-91 MCH-29.8 MCHC-32.6 RDW-13.9 RDWSD-46.3 Plt [MASKED] [MASKED] 08:15PM BLOOD Neuts-57.9 [MASKED] Monos-5.3 Eos-4.0 Baso-0.9 Im [MASKED] AbsNeut-4.68 AbsLymp-2.56 AbsMono-0.43 AbsEos-0.32 AbsBaso-0.07 [MASKED] 08:15PM BLOOD Glucose-100 UreaN-10 Creat-0.8 Na-139 K-4.5 Cl-101 HCO3-27 AnGap-11 [MASKED] 08:15PM BLOOD Albumin-4.0 Calcium-10.1 Phos-3.4 Mg-1.9 Labs at time of discharge: [MASKED] 05:38AM BLOOD WBC-6.6 RBC-3.34* Hgb-9.8* Hct-30.2* MCV-90 MCH-29.3 MCHC-32.5 RDW-14.4 RDWSD-47.1* Plt [MASKED] [MASKED] 05:38AM BLOOD Neuts-64.4 [MASKED] Monos-2.3* Eos-0.6* Baso-0.2 Im [MASKED] AbsNeut-4.26 AbsLymp-2.11 AbsMono-0.15* AbsEos-0.04 AbsBaso-0.01 [MASKED] 05:38AM BLOOD Glucose-110* UreaN-9 Creat-0.8 Na-140 K-4.1 Cl-106 HCO3-26 AnGap-8* [MASKED] 05:38AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.8 Micro: Urine Cx ([MASKED]): REFLEX URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). >100,000 CFU/mL. Brief Hospital Course: [MASKED] w/ HTN, DL, Asthma, T2DM, RA, and poorly differentiated penile SCC s/p partial penectomy [MASKED] now w/ rapid metastatic recurrence presenting for PORT placement and chemo. Patient underwent port placement on [MASKED] and started his first cycle of chemotherapy as an inpatient which was well tolerated. Patient was instructed to follow up in [MASKED] clinic for continued monitoring. # Metastatic Penile Squamous Cell Carcinoma Met to at least soft tissue and RP nodes. Started TIP chemo as follows: - [MASKED] - Taxol 175 mg/m2 over 3 hours on D1 - Ifosfamide 1200 mg/m2 on D [MASKED] w/ mesna - Cisplatin 25 mg/m2 on D1-3 - received IVF 500cc boluses pre/post cisplatin - cont oxy prn w/ colace - plan for neulasta as outpatient on [MASKED] - discharged with 4 days of dexamethasone 4mg BID given possibility of significant nausea with this regimen, will also send with PRN Zofran # Asympatomatic Bacturia - UCx with >100k GNR on routine screening UA - patient without symptoms at time of discharge and as such will not treat - advised with strict return precautions if patient develops symptoms of UTI # T2DM: held home antihyperglycemics, ISS, resume on discharge # Asthma: quiescent, cont advair/flonase, albuterol prn # HTN: held ACEI while on chemo, as well as ASA # DL: held statin while on chemo # RA: on prn oxy Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH TID:PRN dyspnea 2. Atorvastatin 40 mg PO QPM 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Fluticasone Propionate NASAL 1 SPRY NU BID 5. GlipiZIDE XL 5 mg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 8. OxyCODONE (Immediate Release) 2.5 mg PO DAILY:PRN Pain - Moderate 9. Aspirin 81 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Dexamethasone 4 mg PO Q12H Duration: 4 Days take after chemo RX *dexamethasone 4 mg 1 tablet(s) by mouth twice a day Disp #*8 Tablet Refills:*0 2. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours Disp #*12 Tablet Refills:*0 3. Albuterol Inhaler 2 PUFF IH TID:PRN dyspnea 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Fluticasone Propionate NASAL 1 SPRY NU BID 8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 9. GlipiZIDE XL 5 mg PO DAILY 10. Lisinopril 10 mg PO DAILY 11. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 12. OxyCODONE (Immediate Release) 2.5 mg PO DAILY:PRN Pain - Moderate RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every eight (8) hours Disp #*12 Tablet Refills:*0 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Encounter for chemotherapy Penile Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was our pleasure to care for you at [MASKED]. You came to the hospital to start chemotherapy for your cancer. WHAT HAPPENED IN THE HOSPITAL? - you had a port placed in your chest to allow easy access for chemotherapy - you started your first cycle of chemotherapy which you tolerated well WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? - follow up closely with oncology tomorrow [MASKED] for an injection to support your blood counts We wish you all the best! Sincerely, Your care team at [MASKED] Followup Instructions: [MASKED]
|
[] |
[
"I10",
"E785",
"E119",
"J45909"
] |
[
"Z5111: Encounter for antineoplastic chemotherapy",
"C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes",
"C7989: Secondary malignant neoplasm of other specified sites",
"C609: Malignant neoplasm of penis, unspecified",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"E119: Type 2 diabetes mellitus without complications",
"J45909: Unspecified asthma, uncomplicated",
"M069: Rheumatoid arthritis, unspecified"
] |
10,030,682
| 25,960,647
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Cervical stenosis with spinal cord compression
Major Surgical or Invasive Procedure:
___ - C3-C7 laminectomies and posterior fusion
History of Present Illness:
___ is a ___ year old female who presented to the
Emergency Department on ___ as a transfer from an outside
facility status post motor vehicle collision with complaints of
generalized numbness and weakness. The patient was transferred
to ___ for further evaluation
and management. MRI of the cervical spine in the Emergency
Department was concerning for cervical stenosis with spinal cord
compression. The Neurosurgery Service was consulted for question
of acute neurosurgical intervention.
Past Medical History:
- hyperlipidemia
- hypertension
Social History:
___
Family History:
Noncontributory
Physical Exam:
On Admission:
-------------
Vital Signs: T 98.1F, HR 66, BP 126/59, RR 17, O2Sat 96% on room
air
General: Well nourished. In cervical collar.
Extremities: Warm and well perfused.
Neurologic:
Mental Status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
Deltoid Biceps Triceps Wrist Extension Wrist Flexion
Grip
Right4- 4- 4- 0 0
0
Left4- 4- 3 0 0
0
IP Quadriceps Hamstring AT ___ Gastrocnemius
Right2 3 2 2 3 2
Left2 3 2 2 3 2
Sensation: Intact to light touch and pinprick, but complaining
of diffuse numbness.
Reflexes: Right biceps reflex 2+. Unable to elicit left biceps
reflex. Patellar reflexes 2+ bilaterally.
Toes mute. Proprioception intact. Rectal tone intact. No
___ sign bilaterally. No clonus bilaterally.
On Discharge:
-------------
Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious
Orientation: [x]Person [x]Place [x]Time
Follows Commands: [ ]Simple [x]Complex
Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [x]Yes [ ]No
Motor:
Trapezius Deltoid Biceps Triceps Grip WF WE
Right5 4+ 5 5 5 4+ 5
Left5 4+ 4+ 4- 3 4+ 5
IP Quadriceps Hamstring AT ___ Gastrocnemius
Right5 5 4+ 5 5 5
Left5 5 4+ 5 5 5
[x]Sensation intact to light touch
Pertinent Results:
Please see ___ Record for relevant laboratory and
imaging results.
Left Shoulder Xray Study Date of ___ 9:45 AM
IMPRESSION:
1. Calcific tendinosis of the supraspinatus/infraspinatus.
2. Minimal degenerative changes in the left shoulder
3. No acute fracture or dislocation.
Radiology Report ___ NON-TRAUMA ___ VIEWS Study Date of
___ 2:26 ___
IMPRESSION:
There is posterior fusion hardware from C3 to C7. No hardware
related
complications are seen. There are degenerative changes with
loss of
intervertebral disc height at several levels and worse at C3-C4
and C4-C5.
Lung apices are grossly clear.
Radiology Report BILAT LOWER EXT VEINS Study Date of ___
10:52 AM
IMPRESSION:
No evidence of venous thrombosis.
UNILAT UP EXT VEINS US RIGHT Study Date of ___ 3:10 ___
IMPRESSION:
No evidence of deep vein thrombosis in the right upper
extremity.
Radiology Report MR CERVICAL SPINE W/O CONTRAST Study Date of
___ 5:21 AM
IMPRESSION:
1. Status post bilateral laminectomy and posterior fusion at
C3-C7 with
expected postsurgical changes.
2. New focal expansion and increased T2 signal within the cord
at the C3-4
level. Some degree of underlying myelomalacia is suspected at
the C4-5 level.
3. Overall improvement in the degree of spinal canal narrowing
from C2-C7,
with the worst level, at C2-3, displaying mild to moderate
spinal canal
narrowing.
MR ___ W/O CONTRAST Study Date of ___ 3:12 ___
IMPRESSION:
1. Motion limited exam.
2. Prevertebral edema from the craniocervical junction through
C5-C6. No
clear evidence for anterior longitudinal ligament edema or
disruption, but
evaluation is limited by motion. No other evidence for
ligamentous edema or bone marrow edema.
3. From C3-C4 through C5-C6, there are disc protrusions and
endplate
osteophytes severely narrowing the spinal canal and compressing
the spinal
cord. At C6-C7, right paracentral disc protrusion endplate
osteophytes cause moderate spinal canal narrowing with ventral
spinal cord remodeling. There is patchy T2 hyperintensity in the
cord from C2-C3 through C6-C7 levels, which may represent
contusion in the setting of trauma, versus chronic myelomalacia
in the setting of spinal canal stenosis.
4. No evidence for acute traumatic injuries in the thoracic or
lumbar spine.
5. Multilevel lumbar degenerative disease. Spinal canal
stenosis is moderate to severe at L4-L5, and moderate at L3-L4
and L5-S1, with crowding of the intrathecal nerve roots. There
is also mass effect on multiple traversing and exiting nerve
roots, as detailed above.
6. Trace left pleural effusion and mild bilateral dependent
atelectasis.
7. Highly distended bladder. Please correlate clinically
whether the patient is able to void.
Brief Hospital Course:
___ year old female with cervical stenosis s/p motor vehicle
collision with central cord syndrome.
#Cervical Stenosis With Spinal Cord Compression
#Central cord syndrome
The patient was taken emergently to the operating room for a
C3-C7 laminectomy and posterior fusion. The procedure was
uncomplicated. Please see separately dictated operative report
by Dr. ___ further details. A surgical drain was left
in place, which was subsequently removed on POD#5. The patient
was extubated in the operating room and recovered in the PACU.
She was transferred to the step down unit for close neurologic
monitoring. Her neurologic exam slowly improved postoperatively.
Postoperative x-rays of the cervical spine showed no evidence of
retained surgical drain or hardware complications. On ___
overnight, the patient was noted to have worsened weakness on
exam. A CT of the cervical spine was obtained, which was grossly
negative, but there was significant artifact from the hardware.
An MRI of the cervical spine was also obtained, which showed
increased T2 signal in cord at C3-C4, but overall improvement in
the degree of spinal canal narrowing from C2-C7. Her weakness
subsequently improved and continued to improve with continued
physical and occupational therapy.
#Rib Fracture
Acute Care Surgery was consulted for fracture of the first rib
on the left. There was no surgical intervention or follow-up
needed.
#Hypoxia
The patient required supplemental oxygen on ___. She was
subsequently weaned off the supplemental oxygen, and her oxygen
saturations remained stable on room air for the remainder of her
hospitalization.
#Right Shoulder and wrist Pain
The patient complained of significant right shoulder pain. An
x-ray of the right shoulder was obtained, which showed no
definite fracture or dislocation, however there was a well
corticated rounded density, which was thought to reflect sequela
of remote injury or calcific tendinitis. She also c/o
significant right wrist pain. An ultrasound of the right wrist
was negative. Pain medications were adjusted.
#Urinary Retention
The patient experienced urinary retention postoperatively. Her
Foley catheter was discontinued. She failed a voiding trial on
___, and catheter was replaced. Her Foley catheter was
discontinued again on ___, and she was able to void but
still required intermittent straight cath for retention. On
discharge patient was voiding without difficulty.
#Constipation / Ileus
She was started on an aggressive bowel regimen for constipation.
On ___, the patient was noted to have abdominal distension.
KUB showed postop ileus. No nausea/vomiting. She was made NPO,
limited narcotics, and continued on aggressive bowel regimen.
Repeat abdominal XR ___ showed interval improvement. On ___,
the patient was passing her bowels and her diet was advanced to
regular. A repeat KUB showed interval improvement of the ileus.
On discharge patient was moving her bowels without difficulty.
#Fever
#UTI
The patient became febrile postoperatively. Urinalysis was
positive. Urine culture showed PROTEUS MIRABILIS UTI. She was
started on Ceftriaxone ___.
Blood cultures were negative. Chest x-ray was negative. On
discharged there is no evidence of UTI or ongoing infection,
patient is afebrile.
#Hyponatremia
The patient was hyponatremic and was started on sodium chloride
tablets on ___ with improvement. On ___, the patient's
serum Na level remained low and the salt tablets were increased.
The serum Na level normalized on ___ and the sodium was
monitored closely. On ___, the salt tablets were titrated down
to 1g three times daily. The serum sodium continued to be
monitored, and was stable on ___. Her sodium tablets were
weaned off and her serum sodium levels remained stable.
#Elevated BUN
The patient's BUN was elevated. She received a 500mL normal
saline bolus on ___ with improvement. The BUN returned to
normal range on ___. Her BUN was elevated on ___ and
returned to normal limits the next day.
#Left shoulder pain
Patient developed severe left shoulder pain ___. Ibuprofen was
started with some relief. XR on ___ showed no fracture or
dislocation, but did show mild calcific tendinitis. Ibuprofen
was increased and continued ___ was recommended.
#Disposition
Physical Therapy and Occupational Therapy were consulted and
recommended discharge to rehabilitation. However, the patient's
health insurance does not provide any rehabilitation benefits.
Family training was done inpatient to work towards a safe
discharge. Social Work was consulted given her limited health
insurance. A family meeting was organized that resulted in the
patient's family working to get the patient insurance so
benefits can be obtained. The goal was to obtain benefits for
acute rehab at the recommendation of physical therapy, either
through the ___ or ___. A second family meeting was held
___ where her son, ___, was given power of attorney and
health care proxy status as the family worked on insurance.
Patient was approved for health insurance on ___. She was
discharged on ___ to ___ for further care.
Medications on Admission:
- hydrochlorothiazide 12.5mg by mouth once daily
- lisinopril 40mg by mouth once daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line
3. Docusate Sodium 100 mg PO BID
4. Fleet Enema (Mineral Oil) ___AILY:PRN constipation
5. Gabapentin 300 mg PO TID
6. Heparin 5000 UNIT SC BID
7. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
8. Lidocaine 5% Patch 2 PTCH TD QAM
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
10. Polyethylene Glycol 17 g PO DAILY
11. Senna 8.6 mg PO BID
12. Simethicone 40-80 mg PO QID:PRN gas pain
13. Hydrochlorothiazide 12.5 mg PO DAILY
14. Lisinopril 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cervical stenosis with spinal cord compression
Urinary tract infection
ileus
post operative pain
electrolyte abnormalities
Rib fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions
Cervical Spinal Fusion
Surgery
Do not apply any lotions or creams to the site.
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.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
Please do NOT take any blood thinning medication (Plavix,
Coumadin) until cleared by the neurosurgeon. You are cleared to
take Aspirin and Ibuprofen if indicated.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
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:
___
|
[
"S14109A",
"S2232XA",
"N390",
"K567",
"E871",
"S14129A",
"M4802",
"E7800",
"I10",
"Y9289",
"M1990",
"R339",
"E785",
"R001",
"B964",
"K5900",
"R0902",
"V4950XA",
"M9951",
"M25511",
"M25531",
"M48061",
"Z9049",
"Z98890",
"Z751"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Cervical stenosis with spinal cord compression Major Surgical or Invasive Procedure: [MASKED] - C3-C7 laminectomies and posterior fusion History of Present Illness: [MASKED] is a [MASKED] year old female who presented to the Emergency Department on [MASKED] as a transfer from an outside facility status post motor vehicle collision with complaints of generalized numbness and weakness. The patient was transferred to [MASKED] for further evaluation and management. MRI of the cervical spine in the Emergency Department was concerning for cervical stenosis with spinal cord compression. The Neurosurgery Service was consulted for question of acute neurosurgical intervention. Past Medical History: - hyperlipidemia - hypertension Social History: [MASKED] Family History: Noncontributory Physical Exam: On Admission: ------------- Vital Signs: T 98.1F, HR 66, BP 126/59, RR 17, O2Sat 96% on room air General: Well nourished. In cervical collar. Extremities: Warm and well perfused. Neurologic: Mental Status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: Deltoid Biceps Triceps Wrist Extension Wrist Flexion Grip Right4- 4- 4- 0 0 0 Left4- 4- 3 0 0 0 IP Quadriceps Hamstring AT [MASKED] Gastrocnemius Right2 3 2 2 3 2 Left2 3 2 2 3 2 Sensation: Intact to light touch and pinprick, but complaining of diffuse numbness. Reflexes: Right biceps reflex 2+. Unable to elicit left biceps reflex. Patellar reflexes 2+ bilaterally. Toes mute. Proprioception intact. Rectal tone intact. No [MASKED] sign bilaterally. No clonus bilaterally. On Discharge: ------------- Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious Orientation: [x]Person [x]Place [x]Time Follows Commands: [ ]Simple [x]Complex Speech Fluent: [x]Yes [ ]No Comprehension Intact: [x]Yes [ ]No Motor: Trapezius Deltoid Biceps Triceps Grip WF WE Right5 4+ 5 5 5 4+ 5 Left5 4+ 4+ 4- 3 4+ 5 IP Quadriceps Hamstring AT [MASKED] Gastrocnemius Right5 5 4+ 5 5 5 Left5 5 4+ 5 5 5 [x]Sensation intact to light touch Pertinent Results: Please see [MASKED] Record for relevant laboratory and imaging results. Left Shoulder Xray Study Date of [MASKED] 9:45 AM IMPRESSION: 1. Calcific tendinosis of the supraspinatus/infraspinatus. 2. Minimal degenerative changes in the left shoulder 3. No acute fracture or dislocation. Radiology Report [MASKED] NON-TRAUMA [MASKED] VIEWS Study Date of [MASKED] 2:26 [MASKED] IMPRESSION: There is posterior fusion hardware from C3 to C7. No hardware related complications are seen. There are degenerative changes with loss of intervertebral disc height at several levels and worse at C3-C4 and C4-C5. Lung apices are grossly clear. Radiology Report BILAT LOWER EXT VEINS Study Date of [MASKED] 10:52 AM IMPRESSION: No evidence of venous thrombosis. UNILAT UP EXT VEINS US RIGHT Study Date of [MASKED] 3:10 [MASKED] IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. Radiology Report MR CERVICAL SPINE W/O CONTRAST Study Date of [MASKED] 5:21 AM IMPRESSION: 1. Status post bilateral laminectomy and posterior fusion at C3-C7 with expected postsurgical changes. 2. New focal expansion and increased T2 signal within the cord at the C3-4 level. Some degree of underlying myelomalacia is suspected at the C4-5 level. 3. Overall improvement in the degree of spinal canal narrowing from C2-C7, with the worst level, at C2-3, displaying mild to moderate spinal canal narrowing. MR [MASKED] W/O CONTRAST Study Date of [MASKED] 3:12 [MASKED] IMPRESSION: 1. Motion limited exam. 2. Prevertebral edema from the craniocervical junction through C5-C6. No clear evidence for anterior longitudinal ligament edema or disruption, but evaluation is limited by motion. No other evidence for ligamentous edema or bone marrow edema. 3. From C3-C4 through C5-C6, there are disc protrusions and endplate osteophytes severely narrowing the spinal canal and compressing the spinal cord. At C6-C7, right paracentral disc protrusion endplate osteophytes cause moderate spinal canal narrowing with ventral spinal cord remodeling. There is patchy T2 hyperintensity in the cord from C2-C3 through C6-C7 levels, which may represent contusion in the setting of trauma, versus chronic myelomalacia in the setting of spinal canal stenosis. 4. No evidence for acute traumatic injuries in the thoracic or lumbar spine. 5. Multilevel lumbar degenerative disease. Spinal canal stenosis is moderate to severe at L4-L5, and moderate at L3-L4 and L5-S1, with crowding of the intrathecal nerve roots. There is also mass effect on multiple traversing and exiting nerve roots, as detailed above. 6. Trace left pleural effusion and mild bilateral dependent atelectasis. 7. Highly distended bladder. Please correlate clinically whether the patient is able to void. Brief Hospital Course: [MASKED] year old female with cervical stenosis s/p motor vehicle collision with central cord syndrome. #Cervical Stenosis With Spinal Cord Compression #Central cord syndrome The patient was taken emergently to the operating room for a C3-C7 laminectomy and posterior fusion. The procedure was uncomplicated. Please see separately dictated operative report by Dr. [MASKED] further details. A surgical drain was left in place, which was subsequently removed on POD#5. The patient was extubated in the operating room and recovered in the PACU. She was transferred to the step down unit for close neurologic monitoring. Her neurologic exam slowly improved postoperatively. Postoperative x-rays of the cervical spine showed no evidence of retained surgical drain or hardware complications. On [MASKED] overnight, the patient was noted to have worsened weakness on exam. A CT of the cervical spine was obtained, which was grossly negative, but there was significant artifact from the hardware. An MRI of the cervical spine was also obtained, which showed increased T2 signal in cord at C3-C4, but overall improvement in the degree of spinal canal narrowing from C2-C7. Her weakness subsequently improved and continued to improve with continued physical and occupational therapy. #Rib Fracture Acute Care Surgery was consulted for fracture of the first rib on the left. There was no surgical intervention or follow-up needed. #Hypoxia The patient required supplemental oxygen on [MASKED]. She was subsequently weaned off the supplemental oxygen, and her oxygen saturations remained stable on room air for the remainder of her hospitalization. #Right Shoulder and wrist Pain The patient complained of significant right shoulder pain. An x-ray of the right shoulder was obtained, which showed no definite fracture or dislocation, however there was a well corticated rounded density, which was thought to reflect sequela of remote injury or calcific tendinitis. She also c/o significant right wrist pain. An ultrasound of the right wrist was negative. Pain medications were adjusted. #Urinary Retention The patient experienced urinary retention postoperatively. Her Foley catheter was discontinued. She failed a voiding trial on [MASKED], and catheter was replaced. Her Foley catheter was discontinued again on [MASKED], and she was able to void but still required intermittent straight cath for retention. On discharge patient was voiding without difficulty. #Constipation / Ileus She was started on an aggressive bowel regimen for constipation. On [MASKED], the patient was noted to have abdominal distension. KUB showed postop ileus. No nausea/vomiting. She was made NPO, limited narcotics, and continued on aggressive bowel regimen. Repeat abdominal XR [MASKED] showed interval improvement. On [MASKED], the patient was passing her bowels and her diet was advanced to regular. A repeat KUB showed interval improvement of the ileus. On discharge patient was moving her bowels without difficulty. #Fever #UTI The patient became febrile postoperatively. Urinalysis was positive. Urine culture showed PROTEUS MIRABILIS UTI. She was started on Ceftriaxone [MASKED]. Blood cultures were negative. Chest x-ray was negative. On discharged there is no evidence of UTI or ongoing infection, patient is afebrile. #Hyponatremia The patient was hyponatremic and was started on sodium chloride tablets on [MASKED] with improvement. On [MASKED], the patient's serum Na level remained low and the salt tablets were increased. The serum Na level normalized on [MASKED] and the sodium was monitored closely. On [MASKED], the salt tablets were titrated down to 1g three times daily. The serum sodium continued to be monitored, and was stable on [MASKED]. Her sodium tablets were weaned off and her serum sodium levels remained stable. #Elevated BUN The patient's BUN was elevated. She received a 500mL normal saline bolus on [MASKED] with improvement. The BUN returned to normal range on [MASKED]. Her BUN was elevated on [MASKED] and returned to normal limits the next day. #Left shoulder pain Patient developed severe left shoulder pain [MASKED]. Ibuprofen was started with some relief. XR on [MASKED] showed no fracture or dislocation, but did show mild calcific tendinitis. Ibuprofen was increased and continued [MASKED] was recommended. #Disposition Physical Therapy and Occupational Therapy were consulted and recommended discharge to rehabilitation. However, the patient's health insurance does not provide any rehabilitation benefits. Family training was done inpatient to work towards a safe discharge. Social Work was consulted given her limited health insurance. A family meeting was organized that resulted in the patient's family working to get the patient insurance so benefits can be obtained. The goal was to obtain benefits for acute rehab at the recommendation of physical therapy, either through the [MASKED] or [MASKED]. A second family meeting was held [MASKED] where her son, [MASKED], was given power of attorney and health care proxy status as the family worked on insurance. Patient was approved for health insurance on [MASKED]. She was discharged on [MASKED] to [MASKED] for further care. Medications on Admission: - hydrochlorothiazide 12.5mg by mouth once daily - lisinopril 40mg by mouth once daily Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line 3. Docusate Sodium 100 mg PO BID 4. Fleet Enema (Mineral Oil) AILY:PRN constipation 5. Gabapentin 300 mg PO TID 6. Heparin 5000 UNIT SC BID 7. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 8. Lidocaine 5% Patch 2 PTCH TD QAM 9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 10. Polyethylene Glycol 17 g PO DAILY 11. Senna 8.6 mg PO BID 12. Simethicone 40-80 mg PO QID:PRN gas pain 13. Hydrochlorothiazide 12.5 mg PO DAILY 14. Lisinopril 40 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Cervical stenosis with spinal cord compression Urinary tract infection ileus post operative pain electrolyte abnormalities Rib fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Discharge Instructions Cervical Spinal Fusion Surgery Do not apply any lotions or creams to the site. 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. Do NOT smoke. Smoking can affect your healing and fusion. Medications Please do NOT take any blood thinning medication (Plavix, Coumadin) until cleared by the neurosurgeon. You are cleared to take Aspirin and Ibuprofen if indicated. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. 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]
|
[] |
[
"N390",
"E871",
"I10",
"E785",
"K5900"
] |
[
"S14109A: Unspecified injury at unspecified level of cervical spinal cord, initial encounter",
"S2232XA: Fracture of one rib, left side, initial encounter for closed fracture",
"N390: Urinary tract infection, site not specified",
"K567: Ileus, unspecified",
"E871: Hypo-osmolality and hyponatremia",
"S14129A: Central cord syndrome at unspecified level of cervical spinal cord, initial encounter",
"M4802: Spinal stenosis, cervical region",
"E7800: Pure hypercholesterolemia, unspecified",
"I10: Essential (primary) hypertension",
"Y9289: Other specified places as the place of occurrence of the external cause",
"M1990: Unspecified osteoarthritis, unspecified site",
"R339: Retention of urine, unspecified",
"E785: Hyperlipidemia, unspecified",
"R001: Bradycardia, unspecified",
"B964: Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere",
"K5900: Constipation, unspecified",
"R0902: Hypoxemia",
"V4950XA: Passenger injured in collision with unspecified motor vehicles in traffic accident, initial encounter",
"M9951: Intervertebral disc stenosis of neural canal of cervical region",
"M25511: Pain in right shoulder",
"M25531: Pain in right wrist",
"M48061: Spinal stenosis, lumbar region without neurogenic claudication",
"Z9049: Acquired absence of other specified parts of digestive tract",
"Z98890: Other specified postprocedural states",
"Z751: Person awaiting admission to adequate facility elsewhere"
] |
10,030,746
| 22,297,761
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
___ Cardiac catheterization
___: Coronary artery bypass grafts x3 (LIMA-LAD,
SVG-AntRV, SVG-OM1); Endovascular saphenous vein harvest
History of Present Illness:
Mr. ___ is a ___ year old male with a past medical history of
diabetes mellitus type 2, hyperlipidemia, and hypertension. He
initially presented to his PCP with epigastric pain and nausea.
An EKG reportedly showed accelerated junctional rhythm with HR
___. He was then sent to ___ and EKG showed sinus
bradycardia. He ruled in NSTEMI and was then transferred to
___ for coronary angiogram which revealed three-vessel
disease. Cardiac surgery consulted for revascularization.
Past Medical History:
Diabetes mellitus type 2
Gastritis c/b duodenal stricture
Hyperlipidemia
Hypertension
Social History:
___
Family History:
Father w/ MI and passed in his ___
Mother CVA and passed at ___
Physical Exam:
BP: 120/72 HR: 56 RR: 18 O2 sat: 97% RA
Height: 68 in Weight: 74.9 kg
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
___ Right: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit: none
Discharge examination
24 HR Data (last updated ___ @ 727)
Temp: 98.1 (Tm 99.1), BP: 114/65 (112-133/65-79), HR: 64
(60-71), RR: 16 (___), O2 sat: 96% (95-98), O2 delivery: Ra,
Wt: 167.33 lb/75.9 kg
Fluid Balance (last updated ___ @ 859)
Last 8 hours Total cumulative -230ml
IN: Total 420ml, PO Amt 420ml
OUT: Total 650ml, Urine Amt 650ml
Last 24 hours Total cumulative -1270ml
IN: Total 880ml, PO Amt 880ml
OUT: Total 2150ml, Urine Amt 2150ml
Physical Examination:
General: NAD
Neurological: A/O x3 non focal
Cardiovascular: RRR no murmur or rub
Respiratory: CTA No resp distress
GI/Abdomen: Bowel sounds present Soft ND NT multipleBM
andpassing flatus
Extremities:
Right Upper extremity Warm Edema tr
Left Upper extremity Warm Edema tr
Right Lower extremity Warm Edema tr
Left Lower extremity Warm Edema tr
Pulses:
DP Right:p Left:p
___ Right:p Left:p
Radial Right:p Left:p
Sternal: CDI no erythema or drainage Sternum stable
Lower extremity: Left CDI
Pertinent Results:
Cardiac Catheterization ___ at ___
LM: 70% stenosis in the distal segments, eccentric, calcified
LAD: medium caliber vessel.
Cx: large caliber vessel; 70-80% stenosis in the ostium that
extends into the ___ Obtuse Marginal
RCA: 80% stenosis in the ostium; 100% stenosis in the mid and
distal segments. Collaterals from the mid segment of the AM
connect to the distal segment.
Transthoracic Echocardiogram ___
There is no evidence for an atrial septal defect by 2D/color
Doppler. The estimated right atrial pressure is ___ mmHg.
Overall left ventricular systolic function is mildly depressed
secondary to hypokinesis of the inferior and posterior walls.
The visually estimated left ventricular ejection fraction is
45%. Tricuspid annular plane systolic excursion (TAPSE) is
normal. There is no evidence for an aortic arch coarctation.
There is mild [1+] mitral regurgitation. There is mild [1+]
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is borderline elevated.
IMPRESSION: inferior posterior hypokinesis; mild mitral
regurgitation
Transesophageal Echocardiogram ___
PRE-OPERATIVE STATE: Pre-bypass assessment. Sinus rhythm.
Left Atrium ___ Veins: Dilated ___. No spontaneous
echo contrast or thrombus in the ___.
Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC):
Dilated RA. No spontaneous echo contrast or thrombus is seen in
the RA/RA appendage. Normal interatrial septum. No atrial septal
defect by 2D/color flow Doppler.
Left Ventricle (LV): Mild symmetric hypertrophy. Normal cavity
size. Mild-moderate global hypokinesis. Mildly depressed
ejection fraction.
Right Ventricle (RV): Mild global hypokinesis.
Aorta: Normal ascending diameter. No dissection. Simple atheroma
of ascending aorta. Simple arch atheroma. Simple descending
atheroma.
Aortic Valve: Moderately thickened (3) leaflets. Moderate
leaflet calcification. Minimal stenosis. No regurgitation.
Mitral Valve: Moderately thickened leaflets. Moderate leaflet
calcification. No systolic prolapse. No stenosis.
Mild annular calcification. Mild [1+] regurgitation. Central
jet.
Pulmonic Valve: Thickened leaflets. Trivial regurgitation.
Tricuspid Valve: Mildly thickened leaflets. Mild annular
calcification. Mild [1+] regurgitation.
Pericardium: No effusion.
POST-OP STATE: The post-bypass TEE was performed at 14:16:00.
Atrial paced rhythm.
Support: Vasopressor(s): none.
Left Ventricle: Systolic function is improved. Global ejection
fraction is normal.
Right Ventricle: Improved systolic function.
Aorta: Intact. No dissection.
Aortic Valve: No change in aortic valve morphology from
preoperative state. No change in aortic regurgitation.
Mitral Valve: No change in mitral valve morphology from
preoperative state. No change in valvular regurgitation from
preoperative state.
Tricuspid Valve: No change in tricuspid valve morphology vs.
preoperative state.
Pericardium: No effusion.
___ 06:10AM BLOOD WBC-7.5 RBC-3.67* Hgb-11.2* Hct-34.2*
MCV-93 MCH-30.5 MCHC-32.7 RDW-11.9 RDWSD-40.5 Plt ___
___ 06:10AM BLOOD Glucose-137* UreaN-14 Creat-0.9 Na-140
K-3.6 Cl-99 HCO3-31 AnGap-10
___ 11:34PM BLOOD WBC-8.2 RBC-4.46* Hgb-13.8 Hct-41.0
MCV-92 MCH-30.9 MCHC-33.7 RDW-12.0 RDWSD-40.6 Plt ___
___ 06:51AM BLOOD ___ PTT-41.3* ___
___ 11:34PM BLOOD Glucose-270* UreaN-13 Creat-1.2 Na-141
K-3.9 Cl-102 HCO3-27 AnGap-12
___ 07:06PM BLOOD ALT-23 AST-36 LD(LDH)-312* AlkPhos-46
Amylase-30 TotBili-0.4
___ 05:35PM BLOOD CK(CPK)-719*
___ 06:51AM BLOOD CK-MB-30* cTropnT-1.26*
___ 07:06PM BLOOD Lipase-22
___ 05:35PM BLOOD CK-MB-70* MB Indx-9.7*
___ 05:35PM BLOOD cTropnT-0.53*
___ 06:10AM BLOOD Mg-2.0
___ 02:40AM BLOOD Calcium-8.0* Phos-3.4 Mg-2.5
___ 06:10AM BLOOD ALT-9 AST-11 LD(LDH)-203 AlkPhos-41
Amylase-13 TotBili-0.4
Brief Hospital Course:
Presented to OSH with epigastric pain and ruled in for NSTEMI
and was transferred for cardiac workup including cardiac
catheterization that revealed significant coronary artery
disease. He was managed under cardiology and cardiac surgery
was consulted for surgical evaluation. He underwent routine
preoperative testing and evaluation. He remained hemodynamically
stable and was taken to the operating room on ___. He
underwent coronary artery bypass grafting x 3. Please see
operative note for full details. Post operatively he was taken
to the intensive care unit for management on Propofol and
nitroglycerin. Within a few hours he was weaned of sedation,
awoke neurologically intact and was extubated without
complications. He was transitioned to nicardipine for blood
pressure control. He continued to progress and was
transitioned to betablocker and diuretic on post operative day
one allowing nicardipine to be weaned off. He continued to
progress and was transitioned to the floor. Chest tubes and
epicardial wires were removed per protocol. He developed nausea
and medications were adjusted including pain medications and
bowel medications. It resolved after bowel movement and
scopolamine patch. He was then able to tolerate oral intake.
He worked with physical therapy on strength and mobility with
recommendation for home with services. He was clinically
stable, tolerating diet and pain controlled with acetaminophen
at time of discharge home on post operative day four. Plan to
have labs checked in few days due to recent addition of Ace
inhibitor due to recent NSTEMI.
Medications on Admission:
1. Rosuvastatin Calcium 20 mg PO QPM
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. GlipiZIDE 5 mg PO BID
4. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin EC 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Furosemide 40 mg PO DAILY Duration: 7 Days
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
5. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
6. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
8. Scopolamine Patch 1 PTCH TD ONCE nausea Duration: 72 Hours
remove ___. Senna 17.2 mg PO DAILY
change to as needed if loose stool
RX *sennosides 8.6 mg 2 tablets by mouth once a day Disp #*60
Tablet Refills:*0
10. Omeprazole 40 mg PO DAILY
40 mg for 1 month daily then decrease back to 20 mg daily as
prior to admission
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
11. Rosuvastatin Calcium 40 mg PO QPM
RX *rosuvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
12. GlipiZIDE 5 mg PO BID
13. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary Artery Disease s/p coronary revascularization
Non-ST Elevation Myocardial Infarction
Secondary Diagnosis:
Diabetes Mellitus Type II
Gastritis
Hyperlipidemia
Hypertension
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with acetaminophen
Sternal Incision - healing well, no erythema or drainage
Left Leg EVH - healing well, no erythema or drainage
Edema trace
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
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
[
"I214",
"D62",
"I2510",
"Z87891",
"E785",
"I10",
"E119",
"K2970",
"T39395A",
"R110",
"K5900"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Epigastric pain Major Surgical or Invasive Procedure: [MASKED] Cardiac catheterization [MASKED]: Coronary artery bypass grafts x3 (LIMA-LAD, SVG-AntRV, SVG-OM1); Endovascular saphenous vein harvest History of Present Illness: Mr. [MASKED] is a [MASKED] year old male with a past medical history of diabetes mellitus type 2, hyperlipidemia, and hypertension. He initially presented to his PCP with epigastric pain and nausea. An EKG reportedly showed accelerated junctional rhythm with HR [MASKED]. He was then sent to [MASKED] and EKG showed sinus bradycardia. He ruled in NSTEMI and was then transferred to [MASKED] for coronary angiogram which revealed three-vessel disease. Cardiac surgery consulted for revascularization. Past Medical History: Diabetes mellitus type 2 Gastritis c/b duodenal stricture Hyperlipidemia Hypertension Social History: [MASKED] Family History: Father w/ MI and passed in his [MASKED] Mother CVA and passed at [MASKED] Physical Exam: BP: 120/72 HR: 56 RR: 18 O2 sat: 97% RA Height: 68 in Weight: 74.9 kg Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade [MASKED] Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] [MASKED] Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ [MASKED] Right: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit: none Discharge examination 24 HR Data (last updated [MASKED] @ 727) Temp: 98.1 (Tm 99.1), BP: 114/65 (112-133/65-79), HR: 64 (60-71), RR: 16 ([MASKED]), O2 sat: 96% (95-98), O2 delivery: Ra, Wt: 167.33 lb/75.9 kg Fluid Balance (last updated [MASKED] @ 859) Last 8 hours Total cumulative -230ml IN: Total 420ml, PO Amt 420ml OUT: Total 650ml, Urine Amt 650ml Last 24 hours Total cumulative -1270ml IN: Total 880ml, PO Amt 880ml OUT: Total 2150ml, Urine Amt 2150ml Physical Examination: General: NAD Neurological: A/O x3 non focal Cardiovascular: RRR no murmur or rub Respiratory: CTA No resp distress GI/Abdomen: Bowel sounds present Soft ND NT multipleBM andpassing flatus Extremities: Right Upper extremity Warm Edema tr Left Upper extremity Warm Edema tr Right Lower extremity Warm Edema tr Left Lower extremity Warm Edema tr Pulses: DP Right:p Left:p [MASKED] Right:p Left:p Radial Right:p Left:p Sternal: CDI no erythema or drainage Sternum stable Lower extremity: Left CDI Pertinent Results: Cardiac Catheterization [MASKED] at [MASKED] LM: 70% stenosis in the distal segments, eccentric, calcified LAD: medium caliber vessel. Cx: large caliber vessel; 70-80% stenosis in the ostium that extends into the [MASKED] Obtuse Marginal RCA: 80% stenosis in the ostium; 100% stenosis in the mid and distal segments. Collaterals from the mid segment of the AM connect to the distal segment. Transthoracic Echocardiogram [MASKED] There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is [MASKED] mmHg. Overall left ventricular systolic function is mildly depressed secondary to hypokinesis of the inferior and posterior walls. The visually estimated left ventricular ejection fraction is 45%. Tricuspid annular plane systolic excursion (TAPSE) is normal. There is no evidence for an aortic arch coarctation. There is mild [1+] mitral regurgitation. There is mild [1+] tricuspid regurgitation. The estimated pulmonary artery systolic pressure is borderline elevated. IMPRESSION: inferior posterior hypokinesis; mild mitral regurgitation Transesophageal Echocardiogram [MASKED] PRE-OPERATIVE STATE: Pre-bypass assessment. Sinus rhythm. Left Atrium [MASKED] Veins: Dilated [MASKED]. No spontaneous echo contrast or thrombus in the [MASKED]. Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): Dilated RA. No spontaneous echo contrast or thrombus is seen in the RA/RA appendage. Normal interatrial septum. No atrial septal defect by 2D/color flow Doppler. Left Ventricle (LV): Mild symmetric hypertrophy. Normal cavity size. Mild-moderate global hypokinesis. Mildly depressed ejection fraction. Right Ventricle (RV): Mild global hypokinesis. Aorta: Normal ascending diameter. No dissection. Simple atheroma of ascending aorta. Simple arch atheroma. Simple descending atheroma. Aortic Valve: Moderately thickened (3) leaflets. Moderate leaflet calcification. Minimal stenosis. No regurgitation. Mitral Valve: Moderately thickened leaflets. Moderate leaflet calcification. No systolic prolapse. No stenosis. Mild annular calcification. Mild [1+] regurgitation. Central jet. Pulmonic Valve: Thickened leaflets. Trivial regurgitation. Tricuspid Valve: Mildly thickened leaflets. Mild annular calcification. Mild [1+] regurgitation. Pericardium: No effusion. POST-OP STATE: The post-bypass TEE was performed at 14:16:00. Atrial paced rhythm. Support: Vasopressor(s): none. Left Ventricle: Systolic function is improved. Global ejection fraction is normal. Right Ventricle: Improved systolic function. Aorta: Intact. No dissection. Aortic Valve: No change in aortic valve morphology from preoperative state. No change in aortic regurgitation. Mitral Valve: No change in mitral valve morphology from preoperative state. No change in valvular regurgitation from preoperative state. Tricuspid Valve: No change in tricuspid valve morphology vs. preoperative state. Pericardium: No effusion. [MASKED] 06:10AM BLOOD WBC-7.5 RBC-3.67* Hgb-11.2* Hct-34.2* MCV-93 MCH-30.5 MCHC-32.7 RDW-11.9 RDWSD-40.5 Plt [MASKED] [MASKED] 06:10AM BLOOD Glucose-137* UreaN-14 Creat-0.9 Na-140 K-3.6 Cl-99 HCO3-31 AnGap-10 [MASKED] 11:34PM BLOOD WBC-8.2 RBC-4.46* Hgb-13.8 Hct-41.0 MCV-92 MCH-30.9 MCHC-33.7 RDW-12.0 RDWSD-40.6 Plt [MASKED] [MASKED] 06:51AM BLOOD [MASKED] PTT-41.3* [MASKED] [MASKED] 11:34PM BLOOD Glucose-270* UreaN-13 Creat-1.2 Na-141 K-3.9 Cl-102 HCO3-27 AnGap-12 [MASKED] 07:06PM BLOOD ALT-23 AST-36 LD(LDH)-312* AlkPhos-46 Amylase-30 TotBili-0.4 [MASKED] 05:35PM BLOOD CK(CPK)-719* [MASKED] 06:51AM BLOOD CK-MB-30* cTropnT-1.26* [MASKED] 07:06PM BLOOD Lipase-22 [MASKED] 05:35PM BLOOD CK-MB-70* MB Indx-9.7* [MASKED] 05:35PM BLOOD cTropnT-0.53* [MASKED] 06:10AM BLOOD Mg-2.0 [MASKED] 02:40AM BLOOD Calcium-8.0* Phos-3.4 Mg-2.5 [MASKED] 06:10AM BLOOD ALT-9 AST-11 LD(LDH)-203 AlkPhos-41 Amylase-13 TotBili-0.4 Brief Hospital Course: Presented to OSH with epigastric pain and ruled in for NSTEMI and was transferred for cardiac workup including cardiac catheterization that revealed significant coronary artery disease. He was managed under cardiology and cardiac surgery was consulted for surgical evaluation. He underwent routine preoperative testing and evaluation. He remained hemodynamically stable and was taken to the operating room on [MASKED]. He underwent coronary artery bypass grafting x 3. Please see operative note for full details. Post operatively he was taken to the intensive care unit for management on Propofol and nitroglycerin. Within a few hours he was weaned of sedation, awoke neurologically intact and was extubated without complications. He was transitioned to nicardipine for blood pressure control. He continued to progress and was transitioned to betablocker and diuretic on post operative day one allowing nicardipine to be weaned off. He continued to progress and was transitioned to the floor. Chest tubes and epicardial wires were removed per protocol. He developed nausea and medications were adjusted including pain medications and bowel medications. It resolved after bowel movement and scopolamine patch. He was then able to tolerate oral intake. He worked with physical therapy on strength and mobility with recommendation for home with services. He was clinically stable, tolerating diet and pain controlled with acetaminophen at time of discharge home on post operative day four. Plan to have labs checked in few days due to recent addition of Ace inhibitor due to recent NSTEMI. Medications on Admission: 1. Rosuvastatin Calcium 20 mg PO QPM 2. MetFORMIN (Glucophage) 1000 mg PO BID 3. GlipiZIDE 5 mg PO BID 4. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Aspirin EC 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Furosemide 40 mg PO DAILY Duration: 7 Days RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*7 Tablet Refills:*0 5. Lisinopril 2.5 mg PO DAILY RX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 6. Metoprolol Tartrate 50 mg PO BID RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second Line 8. Scopolamine Patch 1 PTCH TD ONCE nausea Duration: 72 Hours remove [MASKED]. Senna 17.2 mg PO DAILY change to as needed if loose stool RX *sennosides 8.6 mg 2 tablets by mouth once a day Disp #*60 Tablet Refills:*0 10. Omeprazole 40 mg PO DAILY 40 mg for 1 month daily then decrease back to 20 mg daily as prior to admission RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 11. Rosuvastatin Calcium 40 mg PO QPM RX *rosuvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 12. GlipiZIDE 5 mg PO BID 13. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Coronary Artery Disease s/p coronary revascularization Non-ST Elevation Myocardial Infarction Secondary Diagnosis: Diabetes Mellitus Type II Gastritis Hyperlipidemia Hypertension Discharge Condition: Alert and oriented x3, non-focal Ambulating, gait steady Sternal pain managed with acetaminophen Sternal Incision - healing well, no erythema or drainage Left Leg EVH - healing well, no erythema or drainage Edema trace 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 Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours** Followup Instructions: [MASKED]
|
[] |
[
"D62",
"I2510",
"Z87891",
"E785",
"I10",
"E119",
"K5900"
] |
[
"I214: Non-ST elevation (NSTEMI) myocardial infarction",
"D62: Acute posthemorrhagic anemia",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z87891: Personal history of nicotine dependence",
"E785: Hyperlipidemia, unspecified",
"I10: Essential (primary) hypertension",
"E119: Type 2 diabetes mellitus without complications",
"K2970: Gastritis, unspecified, without bleeding",
"T39395A: Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], initial encounter",
"R110: Nausea",
"K5900: Constipation, unspecified"
] |
10,030,753
| 20,090,856
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ___
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___.
Chief Complaint:
Traumatic Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old woman with multiple medical comorbidities,
including CAD s/p multiple ___ recently ___ on
ticragelor and aspirin, DM1 c/b ESRD s/p renal transplant on
immunosuppressing agents, who presented after unwitnessed fall
and was found to have left subarachnoid hemorrhage.
History provided by patient and family (niece who is a ___
___). Per patient, she ___ been getting progressively weaker
over the past few months, noting that she never recovered to her
baseline following her coronary angioplasty on ___, which
included PCI of Cx and OM with DES. Of note, she ___ a
complicated cardiac history which includes DES to LAD (___) and
Cx/OM ___ DES to LAD ___.
Patient reports not being able to mobilize around the house as
well as she used to due to her decreased sensation, which ___
been at baseline in the setting of dysautonomia. She reports
frequently having her knees buckle under her. She also ___ been
having episodes of orthostasis after taking furosemide for her
CHFrEF (EF41% ___. In the days prior to her fall, the patient
notes that her continuous glucose monitor was malfunctioning,
reading blood glucose levels of ___ with corresponding finger
sticks in the 200s. For this reason, she discontinued her
continuous glucose monitor. She says that she got up in the
middle of the night to walk to the bathroom and fell to the
floor
on her right side. She does not recall how she felt prior to her
fall. She does not remember feeling dizzy or hot and she did not
wake up sweating. She had no incontinence or tongue lacerations.
She did endorse right-sided pain and pulled herself up to
standing. The next day she still felt sick with nausea,
diarrhea,
right-sided rib pain and was worried about having a rib
fracture.
She called her niece (a nurse) who recommended that she call EMS
due to the snow storm. She was initially brought to ___
where she was found to have glucose 400s with NCHCT demonstrated
right SAH. She was transferred to ___ for further management.
She was initially admitted to the ICU for monitoring of her
subarachnoid hemorrhage and correction of nonketotic
hyperosmolar hyperglycemia. Repeat non con head CT was stable
and her neurological exam remained stable. Her hyperglycemia
resolved s/p transient control with IV insulin. She was deemed
clinically stable to transfer to the general floor after one day
in the ICU for medical management and support of her labile
blood glucose levels. Cardiac workup notable for troponin 0.18,
downtrending to 0.17, with normal CK and without signs of
ischemic changes on EKG.
On admission to ICU:
- insulin gtt transitioned off, blood glucose labile (40s, then
stable on humalog and lantus); ___ consulted.
- repeat non-con head CT unchanged with stable neuro exam
- received 1U Platelets, 1U PRBC for Hgb 6.7, PLT 260s while on
anti-platelet with appropriate correction
Past Medical History:
Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
Hypertension
Dyslipidemia
CAD with PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___. Then DES to LAD in ___ and ___ PCI of Cx and OM with ___
___ w/ CREST syndrome
Gastroparesis
GERD
Hiatal hernia
Gout
OSA
End-stage renal disease due diabetes s/p L-sided living kidney
transplant in ___
anemia
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
Admission exam:
T:98.2 BP:164/75 HR:97 RR:16 O2Sats:99%
Gen:
HEENT: Pupils:4mm bilaterally EOMs Full
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and ___.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light sluggishly,4mm to
3 mm bilaterally, hx of Laser eye surgery.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Unable to assess pronator drift r/t right rib pain.
Motor:
Patient with generalized weakness
TrapDeltoidBicepTricepGrip
Right 4 4 4 4 4
Left 4 4 4 4 4
IPQuadHamATEHLGast
Right4 4 4 4 2 4
Left4 4 4 4+ 2 4
*Exam limited r/t pain
Sensation: peripheral neuropathy to bil hands and bilateral
lower
extremity from knees down
DISCHARGE EXAM:
VITALS: 98.5F 128/65 83 18 94% FSBG 223
General: alert, oriented, no acute distress, flattened affect
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, holosystolic murmur
heard best in the left upper sternal border, no rubs and gallops
Abdomen: Diffusely distended and tympanitic, tender in RUQ near
ribs, no rebound tenderness or guarding, organomegaly not
assessed due to distention
GU: Foley in place for "straight cath"
Ext: warm, several scabbed lesions appreciated on feet, no
edema
Neuro: GCS 15, ___ strength in lower extremities bilaterally
Pertinent Results:
___ 09:01AM BLOOD WBC-4.7 RBC-2.77* Hgb-8.4* Hct-25.4*
MCV-92 MCH-30.3 MCHC-33.1 RDW-15.1 RDWSD-49.7* Plt ___
___ 08:13PM BLOOD Neuts-96.2* Lymphs-1.9* Monos-1.1*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-4.58 AbsLymp-0.09*
AbsMono-0.05* AbsEos-0.01* AbsBaso-0.01
___ 09:01AM BLOOD Plt ___
___ 09:01AM BLOOD Glucose-59* UreaN-56* Creat-2.3* Na-145
K-3.7 Cl-117* HCO3-13* AnGap-15
___ 01:50AM BLOOD Glucose-174* UreaN-57* Creat-2.3* Na-143
K-3.8 Cl-115* HCO3-12* AnGap-16
___ 09:01AM BLOOD CK(CPK)-145
___ 09:01AM BLOOD CK-MB-4 cTropnT-0.17*
___ 01:50AM BLOOD CK-MB-3 cTropnT-0.18*
___ 09:01AM BLOOD Calcium-7.3* Phos-2.7 Mg-2.5
___ 01:50AM BLOOD Calcium-6.9* Phos-2.5* Mg-1.8
___ 08:13PM BLOOD Calcium-7.2* Phos-2.5* Mg-0.7*
NCHCT:
FINDINGS:
Re-demonstrated is right sided subarachnoid hemorrhage, centered
in the
sylvian fissure. No extension or new hemorrhage is identified.
Basal ganglia calcifications are unchanged. No new large
territorial infarct or mass effect. There is prominence of the
ventricles and sulci suggestive of involutional changes.
There is no evidence of 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:
-Essentially unchanged examination from 11 hours prior.
___ MRA:
IMPRESSION:
1. Study is moderately degraded by motion.
2. New left SCA focal occlusion versus high-grade stenosis
compared to ___
prior exam.
3. New nonocclusive irregularity of right M1 segment compared to
___ prior
exam, likely artifactual as described.
4. Otherwise grossly patent circle of ___ as described.
___ CT Torso
1. Nonspecific small volume ascites along the left
paracolic gutter and spleen. Splenic or colonic injury cannot be
excluded on this unenhanced exam. Recommend contrast-enhanced CT
or MRI if possible to further evaluate.
2. 2.1 x 1.4 cm hypodensity in the region of the pancreatic head
is probably a pancreatic lesion rather than duodenal
diverticulum. 1 cm exophytic hypodensity off anterior aspect of
the pancreatic body. No main pancreatic ductal dilation. Lesions
are incompletely characterized without intravenous contrast and
a
contrast enhanced CT or MRI if possible is recommended to
further
evaluate and exclude
malignancy.
3. Nonspecific mesenteric fat stranding and multiple scattered
prominent lymph nodes throughout the abdomen and pelvis, AP and
not enlarged by size criteria.
4. Mild soft tissue fat stranding along the right flank. No
evidence of rib fracture.
5. Anemia.
6. Prominent main pulmonary artery suggests sequelae of chronic
pulmonary hypertension.
7. Status post left lower quadrant renal transplant, stable in
appearance. Markedly atrophic native kidneys.
8. Markedly distended urinary bladder.
Discharge labs:
___ 06:35AM BLOOD WBC-7.1 RBC-2.84* Hgb-8.6* Hct-25.7*
MCV-91 MCH-30.3 MCHC-33.5 RDW-15.7* RDWSD-51.2* Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:35AM BLOOD Glucose-214* UreaN-70* Creat-2.6* Na-140
K-4.2 Cl-105 HCO3-19* AnGap-16
___ 06:35AM BLOOD Calcium-8.0* Phos-4.2 Mg-1.7
___ 06:35AM BLOOD Cyclspr-75*
Brief Hospital Course:
___ year old woman with multiple medical comorbidities, including
CAD s/p multiple ___ recently ___ on ticragelor and
aspirin, DM1 c/b ESRD s/p living donor renal transplant on
immunosuppressing agents, who presented after unwitnessed fall
and was found to have left subarachnoid hemorrhage. Etiology of
her SAH thought to be traumatic in the setting of her fall. Fall
was most likely related to hyperglycemia with component of
orthostatic hypotension/dysautonomia.
#Left ___
Patient presented after traumatic fall, and was admitted to the
Neuro ICU for monitoring of a subarachnoid hemorrhage and
correction of nonketotic hyperosmolar hyperglycemia. Fall was
likely secondary to labile blood sugars with components of
dysautonomia and orthostatic hypotension. EKG was reassuring for
arrhythmia as cause of syncope. No incontinence or tongue
lacerations or report of post-ictal state so seizure unlikely.
Repeat non con head CT showed stability of her bleed, and her
neurological exam remained stable. She was deemed clinically
stable to transfer to the general floor after one day in the ICU
for medical management. On the floor, a repeat MRA brain w/o
contrast that showed grossly patent circle of ___ without
concern for aneurysm. Patient complained of some left sided
lower extremity weakness, however trended Neuro exams were found
to be stable and not significant for new weakness. Neurosurgery
was consulted for management of ___ and trending of Neuro exam.
Blood pressures were closely monitored for a goal of systolic
<160.
Fall was believed likely traumatic. Low suspicion for aneurysmal
rupture. Etiology of fall thought to be related to labile blood
glucose levels with exacerbation from underlying dysautonomia.
Unlikely to be syncopal event from cardiac etiology based on
normal EKG, and normal cardiac enzymes. Fall could be related to
unwitnessed seizures, possibly triggered by labile glucose
levels, although no incontinence or tongue lacerations and no
documentation or report of postictal state. Patient was given
lidocaine patches and analgesics for pain ___ contusions from
fall. ___ consulted for weakness, recommendation for rehab.
#Supine Hypertension/Orthostatic Hypotension/Dysautonomia
Patient had very labile blood pressures while in-house ranging
from 110-202 systolic. Per Neuro-surgery, patient was not at
risk for SAH re-bleed, however, goal to keep systolic <160 to
prevent increased intracranial pressures. In consultation with
Renal Transplant, long-acting anti-hypertensives were favored
for better monitoring of pressures throughout the day. Home
Metoprolol succinate was transitioned to Metoprolol XL 100 mg,
and home Hydralazine 50 mg qHS was maintained throughout
admission, however pressures continued to be significant for
supine hypertensive urgency. Orthostatic vitals were done over
the course of 2 days, and patient was found to be orthostatic
intermittently. CCB were considered as additional agents,
however patient reports significant orthostatic hypotension with
these agents. Captopril was deemed to be too short-acting. A
trial of Losartan was considered, however, given patient's
intermittent orthostatic vitals, high risk of falls, and
pressures in target range of 130-150's systolic when
sitting/standing, an additional agent was not started but may be
considered in the outpatient setting. She was treated with 50mg
PO hydralazine as needed.
#Type 1 Diabetes Mellitus
Patient presented with hyperglycemia to the 600's. She was
brought to the Neuro ICU for her SAH, where an insulin drip
rapidly corrected her blood sugars to the 40-200's. On the
floor, Lantus was restarted in consultation with ___
___, and insulin regimen was dosed daily to good effect. She
maintained normal to low normal blood sugars with Lantus 10U qAM
+/- 5UqPM, ___ fixed dose Humalog at meals +/- ISS. Prior to
discharge she was receiving 8U AM, her Humalog dose was 2U with
meals.
#Incidental Pancreatic Mass
A non-con CT Torso at ___ was significant for 2.1 x
1.4 cm hypodensity in the region of the pancreatic head and a 1
cm exophytic hypodensity off anterior aspect of the pancreatic
body, cannot r/o malignancy. Masses were poorly characterized
without contrast, however patient's ESRD and transplanted kidney
limited imaging modalities to fully characterize the findings.
GI was consulted for an esophageal ultrasound, however, it was
recommended waiting ___ weeks for outpatient EUS to prevent SAH
re-bleed in the setting of increased intracranial pressure ___
anesthesia for the procedure.
#Anemia
Admission H/H of 7.2/21.8 which downtrended to 6.2/19.4. Patient
was given a unit of pRBCs to good effect. Outpatient notes
significant for chronic anemia. Iron/anemia labs significant for
low-normal iron with low iron/TIBC ratio (19%), normal B12, a
low-normal folate, and elevated ferritin. Patient started on
multivitamins and folate supplements. A stool guaiac was ordered
but could not be performed due to lack of specimen while in
house. Recommend hematology work-up as outpatient.
#Gastroparesis
#Nausea/Vomiting/Diarrhea
Patient reported weeks of nausea, vomiting, and diarrhea prior
to admission, though patient did not experience these symptoms
on the medical floor. An infectious work-up was negative. Prior
nausea/vomiting likely secondary to diabetic gastroparesis and
elevated blood glucose at home. N/V likely not related to SAH
given chronic time course.
#Neurogenic Bladder
Patient ___ neurogenic bladder secondary to Diabetes
complications, for which she straight caths at home. Patient was
bladder scanned regularly and straight-cathed appropriately.
#CAD/HFREF
Hx of CAD, no s/p multiple Percutaneous coronary interventions.
Resumed home ASA/Brillinta after repeat imaging showed stability
of SAH. Continued home furosemide 20mg PRN volume exam, however
patient remained euvolemic in-house.
# ESRD s/p LDRT ___
Continued home immunosuppression, cyclosporine, MMF, and
prednisone. Serum cyclosporine and creatinine were monitored
daily. Low bicarb- likely secondary to GI and renal losses- was
treated with sodium bicarbonate. Renal transplant following
throughout admission.
=============================
Transitional Issues
=============================
[] Pancreatic mass: CT Torso at ___ with incompletely
characterized pancreatic lesions not noted on prior CT torso. GI
to schedule esophageal US as outpatient and pt ___ appointment
with Dr. ___ GI on ___.
[]f/u ___ clinic with Dr. ___. Please call ___
for appointment.
[]f/u with Hematology for chronic anemia, appointment ___ been
scheduled
[]Patient will need to call number on back of CGM to order new
CGM from Dexicom
[]Consider DCing Cilostazol, as may be contra-indicated in ___
patients
[]Consider starting Losartan for elevated pressures if not
orthostatic as outpatient.
[]Pt will need to call ___ to schedule an appointment
with Dr. ___ in ___ clinic.
[] Foley was placed for urinary retention of 1000cc iso patient
preference for foley over straight catherization; please perform
void trial at rehab
[] continue to monitor cyclosporine level, Goal 75-125.
[] Pt intermittently required extra doses of hydralazine 50mg PO
to control blood pressures in the 180s-200s systolic
[] check weekly chemistry levels and assess if sodium
bicarbonate dose is adequate
[] consider IV iron if patient still iron deficient since PO
iron can be very constipating
I have seen and examined Ms. ___, reviewed the findings,
data, and plan of care documented by Dr. ___
___, MD dated ___ and agree, except for any
additional comments below.
Ms. ___ is clinically stable for discharge today, ___.
The total time spent today on discharge planning, counseling and
coordination of care today was greater than 30 minutes.
___, MD
___ of ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Calcitriol 0.25 mcg PO DAILY
7. Calcium Carbonate 500 mg PO BID
8. Cilostazol 50 mg PO QPM
9. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
10. Esomeprazole 40 mg Other BID
11. Ferrous Sulfate 325 mg PO DAILY
12. HydrALAZINE 50 mg PO QHS
13. Levothyroxine Sodium 125 mcg PO DAILY
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Mycophenolate Mofetil 500 mg PO BID
16. PredniSONE 6 mg PO DAILY
17. Promethazine 25 mg PO DAILY PRN nausea
18. Ranolazine ER 500 mg PO BID
19. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
20. Vitamin D ___ UNIT PO DAILY
21. Cilostazol 100 mg PO QAM
22. Furosemide 20 mg PO DAILY
23. melatonin 10 mg oral QHS
24. Metoprolol Succinate XL 25 mg PO DAILY
25. naftifine 2 % topical BID To soles of feet and between toe
webs
26. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
27. Toujeo SoloStar (insulin glargine) 36 Units subcutaneous Q
Breakfast
28. Captopril 12.5 mg PO BID PRN SBP > 160
29. trimethobenzamide 300 mg oral BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. FoLIC Acid 1 mg PO DAILY
4. Glargine 8 Units Breakfast
Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Multivitamins 1 TAB PO DAILY
6. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*10 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Sodium Bicarbonate 1300 mg PO TID
9. Furosemide 20 mg PO DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Allopurinol ___ mg PO DAILY
12. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
13. Ascorbic Acid ___ mg PO DAILY
14. Aspirin 81 mg PO DAILY
15. Atorvastatin 20 mg PO QPM
16. Calcitriol 0.25 mcg PO DAILY
17. Calcium Carbonate 500 mg PO BID
18. Cilostazol 50 mg PO QPM
19. Cilostazol 100 mg PO QAM
20. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
21. Esomeprazole 40 mg Other BID
22. Ferrous Sulfate 325 mg PO DAILY
23. HydrALAZINE 50 mg PO QHS
24. Levothyroxine Sodium 125 mcg PO DAILY
25. Lidocaine 5% Patch 1 PTCH TD QAM
26. melatonin 10 mg oral QHS
27. Mycophenolate Mofetil 500 mg PO BID
28. naftifine 2 % topical BID To soles of feet and between toe
webs
29. PredniSONE 6 mg PO DAILY
30. Promethazine 25 mg PO DAILY PRN nausea
31. Ranolazine ER 500 mg PO BID
32. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
33. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
34. Trimethobenzamide 300 mg oral BID
35. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Subarachnoid Hemorrhage
Nonketotic hyperosmolar hyperglycemic state
Type 1 Diabetes Mellitus
Hypertension
Orthostatic Hypotension
Neurogenic Bladder
ESRD status post living donor transplant
Anemia
Secondary diagnoses:
Gastroparesis
Pancreatic mass
CAD s/p ___ Failure with reduced ejection fraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ were admitted to the hospital after ___ suffered from a head
injury when ___ fell. ___ were initially admitted to the
neurosurgery ICU because ___ suffered from a small amount of
blood in your brain (subarachnoid hemorrhage), which occurred
when ___ hit your head.
On admission to the hospital, we found that your blood sugar
levels were high. We think that changes in your blood sugar
levels may have contributed to your fall. We adjusted your
insulin and were able to keep your blood sugars in a normal
range.
We initially held your aspirin and brilanta but restarted it on
___. We imaged your brain arteries to obtain a more
comprehensive picture of the blood in your head. Your MRA showed
that the bleeding had stopped and that your brain arteries were
not clogged. We recommend that ___ try to keep your blood
pressure below 160 to protect your brain from having another
bleed.
While ___ were at ___ ___ had a picture taken of
your belly which showed a pancreatic mass. We cannot tell what
this mass is because the quality of the picture was limited.
Unfortunately, we cannot improve the quality of the picture
because it may cause damage to your kidney transplant.
Therefore, we have scheduled ___ for an outpatient esophageal
ultrasound- another type of picture that will not hurt your
kidneys- to try to get a better look at your pancreas. We were
not able to do this in the hospital because we were worried that
if ___ vomited while getting the anesthesia needed for the
ultrasound, it might make your brain bleed worse. It will be
safer to get this ultrasound done in a week or so when ___ have
healed more.
What ___ should do when ___ get home:
-Work on getting stronger at rehab.
-Continue to monitor your blood pressure and take your blood
pressure medications. Try to keep your blood pressure in the
120-150's to protect your brain from re-bleeding.
-Continue to monitor your blood glucose closely, and take your
insulin. ___ will need a new continuous glucose monitor. Please
call the phone number on the back of your current CGM to order a
new one.
-Follow up in the dysautonomia, hematology, GI, traumatic brain
injury clinics to make sure that ___ are healing well.
-Take great care when ___ get up from lying down or sitting to
prevent yourself from falling again.
Medication changes on this admission:
-We changed your metoprolol succinate to 100 mg Metoprolol XL.
XL is the longer acting form of the medication and will help
control your blood pressure.
-We changed your insulin to 8U Lantus in the morning and 2U
Humalog before meals
Thank ___ for allowing us to participate in your care.
Take Care,
Your SIRS General ___ ___ Team
Followup Instructions:
___
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Allergies: Penicillins / Ativan / carvedilol / amlodipine Chief Complaint: Traumatic Fall Major Surgical or Invasive Procedure: None History of Present Illness: This is a [MASKED] year old woman with multiple medical comorbidities, including CAD s/p multiple [MASKED] recently [MASKED] on ticragelor and aspirin, DM1 c/b ESRD s/p renal transplant on immunosuppressing agents, who presented after unwitnessed fall and was found to have left subarachnoid hemorrhage. History provided by patient and family (niece who is a [MASKED] [MASKED]). Per patient, she [MASKED] been getting progressively weaker over the past few months, noting that she never recovered to her baseline following her coronary angioplasty on [MASKED], which included PCI of Cx and OM with DES. Of note, she [MASKED] a complicated cardiac history which includes DES to LAD ([MASKED]) and Cx/OM [MASKED] DES to LAD [MASKED]. Patient reports not being able to mobilize around the house as well as she used to due to her decreased sensation, which [MASKED] been at baseline in the setting of dysautonomia. She reports frequently having her knees buckle under her. She also [MASKED] been having episodes of orthostasis after taking furosemide for her CHFrEF (EF41% [MASKED]. In the days prior to her fall, the patient notes that her continuous glucose monitor was malfunctioning, reading blood glucose levels of [MASKED] with corresponding finger sticks in the 200s. For this reason, she discontinued her continuous glucose monitor. She says that she got up in the middle of the night to walk to the bathroom and fell to the floor on her right side. She does not recall how she felt prior to her fall. She does not remember feeling dizzy or hot and she did not wake up sweating. She had no incontinence or tongue lacerations. She did endorse right-sided pain and pulled herself up to standing. The next day she still felt sick with nausea, diarrhea, right-sided rib pain and was worried about having a rib fracture. She called her niece (a nurse) who recommended that she call EMS due to the snow storm. She was initially brought to [MASKED] where she was found to have glucose 400s with NCHCT demonstrated right SAH. She was transferred to [MASKED] for further management. She was initially admitted to the ICU for monitoring of her subarachnoid hemorrhage and correction of nonketotic hyperosmolar hyperglycemia. Repeat non con head CT was stable and her neurological exam remained stable. Her hyperglycemia resolved s/p transient control with IV insulin. She was deemed clinically stable to transfer to the general floor after one day in the ICU for medical management and support of her labile blood glucose levels. Cardiac workup notable for troponin 0.18, downtrending to 0.17, with normal CK and without signs of ischemic changes on EKG. On admission to ICU: - insulin gtt transitioned off, blood glucose labile (40s, then stable on humalog and lantus); [MASKED] consulted. - repeat non-con head CT unchanged with stable neuro exam - received 1U Platelets, 1U PRBC for Hgb 6.7, PLT 260s while on anti-platelet with appropriate correction Past Medical History: Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) Hypertension Dyslipidemia CAD with PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED]. Then DES to LAD in [MASKED] and [MASKED] PCI of Cx and OM with [MASKED] [MASKED] w/ CREST syndrome Gastroparesis GERD Hiatal hernia Gout OSA End-stage renal disease due diabetes s/p L-sided living kidney transplant in [MASKED] anemia Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: Admission exam: T:98.2 BP:164/75 HR:97 RR:16 O2Sats:99% Gen: HEENT: Pupils:4mm bilaterally EOMs Full Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and [MASKED]. Recall: [MASKED] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light sluggishly,4mm to 3 mm bilaterally, hx of Laser eye surgery. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Unable to assess pronator drift r/t right rib pain. Motor: Patient with generalized weakness TrapDeltoidBicepTricepGrip Right 4 4 4 4 4 Left 4 4 4 4 4 IPQuadHamATEHLGast Right4 4 4 4 2 4 Left4 4 4 4+ 2 4 *Exam limited r/t pain Sensation: peripheral neuropathy to bil hands and bilateral lower extremity from knees down DISCHARGE EXAM: VITALS: 98.5F 128/65 83 18 94% FSBG 223 General: alert, oriented, no acute distress, flattened affect Lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi CV: regular rate and rhythm, normal S1 + S2, holosystolic murmur heard best in the left upper sternal border, no rubs and gallops Abdomen: Diffusely distended and tympanitic, tender in RUQ near ribs, no rebound tenderness or guarding, organomegaly not assessed due to distention GU: Foley in place for "straight cath" Ext: warm, several scabbed lesions appreciated on feet, no edema Neuro: GCS 15, [MASKED] strength in lower extremities bilaterally Pertinent Results: [MASKED] 09:01AM BLOOD WBC-4.7 RBC-2.77* Hgb-8.4* Hct-25.4* MCV-92 MCH-30.3 MCHC-33.1 RDW-15.1 RDWSD-49.7* Plt [MASKED] [MASKED] 08:13PM BLOOD Neuts-96.2* Lymphs-1.9* Monos-1.1* Eos-0.2* Baso-0.2 Im [MASKED] AbsNeut-4.58 AbsLymp-0.09* AbsMono-0.05* AbsEos-0.01* AbsBaso-0.01 [MASKED] 09:01AM BLOOD Plt [MASKED] [MASKED] 09:01AM BLOOD Glucose-59* UreaN-56* Creat-2.3* Na-145 K-3.7 Cl-117* HCO3-13* AnGap-15 [MASKED] 01:50AM BLOOD Glucose-174* UreaN-57* Creat-2.3* Na-143 K-3.8 Cl-115* HCO3-12* AnGap-16 [MASKED] 09:01AM BLOOD CK(CPK)-145 [MASKED] 09:01AM BLOOD CK-MB-4 cTropnT-0.17* [MASKED] 01:50AM BLOOD CK-MB-3 cTropnT-0.18* [MASKED] 09:01AM BLOOD Calcium-7.3* Phos-2.7 Mg-2.5 [MASKED] 01:50AM BLOOD Calcium-6.9* Phos-2.5* Mg-1.8 [MASKED] 08:13PM BLOOD Calcium-7.2* Phos-2.5* Mg-0.7* NCHCT: FINDINGS: Re-demonstrated is right sided subarachnoid hemorrhage, centered in the sylvian fissure. No extension or new hemorrhage is identified. Basal ganglia calcifications are unchanged. No new large territorial infarct or mass effect. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of 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: -Essentially unchanged examination from 11 hours prior. [MASKED] MRA: IMPRESSION: 1. Study is moderately degraded by motion. 2. New left SCA focal occlusion versus high-grade stenosis compared to [MASKED] prior exam. 3. New nonocclusive irregularity of right M1 segment compared to [MASKED] prior exam, likely artifactual as described. 4. Otherwise grossly patent circle of [MASKED] as described. [MASKED] CT Torso 1. Nonspecific small volume ascites along the left paracolic gutter and spleen. Splenic or colonic injury cannot be excluded on this unenhanced exam. Recommend contrast-enhanced CT or MRI if possible to further evaluate. 2. 2.1 x 1.4 cm hypodensity in the region of the pancreatic head is probably a pancreatic lesion rather than duodenal diverticulum. 1 cm exophytic hypodensity off anterior aspect of the pancreatic body. No main pancreatic ductal dilation. Lesions are incompletely characterized without intravenous contrast and a contrast enhanced CT or MRI if possible is recommended to further evaluate and exclude malignancy. 3. Nonspecific mesenteric fat stranding and multiple scattered prominent lymph nodes throughout the abdomen and pelvis, AP and not enlarged by size criteria. 4. Mild soft tissue fat stranding along the right flank. No evidence of rib fracture. 5. Anemia. 6. Prominent main pulmonary artery suggests sequelae of chronic pulmonary hypertension. 7. Status post left lower quadrant renal transplant, stable in appearance. Markedly atrophic native kidneys. 8. Markedly distended urinary bladder. Discharge labs: [MASKED] 06:35AM BLOOD WBC-7.1 RBC-2.84* Hgb-8.6* Hct-25.7* MCV-91 MCH-30.3 MCHC-33.5 RDW-15.7* RDWSD-51.2* Plt [MASKED] [MASKED] 06:35AM BLOOD Plt [MASKED] [MASKED] 06:35AM BLOOD Glucose-214* UreaN-70* Creat-2.6* Na-140 K-4.2 Cl-105 HCO3-19* AnGap-16 [MASKED] 06:35AM BLOOD Calcium-8.0* Phos-4.2 Mg-1.7 [MASKED] 06:35AM BLOOD Cyclspr-75* Brief Hospital Course: [MASKED] year old woman with multiple medical comorbidities, including CAD s/p multiple [MASKED] recently [MASKED] on ticragelor and aspirin, DM1 c/b ESRD s/p living donor renal transplant on immunosuppressing agents, who presented after unwitnessed fall and was found to have left subarachnoid hemorrhage. Etiology of her SAH thought to be traumatic in the setting of her fall. Fall was most likely related to hyperglycemia with component of orthostatic hypotension/dysautonomia. #Left [MASKED] Patient presented after traumatic fall, and was admitted to the Neuro ICU for monitoring of a subarachnoid hemorrhage and correction of nonketotic hyperosmolar hyperglycemia. Fall was likely secondary to labile blood sugars with components of dysautonomia and orthostatic hypotension. EKG was reassuring for arrhythmia as cause of syncope. No incontinence or tongue lacerations or report of post-ictal state so seizure unlikely. Repeat non con head CT showed stability of her bleed, and her neurological exam remained stable. She was deemed clinically stable to transfer to the general floor after one day in the ICU for medical management. On the floor, a repeat MRA brain w/o contrast that showed grossly patent circle of [MASKED] without concern for aneurysm. Patient complained of some left sided lower extremity weakness, however trended Neuro exams were found to be stable and not significant for new weakness. Neurosurgery was consulted for management of [MASKED] and trending of Neuro exam. Blood pressures were closely monitored for a goal of systolic <160. Fall was believed likely traumatic. Low suspicion for aneurysmal rupture. Etiology of fall thought to be related to labile blood glucose levels with exacerbation from underlying dysautonomia. Unlikely to be syncopal event from cardiac etiology based on normal EKG, and normal cardiac enzymes. Fall could be related to unwitnessed seizures, possibly triggered by labile glucose levels, although no incontinence or tongue lacerations and no documentation or report of postictal state. Patient was given lidocaine patches and analgesics for pain [MASKED] contusions from fall. [MASKED] consulted for weakness, recommendation for rehab. #Supine Hypertension/Orthostatic Hypotension/Dysautonomia Patient had very labile blood pressures while in-house ranging from 110-202 systolic. Per Neuro-surgery, patient was not at risk for SAH re-bleed, however, goal to keep systolic <160 to prevent increased intracranial pressures. In consultation with Renal Transplant, long-acting anti-hypertensives were favored for better monitoring of pressures throughout the day. Home Metoprolol succinate was transitioned to Metoprolol XL 100 mg, and home Hydralazine 50 mg qHS was maintained throughout admission, however pressures continued to be significant for supine hypertensive urgency. Orthostatic vitals were done over the course of 2 days, and patient was found to be orthostatic intermittently. CCB were considered as additional agents, however patient reports significant orthostatic hypotension with these agents. Captopril was deemed to be too short-acting. A trial of Losartan was considered, however, given patient's intermittent orthostatic vitals, high risk of falls, and pressures in target range of 130-150's systolic when sitting/standing, an additional agent was not started but may be considered in the outpatient setting. She was treated with 50mg PO hydralazine as needed. #Type 1 Diabetes Mellitus Patient presented with hyperglycemia to the 600's. She was brought to the Neuro ICU for her SAH, where an insulin drip rapidly corrected her blood sugars to the 40-200's. On the floor, Lantus was restarted in consultation with [MASKED] [MASKED], and insulin regimen was dosed daily to good effect. She maintained normal to low normal blood sugars with Lantus 10U qAM +/- 5UqPM, [MASKED] fixed dose Humalog at meals +/- ISS. Prior to discharge she was receiving 8U AM, her Humalog dose was 2U with meals. #Incidental Pancreatic Mass A non-con CT Torso at [MASKED] was significant for 2.1 x 1.4 cm hypodensity in the region of the pancreatic head and a 1 cm exophytic hypodensity off anterior aspect of the pancreatic body, cannot r/o malignancy. Masses were poorly characterized without contrast, however patient's ESRD and transplanted kidney limited imaging modalities to fully characterize the findings. GI was consulted for an esophageal ultrasound, however, it was recommended waiting [MASKED] weeks for outpatient EUS to prevent SAH re-bleed in the setting of increased intracranial pressure [MASKED] anesthesia for the procedure. #Anemia Admission H/H of 7.2/21.8 which downtrended to 6.2/19.4. Patient was given a unit of pRBCs to good effect. Outpatient notes significant for chronic anemia. Iron/anemia labs significant for low-normal iron with low iron/TIBC ratio (19%), normal B12, a low-normal folate, and elevated ferritin. Patient started on multivitamins and folate supplements. A stool guaiac was ordered but could not be performed due to lack of specimen while in house. Recommend hematology work-up as outpatient. #Gastroparesis #Nausea/Vomiting/Diarrhea Patient reported weeks of nausea, vomiting, and diarrhea prior to admission, though patient did not experience these symptoms on the medical floor. An infectious work-up was negative. Prior nausea/vomiting likely secondary to diabetic gastroparesis and elevated blood glucose at home. N/V likely not related to SAH given chronic time course. #Neurogenic Bladder Patient [MASKED] neurogenic bladder secondary to Diabetes complications, for which she straight caths at home. Patient was bladder scanned regularly and straight-cathed appropriately. #CAD/HFREF Hx of CAD, no s/p multiple Percutaneous coronary interventions. Resumed home ASA/Brillinta after repeat imaging showed stability of SAH. Continued home furosemide 20mg PRN volume exam, however patient remained euvolemic in-house. # ESRD s/p LDRT [MASKED] Continued home immunosuppression, cyclosporine, MMF, and prednisone. Serum cyclosporine and creatinine were monitored daily. Low bicarb- likely secondary to GI and renal losses- was treated with sodium bicarbonate. Renal transplant following throughout admission. ============================= Transitional Issues ============================= [] Pancreatic mass: CT Torso at [MASKED] with incompletely characterized pancreatic lesions not noted on prior CT torso. GI to schedule esophageal US as outpatient and pt [MASKED] appointment with Dr. [MASKED] GI on [MASKED]. []f/u [MASKED] clinic with Dr. [MASKED]. Please call [MASKED] for appointment. []f/u with Hematology for chronic anemia, appointment [MASKED] been scheduled []Patient will need to call number on back of CGM to order new CGM from Dexicom []Consider DCing Cilostazol, as may be contra-indicated in [MASKED] patients []Consider starting Losartan for elevated pressures if not orthostatic as outpatient. []Pt will need to call [MASKED] to schedule an appointment with Dr. [MASKED] in [MASKED] clinic. [] Foley was placed for urinary retention of 1000cc iso patient preference for foley over straight catherization; please perform void trial at rehab [] continue to monitor cyclosporine level, Goal 75-125. [] Pt intermittently required extra doses of hydralazine 50mg PO to control blood pressures in the 180s-200s systolic [] check weekly chemistry levels and assess if sodium bicarbonate dose is adequate [] consider IV iron if patient still iron deficient since PO iron can be very constipating I have seen and examined Ms. [MASKED], reviewed the findings, data, and plan of care documented by Dr. [MASKED] [MASKED], MD dated [MASKED] and agree, except for any additional comments below. Ms. [MASKED] is clinically stable for discharge today, [MASKED]. The total time spent today on discharge planning, counseling and coordination of care today was greater than 30 minutes. [MASKED], MD [MASKED] of [MASKED] [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 3. Ascorbic Acid [MASKED] mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Calcitriol 0.25 mcg PO DAILY 7. Calcium Carbonate 500 mg PO BID 8. Cilostazol 50 mg PO QPM 9. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 10. Esomeprazole 40 mg Other BID 11. Ferrous Sulfate 325 mg PO DAILY 12. HydrALAZINE 50 mg PO QHS 13. Levothyroxine Sodium 125 mcg PO DAILY 14. Lidocaine 5% Patch 1 PTCH TD QAM 15. Mycophenolate Mofetil 500 mg PO BID 16. PredniSONE 6 mg PO DAILY 17. Promethazine 25 mg PO DAILY PRN nausea 18. Ranolazine ER 500 mg PO BID 19. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 20. Vitamin D [MASKED] UNIT PO DAILY 21. Cilostazol 100 mg PO QAM 22. Furosemide 20 mg PO DAILY 23. melatonin 10 mg oral QHS 24. Metoprolol Succinate XL 25 mg PO DAILY 25. naftifine 2 % topical BID To soles of feet and between toe webs 26. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 27. Toujeo SoloStar (insulin glargine) 36 Units subcutaneous Q Breakfast 28. Captopril 12.5 mg PO BID PRN SBP > 160 29. trimethobenzamide 300 mg oral BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. FoLIC Acid 1 mg PO DAILY 4. Glargine 8 Units Breakfast Humalog 2 Units Breakfast Humalog 2 Units Lunch Humalog 2 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Multivitamins 1 TAB PO DAILY 6. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - Severe RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #*10 Tablet Refills:*0 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Sodium Bicarbonate 1300 mg PO TID 9. Furosemide 20 mg PO DAILY 10. Metoprolol Succinate XL 100 mg PO DAILY 11. Allopurinol [MASKED] mg PO DAILY 12. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 13. Ascorbic Acid [MASKED] mg PO DAILY 14. Aspirin 81 mg PO DAILY 15. Atorvastatin 20 mg PO QPM 16. Calcitriol 0.25 mcg PO DAILY 17. Calcium Carbonate 500 mg PO BID 18. Cilostazol 50 mg PO QPM 19. Cilostazol 100 mg PO QAM 20. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 21. Esomeprazole 40 mg Other BID 22. Ferrous Sulfate 325 mg PO DAILY 23. HydrALAZINE 50 mg PO QHS 24. Levothyroxine Sodium 125 mcg PO DAILY 25. Lidocaine 5% Patch 1 PTCH TD QAM 26. melatonin 10 mg oral QHS 27. Mycophenolate Mofetil 500 mg PO BID 28. naftifine 2 % topical BID To soles of feet and between toe webs 29. PredniSONE 6 mg PO DAILY 30. Promethazine 25 mg PO DAILY PRN nausea 31. Ranolazine ER 500 mg PO BID 32. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 33. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 34. Trimethobenzamide 300 mg oral BID 35. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary Diagnoses: Subarachnoid Hemorrhage Nonketotic hyperosmolar hyperglycemic state Type 1 Diabetes Mellitus Hypertension Orthostatic Hypotension Neurogenic Bladder ESRD status post living donor transplant Anemia Secondary diagnoses: Gastroparesis Pancreatic mass CAD s/p [MASKED] Failure with reduced ejection fraction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear [MASKED], [MASKED] were admitted to the hospital after [MASKED] suffered from a head injury when [MASKED] fell. [MASKED] were initially admitted to the neurosurgery ICU because [MASKED] suffered from a small amount of blood in your brain (subarachnoid hemorrhage), which occurred when [MASKED] hit your head. On admission to the hospital, we found that your blood sugar levels were high. We think that changes in your blood sugar levels may have contributed to your fall. We adjusted your insulin and were able to keep your blood sugars in a normal range. We initially held your aspirin and brilanta but restarted it on [MASKED]. We imaged your brain arteries to obtain a more comprehensive picture of the blood in your head. Your MRA showed that the bleeding had stopped and that your brain arteries were not clogged. We recommend that [MASKED] try to keep your blood pressure below 160 to protect your brain from having another bleed. While [MASKED] were at [MASKED] [MASKED] had a picture taken of your belly which showed a pancreatic mass. We cannot tell what this mass is because the quality of the picture was limited. Unfortunately, we cannot improve the quality of the picture because it may cause damage to your kidney transplant. Therefore, we have scheduled [MASKED] for an outpatient esophageal ultrasound- another type of picture that will not hurt your kidneys- to try to get a better look at your pancreas. We were not able to do this in the hospital because we were worried that if [MASKED] vomited while getting the anesthesia needed for the ultrasound, it might make your brain bleed worse. It will be safer to get this ultrasound done in a week or so when [MASKED] have healed more. What [MASKED] should do when [MASKED] get home: -Work on getting stronger at rehab. -Continue to monitor your blood pressure and take your blood pressure medications. Try to keep your blood pressure in the 120-150's to protect your brain from re-bleeding. -Continue to monitor your blood glucose closely, and take your insulin. [MASKED] will need a new continuous glucose monitor. Please call the phone number on the back of your current CGM to order a new one. -Follow up in the dysautonomia, hematology, GI, traumatic brain injury clinics to make sure that [MASKED] are healing well. -Take great care when [MASKED] get up from lying down or sitting to prevent yourself from falling again. Medication changes on this admission: -We changed your metoprolol succinate to 100 mg Metoprolol XL. XL is the longer acting form of the medication and will help control your blood pressure. -We changed your insulin to 8U Lantus in the morning and 2U Humalog before meals Thank [MASKED] for allowing us to participate in your care. Take Care, Your SIRS General [MASKED] [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"D62",
"N390",
"Z794",
"I2510",
"Z87891"
] |
[
"S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter",
"E1010: Type 1 diabetes mellitus with ketoacidosis without coma",
"I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified",
"K3184: Gastroparesis",
"M341: CR(E)ST syndrome",
"N186: End stage renal disease",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"D62: Acute posthemorrhagic anemia",
"I5022: Chronic systolic (congestive) heart failure",
"Z940: Kidney transplant status",
"N390: Urinary tract infection, site not specified",
"R402412: Glasgow coma scale score 13-15, at arrival to emergency department",
"W1839XA: Other fall on same level, initial encounter",
"Z794: Long term (current) use of insulin",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z95818: Presence of other cardiac implants and grafts",
"I951: Orthostatic hypotension",
"D631: Anemia in chronic kidney disease",
"N319: Neuromuscular dysfunction of bladder, unspecified",
"Z87891: Personal history of nicotine dependence",
"E876: Hypokalemia",
"E8342: Hypomagnesemia",
"K869: Disease of pancreas, unspecified"
] |
10,030,753
| 20,954,507
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan
Attending: ___
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
___ - Lumbar puncture
History of Present Illness:
Ms. ___ is a ___ woman with a PMH notable for ESRD
s/p LRRT in ___, T1DM, CREST syndrome, CAD s/p MI x2 and DES
x3 in ___, and possible APLS, who presents with confusion,
fevers, and headache.
The patient was somnolent and unable to provide any history on
interview. All information is obtained from the chart. Per
review, the patient first presented to ___ the evening
of ___ after her sister found her at home confused and having
word finding difficulties. In the ___, she was found to
have BP of 220/110, and she received metoprolol IV x2 with
improvement of BP and mental status. She reported at that time
nausea and headache as well. After being admitted to ___,
she was found to have a fever to ___. She a head CT that was
unremarkable. Given concern for meningitis, she was transferred
to ___ for urgent LP.
In the ___ ___, the patient refused to get an LP, which was
declined by her HCP as well. She was seen by the Renal
Transplant Service, who consulted with ID regarding treatment.
Ultimately, she received ceftriaxone and IV Bactrim for listeria
due to penicillin allergy in addition to the IV vancomycin that
she received at ___ prior to transfer.
On arrival to the floor, the patient was somnolent and only
able to respond with one to two word responses.
Review of systems:
(+) Per HPI
Unable to be obtained fully due to patient's mental status.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___,
DES to LAD and Cx/OM ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
- End-stage renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
- Scleroderma w/ CREST syndrome
- Gastroparesis/GERD/Hiatal hernia
- Gout diagnosed ___ years ago
- OSA
NOT ACCURATE: - Antiphospholipid antibody syndrome and remote PE
history on Coumadin ___ - this diagnosis viewed unlikely per
___ hematology/oncology note
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: T 97.5, BP 173/73, HR 76, RR 18, O2 SAT 97% on RA
General: Somnolent, not easily arousable, responds to questions
with only ___ words sentences, does not comply with any
instructions for physical exam
HEENT: Sclerae anicteric; pupils 7-8 mm, symmetric, minimally
responsive
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Poor inspiratory efforts, bibasilar inspiratory crackles
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Unable to comply with exam, no gross asymmetry in
strength or facial musculature
DISCHARGE PHYSICAL EXAM:
=======================
VITALS: 98.2 | 160/71 | 89 | 16 | 95%RA
GENERAL: Awake, alert, laying in bed, no acute distress.
Oriented to ___, year/date, current situation.
HEENT: Sclerae anicteric, MMM, oropharynx clear.
NECK: No lymphadenopathy. +Full active range of motion.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, soft systolic
murmur heard best at left upper sternal border.
ABD: Soft, non-distended, bowel sounds present. No rebound
tenderness or guarding, no organomegaly. Transplanted kidney on
left side, nontender.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Without rashes or lesions on legs, arms, face or back.
NEURO: Pupils roughly equal (L 5mm, R 4mm), but not reactive to
light. Face symmetric. Moving all limbs with purpose against
gravity. Attentive to months of the year backwards from
___. Still does not feel she can recall how to dose her
insulin, but recalled rules card game she had previously
forgotten.
Pertinent Results:
--ADMISSION LABS--
===================
___ 02:10PM BLOOD WBC-8.4# RBC-2.97* Hgb-9.3* Hct-27.0*
MCV-91 MCH-31.3 MCHC-34.4 RDW-12.3 RDWSD-40.3 Plt ___
___ 02:10PM BLOOD Neuts-88.9* Lymphs-4.7* Monos-5.1
Eos-0.5* Baso-0.4 Im ___ AbsNeut-7.46* AbsLymp-0.39*
AbsMono-0.43 AbsEos-0.04 AbsBaso-0.03
___ 07:17AM BLOOD ___ PTT-36.5 ___
___ 02:10PM BLOOD Glucose-117* UreaN-18 Creat-1.4* Na-137
K-4.5 Cl-102 HCO3-24 AnGap-16
___ 02:10PM BLOOD Triglyc-239* HDL-46 CHOL/HD-4.7
LDLcalc-124
___ 02:10PM BLOOD TSH-3.1
___ 02:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:30PM BLOOD Lactate-1.2
--MICRO--
==========
___ - Urine culture negative
___ - Urine Culture YEAST (Contaminant)
___ - Blood cultures negative
___- Cryptococcal antigen negative
___ - Lyme IgG-PENDING; Lyme IgM-negative
___ - RAPID PLASMA REAGIN TEST: negative
___ LUMBAR PUNCTURE: GRAM STAIN (Final ___: No PMNs, no
microorganisms, no fungal growth or culture.
ACID FAST CULTURE (Preliminary): no growth to date
Enterovirus Culture (Preliminary): No Enterovirus isolated
___ CSF HSV, EBV - negative
___ CSF CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS. Rare cell
with features suggestive of viral cytopathic changes (CMV vs
HSV) seen on ___ stain. **on discussion, this was 1 cell and
cannot be interpreted as necessarily infectious**
Background of lymphocytes and monocytes. Four heme slides
reviewed.
--IMAGING--
===========
___ CT HEAD WITHOUT CONTRAST IMPRESSION: Limited exam due
to patient motion, grossly there is no evidence of acute
intracranial process or hemorrhage.
___ MR HEAD W/O CONTRAST IMPRESSION: Of note, this is a
suboptimal study due to significant patient motion, which limits
the assessment of intracranial structures. Within the
limitations of the study, there is no evidence of mass effect,
midline shift, or acute infarction.
___ RENAL TRANSPLANT ULTRASOUND IMPRESSION: Moderately
elevated intrarenal resistive indices, increased since prior
ultrasound from ___. This could be seen in the
setting of rejection.
___ NONCON HEAD CT IMPRESSION:
1. Study is mildly degraded by motion.
2. No acute intracranial abnormality, with no evidence acute
intracranial hemorrhage.
3. Please note MRI of the brain is more sensitive for the
detection of acute infarct.
4. Stable chronic left frontal infarct.
___ NONCONTRAST MRI HEAD IMPRESSION:
1. Punctate foci of hyperintense DWI signal in the corona
radiata as
described, which may represent tiny late acute to subacute white
matter
infarct.
2. Scattered bilateral periventricular/subcortical white matter
and pontine foci of FLAIR hyperintense signal are nonspecific,
but may represent progression of chronic microangiopathy as
compared to the prior examination of ___, but
unchanged from recent MRIs.
3. T1 hyperintense focus of the right thalamus on sagittal T1
sequence without correlate of signal abnormality on other
sequences. This is presumably artifactual in nature. However,
CT examination could be performed further evaluation.
4. There is no imaging abnormality to suggest PRES or
encephalitis.
--EEG--
=======
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because of mild diffuse background slowing, slow posterior
dominant rhythm, and intermittent focal slowing in the right
parietal region. These findings are indicative of focal cerebral
dysfunction in the right parietal region, superimposed on more
diffuse cerebral dysfunction, which is nonspecific as to
etiology. No epileptiform discharges or electrographic seizures
are present.
--INTERVAL LABS--
===============
___ 09:30AM BLOOD Cyclspr-172
___ 09:15PM BLOOD Glucose-124* UreaN-47* Creat-2.0* Na-138
K-5.5* Cl-105 HCO3-23 AnGap-16
--DISCHARGE LABS--
==================
___ 06:40AM BLOOD WBC-8.3 RBC-2.62* Hgb-8.0* Hct-25.3*
MCV-97 MCH-30.5 MCHC-31.6* RDW-13.7 RDWSD-43.1 Plt ___
___ 06:40AM BLOOD Glucose-89 UreaN-44* Creat-1.8* Na-141
K-4.6 Cl-106 HCO3-23 AnGap-17
___ 06:40AM BLOOD Calcium-9.7 Phos-4.2 Mg-1.7
___ 06:40AM BLOOD Cyclspr-80*
Brief Hospital Course:
Ms. ___ is a ___ woman with a PMH notable for ESRD
s/p LRRT in ___ (on tacro, cyclosporin, and prednisone),
T1DM, CREST syndrome, CAD s/p MI x2 and DES x3 in ___, who
presented with confusion, fevers, and headache, as well as
nausea/vomiting.
#ENCEPHALOPATHY: She has had several prior presentations for
confusion in the past few years without any definitive etiology,
previously attributed to Tacrolimus toxicity (at which time she
was switched to rapamycin, but switched back to Tacro after
developing proteinuria) and hypoglycemia. After these episodes,
she returns to her baseline.
On this admission, she was evaluated for many causes including
infection; iatrogenic etiologies; PRES and vascular dementia.
1) INFECTION: Ruled out for meningitis with an LP (negative for
bacterial etiologies as well as HSV, CMV, and other viruses).
She received approximately 7 days of ceftriaxone, vancomycin and
aclyovir while awaiting study results, and 5 days of bactrim.
She also had significant pyuria but no bacteria grew on urine
culture; however, 7d of cef/vanc treated this possible
diagnosis. She had no other localizing signs or symptoms of
infection.
2) IATROGENIC CAUSES: Though she didn't have characteristic
tremors, her tacro was replaced by cyclosporin in case this was
toxicity. Several other medication changes were made, detailed
under transitional issues below, to minimize those that can
cause confusion.
3) POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME (PRES) and
4) VASCULAR DEMENTIA: The patient did initially get better by
___, but on subsequent days was more confused again,
particularly about higher-level functioning, such as not
remembering how she gives herself insulin with meals. Given some
ongoing hypertension (pressures often in the 150s-170s, rarely
as high as 180s-190s), and the relapsing-remitting presentation,
there was concern for PRES in the setting of immunosuppression.
Her initial MRI was of limited utility due to artifact so a
repeat MRI was done on ___ which did not show evidence of PRES
or lingering encephalitis. However, it did show microangiopathy
and microvascular changes that could have progressed from prior
scans -- not from most recent scan, however.
Course additionally notable for grossly normal electrolytes; EEG
with no seizures but intermittent right parietal slowing not
correlating to findings on exam or imaging; and normal
folate/B12/TSH.
The patient was clearly improved (close to her "real" self, per
her sister) at time of discharge, but still lacked some
higher-level functioning (not remembering how she doses insulin
with meals). It was not clear to us that glucose, blood pressure
could explain her course. Unfortunately, we did not come to a
satisfying diagnosis for the patient. Given what appears to be a
stepwise decline, and her elevated blood pressures, and MRI
findings, we are concerned for vascular dementia, but if this
were to explain her previous episodes, we would expect her not
to regain functioning in-between, and would expect worsening on
imaging since ___. It could have been that N/V lead to an
___ causing transient Tacro toxicity and leading the patient to
commit errors in taking her medications, exacerbating confusion,
but this is entirely impossible to prove (and she had no ___ on
admission). Ultimately, we discussed with the family the need
for further outpatient workup and to minimize medications that
can contribute to confusion.
# HYPERTENSION: Persistent on home medication, generally higher
in the morning. Has been <180 except for rare exceptions, but
regularly 150-170s. With proteinuruia that developed during
admission, likely not attributable to cyclosporin. Unclear if
elevated from neuropathic pain or nausea as patient only
intermittently endorses these. Increased amlodipine to 10mg
daily and ultimately held losartan due to ___. Continued
metoprolol.
# ACUTE KIDNEY INJURY and
# PROTEINURIA in the setting of
# ESRD s/p LRRT: Generally maintained UOP >2L/day. Did develop
proteinuria on ___ (noted due periorbital edema), but this
downtrended. Of note, patient was switched to cyclosporine on
___ due to concern for Tacro contribution to AMS and had an
___ on ___ attributed to elevated cyclosporin levels,
downtrending by discharge. Mycophenolate and prednisone
continued. There was initial concern for rejection based on
transplant ultrasound, but stable function and output were
reassuring.
# BRITTLE T1DM: Complicated by nephropathy, retinopathy, and
neuropathy. Insulin adjusted as per discharge medication list.
# NEUROPATHY: Chronic problem for patient for which she is on
many medications that can contribute to altered mental status.
Held all of these, and she was able to tolerate. Discussed
utility of adding back slowly and with help of a doctor to
ensure she is not more confused on any of them.
# ANTICOAGULATION: Patient has a reported history of APLS, but
the diagnosis was not clear when Hematology was consulted in
___. Patient prefers to be on anticoagulation per that
documentation. Discussed reasoning for being on warfarin with
patient and her sister. The 3 concerns the patient had were for
pulmonary embolism, stroke and protecting her stents. We talked
about the risks of bleed (which she has already had) on warfarn;
the role of aspirin in protecting her stents; absence of
literature using warfarin as empiric stroke protection in
patients without AF (and risk of hemorrhagic conversion if
stroke occurred); and the fact that her PE in the 1990s was
provoked and only required brief treatment. Though the risk of
PE and potentially stroke are higher off of warfarin, her
history of massive GI bleed and presence other modifiable risk
factors to reduce likelihood of stroke made discontinuing
warfarin a reasonable plan. We initially held warfarin in
setting of possibility for procedures and her INR was reversed
for LP; after discussing with patient we decided to continue to
hold warfarin but touch base with outpatient providers. They
agreed over email to the discontinuation.
# NAUSEA/VOMITING: Likely gastroparesis. Abdomen exam benign;
LFTs and lipase normal. Per patient, had been going on for
months (since pre-___). Became much less frequent while
inpatient. Of note, family thinks this could be tied to
confusion as primary neurologic cause. We discharged her with
metoclopramide in addition to ondansetron as PRN antiemetics.
# CAD: home aspirin, atorvastatin, ranolazine, metoprolol.
Underwent triple angioplasty at ___ for CAD for angina in
___. Atorvastatin dose-reduced to 10mg in setting of
cyclosporin, which increases myopathies; it can be increased as
patient tolerates, and she was discharged on 20mg.
# PVD: Home cilostazol
# Hypothyroidism: Home levothyroxine
# History of GI Bleed: Home esomeprazole.
# CODE: FULL (presumed)
# CONTACT: ___ (sister, ___
TRANSITIONAL ISSUES
==================
#FOLLOW UP LABS: Please obtain Chem-10, CBC, UA, CK and
cyclosporin levels on ___ and fax them to ___, MD,
at the ___ Kidney ___ (FAX: ___
#HYPERTENSION: If the patient's blood pressure is consistently
>160/90, please contact Dr. ___ at the Kidney
___ @ ___
MEDICATION CHANGES:
-------------------
NEUROPATHY MEDS: Gabapentin, duloxetine and vicodin all held in
the setting of altered mental status. The patient reported that
her neuropathy was not bothering her significantly during
admission. Please consult with transplant team (specifically
transplant pharmacology) if patient has escalating neuropathy,
as there may be an alternative medicine (such as pregabalin)
that could cause less confusion while also not interacting with
immunosuppression.
#NAUSEA MEDS: Switched ondansetron for promethazine as an
antihistamine may contribute more to confusion. Change approved
by transplant pharmacy.
#ANTIHYPERTENSIVES:
-AMLODIPINE increased from 2.5mg BID to 10mg daily
-LOSARTAN discontinued due to ___
-METOPROLOL continued
#ANTICOAGULATION: As described above, long conversation with
patient and sister (HCP ___ resulted in holding Warfarin. She
was reversed with Vitamin K for her LP, so last day of
therapeutic coverage wasa ___.
#ATORVASTATIN: lowered dose from 40mg to 10mg per day because of
increased myopathy risk in cyclosporine. She tolerated 10mg for
several days and was increased to 20mg on day of discharge. Okay
to increase back to 40mg if patient tolerates it without side
effects.
#RANITIDINE: This was held after confirming with GI Dr. ___
___. Concerned that large dose could contribute to patient's
confusion.
#PRAMIPEXOLE: Held in setting ___ and not restarted due to
nausea and headaches (presenting complaints) being side effect,
and patient having significant restless leg syndrome during
inpatient stay.
Of note, she was stable and without worsened neuropathy,
headache or nausea for several days on this altered regimen
prior to discharge.
FOLLOW UP
----------
- Patient should see Dr. ___ about possible
diagnosis of vascular dementia vs. other etiologies for
recurrent/worsening confusion.
- MRI showed "T1 hyperintense focus of the right thalamus on
sagittal T1 sequence without correlate of signal abnormality on
other sequences. This is presumably artifactual in nature," but
CT could be obtained to compare.
- Hematology: Per ___ inpatient hematology note, patient
should follow up in ___ clinic for possible APLS, though doees
not appear from this documentation and concurrent labs that this
patient carries this diagnosis. Conversation with patient about
anticoagulation documented above. Likely does not need
hematology f/u, but this should be on the radar particularly if
the patient has other questions given her history.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 2.5 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Calcitriol 0.25 mcg PO DAILY
6. Cilostazol 50 mg PO QPM
7. DULoxetine 60 mg PO DAILY
8. Gabapentin 100 mg PO QHS
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Losartan Potassium 50 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO BID
12. Mycophenolate Mofetil 500 mg PO BID
13. PredniSONE 5 mg PO DAILY
14. Promethazine 25 mg PO Q8H:PRN nausea
15. Ranolazine ER 500 mg PO BID
16. Tacrolimus 2 mg PO Q12H
17. TraZODone 50 mg PO QHS:PRN insomnia
18. Vitamin D ___ UNIT PO DAILY
19. Warfarin 2 mg PO DAILY16
20. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
21. esomeprazole magnesium 40 mg oral BID
22. Cilostazol 100 mg PO QAM
23. Ranitidine 300 mg PO QHS
24. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO BID:PRN
Pain - Moderate
25. Pramipexole 0.25 mg PO QHS:PRN insomnia
26. Glargine 60 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
3. Metoclopramide ___ mg PO QIDACHS:PRN nausea
First-line, try before ondansetron if you think the pain is from
your n/v.
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Allopurinol ___ mg PO DAILY
6. amLODIPine 10 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Glargine 35 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
9. Aspirin 81 mg PO DAILY
10. Calcitriol 0.25 mcg PO DAILY
11. Cilostazol 50 mg PO QPM
12. Cilostazol 100 mg PO QAM
13. Esomeprazole Magnesium 40 mg oral BID
14. Levothyroxine Sodium 125 mcg PO DAILY
15. Metoprolol Succinate XL 25 mg PO BID
16. Mycophenolate Mofetil 500 mg PO BID
17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
18. PredniSONE 5 mg PO DAILY
19. Ranolazine ER 500 mg PO BID
20. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
#ENCEPHALOPATHY
#ACUTE ON CHRONIC KIDNEY INJURY with PROTEINURIA
#BRITTLE T1DM c/b NEUROPATHY
#ESRD s/p LRRT
SECONDARY DIAGNOSES
===================
#HYPERTENSION
#CAD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ -
___ was a pleasure caring for you. Please see below for
information on your stay.
WHY WAS I IN THE HOSPITAL?
- You were very confused, and your family was worried about you
WHAT HAPPENED IN THE HOSPITAL?
- Many CT scan pictures of your head ruled out stroke or big
problems in your brain
- A lumbar puncture (LP) was negative for any bacterial
infection. Studies sent off for infections caused by viruses
were also negative. 7 days of antibiotics were given while
waiting for these results.
- 7 days of antibiotics were given to treat a possible urinary
tract infection, though your urine never grew bacteria
- Many of the medicines you were on could cause confusion, so we
stopped the ones we thought it was safe to stop
- Your kidney transplant medicine, Tacrolimus, was switched to
another called Cyclosporin
- An MRI of the brain ruled out certain reasons for your
confusion, but did show evidence of possible tiny strokes.
- Your blood pressure was very high, so your antihypertensive
medicine was adjusted
- Your sugars were low at first when you weren't eating, and
then were very high, so your insulin was adjusted.
- We talked about stopping your coumadin/warfarn because it is a
dangerous medicine and you do not have a strong reason to be on
it
- Your creatinine went up, which we think was due to too much
cyclosporin. This medicine was reduced.
- You got much better, but weren't 100% back to your normal
self. We talked about the importance of following up with your
outpatient team.
WHAT SHOULD I DO WHEN I GO HOME?
- Talk seriously with your doctors before ___ of
the medicines we stopped.
- Follow up with cognitive neurology and your primary care
doctor. We could not find any definite cause for your symptoms
or why they did not completely resolve. This is something that
needs to be further investigated by the people who know you best
in the outpatient setting.
We wish you the best!
-Your care team at ___
Followup Instructions:
___
|
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"Y92009"
] |
Allergies: Penicillins / Ativan Chief Complaint: Confusion Major Surgical or Invasive Procedure: [MASKED] - Lumbar puncture History of Present Illness: Ms. [MASKED] is a [MASKED] woman with a PMH notable for ESRD s/p LRRT in [MASKED], T1DM, CREST syndrome, CAD s/p MI x2 and DES x3 in [MASKED], and possible APLS, who presents with confusion, fevers, and headache. The patient was somnolent and unable to provide any history on interview. All information is obtained from the chart. Per review, the patient first presented to [MASKED] the evening of [MASKED] after her sister found her at home confused and having word finding difficulties. In the [MASKED], she was found to have BP of 220/110, and she received metoprolol IV x2 with improvement of BP and mental status. She reported at that time nausea and headache as well. After being admitted to [MASKED], she was found to have a fever to [MASKED]. She a head CT that was unremarkable. Given concern for meningitis, she was transferred to [MASKED] for urgent LP. In the [MASKED] [MASKED], the patient refused to get an LP, which was declined by her HCP as well. She was seen by the Renal Transplant Service, who consulted with ID regarding treatment. Ultimately, she received ceftriaxone and IV Bactrim for listeria due to penicillin allergy in addition to the IV vancomycin that she received at [MASKED] prior to transfer. On arrival to the floor, the patient was somnolent and only able to respond with one to two word responses. Review of systems: (+) Per HPI Unable to be obtained fully due to patient's mental status. Past Medical History: 1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA [MASKED], DES to LAD and Cx/OM [MASKED] - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) - End-stage renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] - Scleroderma w/ CREST syndrome - Gastroparesis/GERD/Hiatal hernia - Gout diagnosed [MASKED] years ago - OSA NOT ACCURATE: - Antiphospholipid antibody syndrome and remote PE history on Coumadin [MASKED] - this diagnosis viewed unlikely per [MASKED] hematology/oncology note Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vital Signs: T 97.5, BP 173/73, HR 76, RR 18, O2 SAT 97% on RA General: Somnolent, not easily arousable, responds to questions with only [MASKED] words sentences, does not comply with any instructions for physical exam HEENT: Sclerae anicteric; pupils 7-8 mm, symmetric, minimally responsive CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Poor inspiratory efforts, bibasilar inspiratory crackles Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Unable to comply with exam, no gross asymmetry in strength or facial musculature DISCHARGE PHYSICAL EXAM: ======================= VITALS: 98.2 | 160/71 | 89 | 16 | 95%RA GENERAL: Awake, alert, laying in bed, no acute distress. Oriented to [MASKED], year/date, current situation. HEENT: Sclerae anicteric, MMM, oropharynx clear. NECK: No lymphadenopathy. +Full active range of motion. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi. CV: Regular rate and rhythm, normal S1 + S2, soft systolic murmur heard best at left upper sternal border. ABD: Soft, non-distended, bowel sounds present. No rebound tenderness or guarding, no organomegaly. Transplanted kidney on left side, nontender. EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: Without rashes or lesions on legs, arms, face or back. NEURO: Pupils roughly equal (L 5mm, R 4mm), but not reactive to light. Face symmetric. Moving all limbs with purpose against gravity. Attentive to months of the year backwards from [MASKED]. Still does not feel she can recall how to dose her insulin, but recalled rules card game she had previously forgotten. Pertinent Results: --ADMISSION LABS-- =================== [MASKED] 02:10PM BLOOD WBC-8.4# RBC-2.97* Hgb-9.3* Hct-27.0* MCV-91 MCH-31.3 MCHC-34.4 RDW-12.3 RDWSD-40.3 Plt [MASKED] [MASKED] 02:10PM BLOOD Neuts-88.9* Lymphs-4.7* Monos-5.1 Eos-0.5* Baso-0.4 Im [MASKED] AbsNeut-7.46* AbsLymp-0.39* AbsMono-0.43 AbsEos-0.04 AbsBaso-0.03 [MASKED] 07:17AM BLOOD [MASKED] PTT-36.5 [MASKED] [MASKED] 02:10PM BLOOD Glucose-117* UreaN-18 Creat-1.4* Na-137 K-4.5 Cl-102 HCO3-24 AnGap-16 [MASKED] 02:10PM BLOOD Triglyc-239* HDL-46 CHOL/HD-4.7 LDLcalc-124 [MASKED] 02:10PM BLOOD TSH-3.1 [MASKED] 02:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 02:30PM BLOOD Lactate-1.2 --MICRO-- ========== [MASKED] - Urine culture negative [MASKED] - Urine Culture YEAST (Contaminant) [MASKED] - Blood cultures negative [MASKED]- Cryptococcal antigen negative [MASKED] - Lyme IgG-PENDING; Lyme IgM-negative [MASKED] - RAPID PLASMA REAGIN TEST: negative [MASKED] LUMBAR PUNCTURE: GRAM STAIN (Final [MASKED]: No PMNs, no microorganisms, no fungal growth or culture. ACID FAST CULTURE (Preliminary): no growth to date Enterovirus Culture (Preliminary): No Enterovirus isolated [MASKED] CSF HSV, EBV - negative [MASKED] CSF CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS. Rare cell with features suggestive of viral cytopathic changes (CMV vs HSV) seen on [MASKED] stain. **on discussion, this was 1 cell and cannot be interpreted as necessarily infectious** Background of lymphocytes and monocytes. Four heme slides reviewed. --IMAGING-- =========== [MASKED] CT HEAD WITHOUT CONTRAST IMPRESSION: Limited exam due to patient motion, grossly there is no evidence of acute intracranial process or hemorrhage. [MASKED] MR HEAD W/O CONTRAST IMPRESSION: Of note, this is a suboptimal study due to significant patient motion, which limits the assessment of intracranial structures. Within the limitations of the study, there is no evidence of mass effect, midline shift, or acute infarction. [MASKED] RENAL TRANSPLANT ULTRASOUND IMPRESSION: Moderately elevated intrarenal resistive indices, increased since prior ultrasound from [MASKED]. This could be seen in the setting of rejection. [MASKED] NONCON HEAD CT IMPRESSION: 1. Study is mildly degraded by motion. 2. No acute intracranial abnormality, with no evidence acute intracranial hemorrhage. 3. Please note MRI of the brain is more sensitive for the detection of acute infarct. 4. Stable chronic left frontal infarct. [MASKED] NONCONTRAST MRI HEAD IMPRESSION: 1. Punctate foci of hyperintense DWI signal in the corona radiata as described, which may represent tiny late acute to subacute white matter infarct. 2. Scattered bilateral periventricular/subcortical white matter and pontine foci of FLAIR hyperintense signal are nonspecific, but may represent progression of chronic microangiopathy as compared to the prior examination of [MASKED], but unchanged from recent MRIs. 3. T1 hyperintense focus of the right thalamus on sagittal T1 sequence without correlate of signal abnormality on other sequences. This is presumably artifactual in nature. However, CT examination could be performed further evaluation. 4. There is no imaging abnormality to suggest PRES or encephalitis. --EEG-- ======= IMPRESSION: This is an abnormal continuous ICU EEG monitoring study because of mild diffuse background slowing, slow posterior dominant rhythm, and intermittent focal slowing in the right parietal region. These findings are indicative of focal cerebral dysfunction in the right parietal region, superimposed on more diffuse cerebral dysfunction, which is nonspecific as to etiology. No epileptiform discharges or electrographic seizures are present. --INTERVAL LABS-- =============== [MASKED] 09:30AM BLOOD Cyclspr-172 [MASKED] 09:15PM BLOOD Glucose-124* UreaN-47* Creat-2.0* Na-138 K-5.5* Cl-105 HCO3-23 AnGap-16 --DISCHARGE LABS-- ================== [MASKED] 06:40AM BLOOD WBC-8.3 RBC-2.62* Hgb-8.0* Hct-25.3* MCV-97 MCH-30.5 MCHC-31.6* RDW-13.7 RDWSD-43.1 Plt [MASKED] [MASKED] 06:40AM BLOOD Glucose-89 UreaN-44* Creat-1.8* Na-141 K-4.6 Cl-106 HCO3-23 AnGap-17 [MASKED] 06:40AM BLOOD Calcium-9.7 Phos-4.2 Mg-1.7 [MASKED] 06:40AM BLOOD Cyclspr-80* Brief Hospital Course: Ms. [MASKED] is a [MASKED] woman with a PMH notable for ESRD s/p LRRT in [MASKED] (on tacro, cyclosporin, and prednisone), T1DM, CREST syndrome, CAD s/p MI x2 and DES x3 in [MASKED], who presented with confusion, fevers, and headache, as well as nausea/vomiting. #ENCEPHALOPATHY: She has had several prior presentations for confusion in the past few years without any definitive etiology, previously attributed to Tacrolimus toxicity (at which time she was switched to rapamycin, but switched back to Tacro after developing proteinuria) and hypoglycemia. After these episodes, she returns to her baseline. On this admission, she was evaluated for many causes including infection; iatrogenic etiologies; PRES and vascular dementia. 1) INFECTION: Ruled out for meningitis with an LP (negative for bacterial etiologies as well as HSV, CMV, and other viruses). She received approximately 7 days of ceftriaxone, vancomycin and aclyovir while awaiting study results, and 5 days of bactrim. She also had significant pyuria but no bacteria grew on urine culture; however, 7d of cef/vanc treated this possible diagnosis. She had no other localizing signs or symptoms of infection. 2) IATROGENIC CAUSES: Though she didn't have characteristic tremors, her tacro was replaced by cyclosporin in case this was toxicity. Several other medication changes were made, detailed under transitional issues below, to minimize those that can cause confusion. 3) POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME (PRES) and 4) VASCULAR DEMENTIA: The patient did initially get better by [MASKED], but on subsequent days was more confused again, particularly about higher-level functioning, such as not remembering how she gives herself insulin with meals. Given some ongoing hypertension (pressures often in the 150s-170s, rarely as high as 180s-190s), and the relapsing-remitting presentation, there was concern for PRES in the setting of immunosuppression. Her initial MRI was of limited utility due to artifact so a repeat MRI was done on [MASKED] which did not show evidence of PRES or lingering encephalitis. However, it did show microangiopathy and microvascular changes that could have progressed from prior scans -- not from most recent scan, however. Course additionally notable for grossly normal electrolytes; EEG with no seizures but intermittent right parietal slowing not correlating to findings on exam or imaging; and normal folate/B12/TSH. The patient was clearly improved (close to her "real" self, per her sister) at time of discharge, but still lacked some higher-level functioning (not remembering how she doses insulin with meals). It was not clear to us that glucose, blood pressure could explain her course. Unfortunately, we did not come to a satisfying diagnosis for the patient. Given what appears to be a stepwise decline, and her elevated blood pressures, and MRI findings, we are concerned for vascular dementia, but if this were to explain her previous episodes, we would expect her not to regain functioning in-between, and would expect worsening on imaging since [MASKED]. It could have been that N/V lead to an [MASKED] causing transient Tacro toxicity and leading the patient to commit errors in taking her medications, exacerbating confusion, but this is entirely impossible to prove (and she had no [MASKED] on admission). Ultimately, we discussed with the family the need for further outpatient workup and to minimize medications that can contribute to confusion. # HYPERTENSION: Persistent on home medication, generally higher in the morning. Has been <180 except for rare exceptions, but regularly 150-170s. With proteinuruia that developed during admission, likely not attributable to cyclosporin. Unclear if elevated from neuropathic pain or nausea as patient only intermittently endorses these. Increased amlodipine to 10mg daily and ultimately held losartan due to [MASKED]. Continued metoprolol. # ACUTE KIDNEY INJURY and # PROTEINURIA in the setting of # ESRD s/p LRRT: Generally maintained UOP >2L/day. Did develop proteinuria on [MASKED] (noted due periorbital edema), but this downtrended. Of note, patient was switched to cyclosporine on [MASKED] due to concern for Tacro contribution to AMS and had an [MASKED] on [MASKED] attributed to elevated cyclosporin levels, downtrending by discharge. Mycophenolate and prednisone continued. There was initial concern for rejection based on transplant ultrasound, but stable function and output were reassuring. # BRITTLE T1DM: Complicated by nephropathy, retinopathy, and neuropathy. Insulin adjusted as per discharge medication list. # NEUROPATHY: Chronic problem for patient for which she is on many medications that can contribute to altered mental status. Held all of these, and she was able to tolerate. Discussed utility of adding back slowly and with help of a doctor to ensure she is not more confused on any of them. # ANTICOAGULATION: Patient has a reported history of APLS, but the diagnosis was not clear when Hematology was consulted in [MASKED]. Patient prefers to be on anticoagulation per that documentation. Discussed reasoning for being on warfarin with patient and her sister. The 3 concerns the patient had were for pulmonary embolism, stroke and protecting her stents. We talked about the risks of bleed (which she has already had) on warfarn; the role of aspirin in protecting her stents; absence of literature using warfarin as empiric stroke protection in patients without AF (and risk of hemorrhagic conversion if stroke occurred); and the fact that her PE in the 1990s was provoked and only required brief treatment. Though the risk of PE and potentially stroke are higher off of warfarin, her history of massive GI bleed and presence other modifiable risk factors to reduce likelihood of stroke made discontinuing warfarin a reasonable plan. We initially held warfarin in setting of possibility for procedures and her INR was reversed for LP; after discussing with patient we decided to continue to hold warfarin but touch base with outpatient providers. They agreed over email to the discontinuation. # NAUSEA/VOMITING: Likely gastroparesis. Abdomen exam benign; LFTs and lipase normal. Per patient, had been going on for months (since pre-[MASKED]). Became much less frequent while inpatient. Of note, family thinks this could be tied to confusion as primary neurologic cause. We discharged her with metoclopramide in addition to ondansetron as PRN antiemetics. # CAD: home aspirin, atorvastatin, ranolazine, metoprolol. Underwent triple angioplasty at [MASKED] for CAD for angina in [MASKED]. Atorvastatin dose-reduced to 10mg in setting of cyclosporin, which increases myopathies; it can be increased as patient tolerates, and she was discharged on 20mg. # PVD: Home cilostazol # Hypothyroidism: Home levothyroxine # History of GI Bleed: Home esomeprazole. # CODE: FULL (presumed) # CONTACT: [MASKED] (sister, [MASKED] TRANSITIONAL ISSUES ================== #FOLLOW UP LABS: Please obtain Chem-10, CBC, UA, CK and cyclosporin levels on [MASKED] and fax them to [MASKED], MD, at the [MASKED] Kidney [MASKED] (FAX: [MASKED] #HYPERTENSION: If the patient's blood pressure is consistently >160/90, please contact Dr. [MASKED] at the Kidney [MASKED] @ [MASKED] MEDICATION CHANGES: ------------------- NEUROPATHY MEDS: Gabapentin, duloxetine and vicodin all held in the setting of altered mental status. The patient reported that her neuropathy was not bothering her significantly during admission. Please consult with transplant team (specifically transplant pharmacology) if patient has escalating neuropathy, as there may be an alternative medicine (such as pregabalin) that could cause less confusion while also not interacting with immunosuppression. #NAUSEA MEDS: Switched ondansetron for promethazine as an antihistamine may contribute more to confusion. Change approved by transplant pharmacy. #ANTIHYPERTENSIVES: -AMLODIPINE increased from 2.5mg BID to 10mg daily -LOSARTAN discontinued due to [MASKED] -METOPROLOL continued #ANTICOAGULATION: As described above, long conversation with patient and sister (HCP [MASKED] resulted in holding Warfarin. She was reversed with Vitamin K for her LP, so last day of therapeutic coverage wasa [MASKED]. #ATORVASTATIN: lowered dose from 40mg to 10mg per day because of increased myopathy risk in cyclosporine. She tolerated 10mg for several days and was increased to 20mg on day of discharge. Okay to increase back to 40mg if patient tolerates it without side effects. #RANITIDINE: This was held after confirming with GI Dr. [MASKED] [MASKED]. Concerned that large dose could contribute to patient's confusion. #PRAMIPEXOLE: Held in setting [MASKED] and not restarted due to nausea and headaches (presenting complaints) being side effect, and patient having significant restless leg syndrome during inpatient stay. Of note, she was stable and without worsened neuropathy, headache or nausea for several days on this altered regimen prior to discharge. FOLLOW UP ---------- - Patient should see Dr. [MASKED] about possible diagnosis of vascular dementia vs. other etiologies for recurrent/worsening confusion. - MRI showed "T1 hyperintense focus of the right thalamus on sagittal T1 sequence without correlate of signal abnormality on other sequences. This is presumably artifactual in nature," but CT could be obtained to compare. - Hematology: Per [MASKED] inpatient hematology note, patient should follow up in [MASKED] clinic for possible APLS, though doees not appear from this documentation and concurrent labs that this patient carries this diagnosis. Conversation with patient about anticoagulation documented above. Likely does not need hematology f/u, but this should be on the radar particularly if the patient has other questions given her history. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. amLODIPine 2.5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Calcitriol 0.25 mcg PO DAILY 6. Cilostazol 50 mg PO QPM 7. DULoxetine 60 mg PO DAILY 8. Gabapentin 100 mg PO QHS 9. Levothyroxine Sodium 125 mcg PO DAILY 10. Losartan Potassium 50 mg PO DAILY 11. Metoprolol Succinate XL 25 mg PO BID 12. Mycophenolate Mofetil 500 mg PO BID 13. PredniSONE 5 mg PO DAILY 14. Promethazine 25 mg PO Q8H:PRN nausea 15. Ranolazine ER 500 mg PO BID 16. Tacrolimus 2 mg PO Q12H 17. TraZODone 50 mg PO QHS:PRN insomnia 18. Vitamin D [MASKED] UNIT PO DAILY 19. Warfarin 2 mg PO DAILY16 20. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 21. esomeprazole magnesium 40 mg oral BID 22. Cilostazol 100 mg PO QAM 23. Ranitidine 300 mg PO QHS 24. HYDROcodone-Acetaminophen (5mg-325mg) [MASKED] TAB PO BID:PRN Pain - Moderate 25. Pramipexole 0.25 mg PO QHS:PRN insomnia 26. Glargine 60 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 3. Metoclopramide [MASKED] mg PO QIDACHS:PRN nausea First-line, try before ondansetron if you think the pain is from your n/v. 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. Allopurinol [MASKED] mg PO DAILY 6. amLODIPine 10 mg PO DAILY 7. Atorvastatin 20 mg PO QPM 8. Glargine 35 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 9. Aspirin 81 mg PO DAILY 10. Calcitriol 0.25 mcg PO DAILY 11. Cilostazol 50 mg PO QPM 12. Cilostazol 100 mg PO QAM 13. Esomeprazole Magnesium 40 mg oral BID 14. Levothyroxine Sodium 125 mcg PO DAILY 15. Metoprolol Succinate XL 25 mg PO BID 16. Mycophenolate Mofetil 500 mg PO BID 17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 18. PredniSONE 5 mg PO DAILY 19. Ranolazine ER 500 mg PO BID 20. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Rehabilitation and Sub-Acute Care) Discharge Diagnosis: PRIMARY DIAGNOSIS ================= #ENCEPHALOPATHY #ACUTE ON CHRONIC KIDNEY INJURY with PROTEINURIA #BRITTLE T1DM c/b NEUROPATHY #ESRD s/p LRRT SECONDARY DIAGNOSES =================== #HYPERTENSION #CAD Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED] - [MASKED] was a pleasure caring for you. Please see below for information on your stay. WHY WAS I IN THE HOSPITAL? - You were very confused, and your family was worried about you WHAT HAPPENED IN THE HOSPITAL? - Many CT scan pictures of your head ruled out stroke or big problems in your brain - A lumbar puncture (LP) was negative for any bacterial infection. Studies sent off for infections caused by viruses were also negative. 7 days of antibiotics were given while waiting for these results. - 7 days of antibiotics were given to treat a possible urinary tract infection, though your urine never grew bacteria - Many of the medicines you were on could cause confusion, so we stopped the ones we thought it was safe to stop - Your kidney transplant medicine, Tacrolimus, was switched to another called Cyclosporin - An MRI of the brain ruled out certain reasons for your confusion, but did show evidence of possible tiny strokes. - Your blood pressure was very high, so your antihypertensive medicine was adjusted - Your sugars were low at first when you weren't eating, and then were very high, so your insulin was adjusted. - We talked about stopping your coumadin/warfarn because it is a dangerous medicine and you do not have a strong reason to be on it - Your creatinine went up, which we think was due to too much cyclosporin. This medicine was reduced. - You got much better, but weren't 100% back to your normal self. We talked about the importance of following up with your outpatient team. WHAT SHOULD I DO WHEN I GO HOME? - Talk seriously with your doctors before [MASKED] of the medicines we stopped. - Follow up with cognitive neurology and your primary care doctor. We could not find any definite cause for your symptoms or why they did not completely resolve. This is something that needs to be further investigated by the people who know you best in the outpatient setting. We wish you the best! -Your care team at [MASKED] Followup Instructions: [MASKED]
|
[] |
[
"N390",
"N179",
"E871",
"I2510",
"Z955",
"I252",
"I10",
"E785",
"Z794",
"K219",
"M109",
"G4733",
"Z87891",
"Y92230",
"E039",
"Z8673"
] |
[
"G92: Toxic encephalopathy",
"N390: Urinary tract infection, site not specified",
"N179: Acute kidney failure, unspecified",
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"E10649: Type 1 diabetes mellitus with hypoglycemia without coma",
"K3184: Gastroparesis",
"E1065: Type 1 diabetes mellitus with hyperglycemia",
"M341: CR(E)ST syndrome",
"Z940: Kidney transplant status",
"E871: Hypo-osmolality and hyponatremia",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z955: Presence of coronary angioplasty implant and graft",
"I252: Old myocardial infarction",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"Z794: Long term (current) use of insulin",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"N319: Neuromuscular dysfunction of bladder, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"M109: Gout, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"Z87891: Personal history of nicotine dependence",
"Z841: Family history of disorders of kidney and ureter",
"F0150: Vascular dementia without behavioral disturbance",
"T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter",
"Y92230: Patient room in hospital as the place of occurrence of the external cause",
"I739: Peripheral vascular disease, unspecified",
"E039: Hypothyroidism, unspecified",
"G2581: Restless legs syndrome",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"Z86711: Personal history of pulmonary embolism",
"E875: Hyperkalemia",
"T50995A: Adverse effect of other drugs, medicaments and biological substances, initial encounter",
"Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause"
] |
10,030,753
| 21,062,398
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ Female with ESRD (s/p LURT ___ on
immunosuppression), anemia (weekly transusions and epo
injections), CAD s/p ___ 4 (most recently ___, HFrEF (55%
EF ___, HTN, T1DM (A1c 9.9% ___, and h/o multiple MDR
UTIs (Klebsiella, E.coli, Enterococcus), sclerodermda/CREST and
chart history antiphospholipid antibody syndrome (but on
evaluation by hematology does not appear to meet diagnostic
criteria) with h/o remote PE in ___, presenting with 3
witnessed
pre-syncopal episodes.
Reports was sitting on the couch - feeling nauseated, and tired,
and lightheaded. Reports most of the afternoon wasn't feeling
well. Report tried to get up to go to the bathroom but couldn't
make it bc was getting really disoriented and dizzy and felt
like
she was going to pass out. Reports around 5 pm daughter was
trying to help her. Tried on rollator and kept slumping over,
feeling transiently out of it, not responding. She denies losing
consciousness during these episodes. Reports 3 episodes of
slumping over. Denies chest pain, palpitations. Reports feels
similar to when had orthostatic episodes in the past. Reports
was
feeling SOB when was trying to get into bed. She did not feel
chest tightness or pain. She was not diaphoretic.
Reports when woke up this morning took BP and was 130/65 which
is
low for her. Reports skipped metoprolol this morning from the
low
bp and all day every time stood up was so lightheaded. Denies
cough. Reports has issue with vomiting but this has been at her
baseline; she has not seen blood in her vomitus. Denies BRBPR or
melena. Reports saw cardiology on ___ and was put back on 20
mg lasix daily. Denies SOB now, chest pain.
Of note, the pt reports she is also being worked up for a 4 cm
pancreatic mass with plans for biopsy in ___ once she can stop
taking DAPT (6 mos after her DES). She also reports that she has
been increasingly pruritic and that family members have noted
that she appears to have a more yellow complexion. She has also
had a 20 pound unintentional weight loss.
Past Medical History:
-CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___ DES to LAD ___
PCI of Cx and OM with ___
-___ renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
-Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
-Hypertension
-Dyslipidemia
-Scleroderma w/ CREST syndrome
-Gastroparesis/GERD/Hiatal hernia
-Gout diagnosed ___ years ago
-OSA
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION EXAM:
==============
GENERAL: Yellow complexion, NAD
HEENT: AT/NC, EOMI, PERRL, scleral icterus present, pink
conjunctiva, MMM, no sublingual icterus noted
NECK: supple, no LAD, no JVD
HEART: RRR, normal S1 and S2, II/VI holosystolic murmur, no
gallops or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: BS+, distended abdomen without fluid wave, mildly TTP
in
supraumbilical and suprapubic regions, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: Jaundiced, warm and well perfused, no excoriations or
lesions, no rashes
DISCHARGE EXAM;
=============
Temp: 98.9 (Tm 98.9), BP: 160/75 (96-175/60-107), HR: 94
(80-96),
RR: 20 (___), O2 sat: 97% (96-100)
GENERAL: Lying comfortably in bed
HEENT: AT/NC, EOMI, PERRL, scleral icterus present, pink
conjunctiva, MMM, no sublingual icterus noted
NECK: supple, no LAD, no JVD
HEART: RRR, normal S1 and S2, II/VI holosystolic murmur, no
gallops or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: BS+, distended abdomen without fluid wave, mildly TTP
in
supraumbilical and suprapubic regions, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS:
-------------------
___ 07:05PM BLOOD WBC-8.1 RBC-1.91* Hgb-5.8* Hct-17.9*
MCV-94 MCH-30.4 MCHC-32.4 RDW-18.6* RDWSD-61.7* Plt ___
___ 07:05PM BLOOD Glucose-288* UreaN-68* Creat-2.3* Na-138
K-3.6 Cl-109* HCO3-16* AnGap-13
___ 07:05PM BLOOD CK-MB-4 ___
___ 07:05PM BLOOD Calcium-7.7* Phos-3.6 Mg-1.5*
RADIOLOGY:
Transplant US ___:
The left iliac fossa transplant renal morphology is normal.
Specifically, the
cortex is of normal thickness and echogenicity, pyramids are
normal, there is
no urothelial thickening, and renal sinus fat is normal. There
is no
hydronephrosis and no perinephric fluid collection.
No diastolic flow is detected within the intrarenal arteries
with a resistive
index of 1.0. The main renal artery shows an abnormal waveform,
with prompt
systolic upstroke but without continuous diastolic flow. Peak
systolic
velocity of 51.8 centimeters/second is seen in the main renal
artery.
Vascularity is symmetric throughout transplant. The transplant
renal vein is
patent and shows normal waveform.
IMPRESSION:
1. No diastolic flow within the intrarenal arteries with
resistive index of 1,
new since ___ with lack of continuous diastolic flow
within the main
renal artery.
2. Patent main renal vein.
3. No hydronephrosis or perinephric fluid collection.
MICRO:
Urine culture: No growth
DISCHARGE LABS:
___ 05:00AM BLOOD WBC-6.4 RBC-2.86* Hgb-8.8* Hct-26.2*
MCV-92 MCH-30.8 MCHC-33.6 RDW-18.1* RDWSD-59.3* Plt ___
___ 05:00AM BLOOD ___ PTT-28.6 ___
___ 05:00AM BLOOD Glucose-433* UreaN-71* Creat-2.5* Na-138
K-4.8 Cl-109* HCO3-18* AnGap-11
___ 05:00AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.7
___ 09:35AM BLOOD Cyclspr-68*
Brief Hospital Course:
___ woman with transfusion-dependent anemia on epo, CAD
s/p DESx4 (most recent ___, HFrEF (EF now 55%), ESRD ___
T1DM s/p LURT PMH HFrEF (EF 41%), ESRD ___ T1DM s/p LURT ___
(on cellcept, prednisone, and cyclosporine), CREST/systemic
sclerosis and dysautonomia with orthostatic hypotension who
presented with presyncope, found to be profoundly anemic. She
was transfused and volume resuscitated with normalization of her
orthostatic vital signs and was discharged home with close
heme/onc follow up.
ACUTE ISSUES:
===============
#Syncope: The patient's symptoms and presentation all seemed
most consistent with orthostasis, particularly given orthostatic
VS on check ___. However, given her extensive cardiac history
including a recent MI, she was a monitored on telemetry for
evidence of arrhythmia. Her telemetry remained without any
events. She was volume resuscitated gently given her history of
heart failure. Her orthostatic vital signs were trended and
ultimately normalized after IVF and PRBCs.
# Type II NSTEMI: The patient had a troponin of 0.2 on admission
which downtrended to 0.___K-MB. She did not
complain of any chest pain or anginal symptoms on admission. In
the setting of her acute anemia (discussed below) she did have
some EKG changes including ST segment depressions in her lateral
precordial leads. However, with the resolution of her underlying
anemia her EKG changes resolved. Her home regimen consisting of
ASA 81mg daily, Ticagrelor 90mg BID, Ranolazine 500mg ER BID,
cilostazole 100mg qAM, 50mg qPM was continued on discharge. No
statin due to interaction with immunosuppression.
#Anemia: The patient's baseline Hgb is ___. Iron studies
conducted on previous admission suggest anemia of chronic
inflammation; reduced renal function and low epo also likely
cause. She is being followed closely as an outpatient by
heme/onc, and is currently getting weekly transfusions of one
unit of packed red blood cells and epo. She had no signs of
active bleeding during her hospitalization, and her Hgb remained
stable following the transfusion of two units of pRBCs.
#Pancreatic mass
The patient has a known pancreatic mass detected on abd CT
___ s/p fall. Pt awaiting biopsy in ___ mos s/p ___
___ when she can stop DAPT. Very concerning for malignancy
given pt reporting full body pruritus, unintentional weight
loss, malaise, early satiety, and gnawing abdominal pain. LFTs
not concerning right now for any obstructive process.
#HFrEF: LVEF 55% on admission in ___, recovered from 40%. At
that time discharged on Lasix 40mg PO BID, Metoprolol succinate
50mg PO daily, Hydralazine 50mg PO BID. Her weight on discharge
was 56.97, which is her current admit weight. On this admission,
she displayed no signs/sx of volume overload. Her lasix was held
on admission given her recent syncopal episodes. Ultimately, her
discharge heart failure regimen was as follows:
#Pyuria
The patient has a history of MDR UTIs. Her urine culture was
negative on admission and she was not treated with antibiotics.
CHRONIC ISSUES:
===============
#ESRD s/p Transplant: Ongoing CKD likely related to poorly
controlled T1DM. Discharge creatinine was 2.5.
# DM1:
Poorly controlled, most recent A1c 9.9% at ___ on ___,
with multiple sequelae. Patient was hyperglycemic during her
hospital stay while off her home ___, however on the day
prior to discharge was transitioned to 25u of glargine with
better control of her sugars. At discharge her home insulin
regimen was continued.
# Hypothyroidism: Continued on home levothyroxine
# Gout: Continued on home allopurinol
TRANSITIONAL ISSUES:
==================
[ ] follow up CBC and transfusion per heme/onc, next scheduled
for ___
[ ] Lasix was held in setting of hypovolemia on presentation
[ ] renal transplant showed no diastolic flow within the
intrarenal arteries with resistive index of 1, new since ___ with lack of continuous diastolic flow within the main
renal artery. This was discussed with radiology who reported the
artery remained patent.
[ ] consider uptitration of home ___ given hyperglycemia
while in the hospital
# CODE: Presumed FULL
# CONTACT: ___ (SISTER) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. melatonin 10 mg oral QHS
2. naftifine 2 % topical BID To soles of feet and between toe
webs
3. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Allopurinol ___ mg PO DAILY
6. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
7. Aspirin 81 mg PO DAILY
8. Calcitriol 0.25 mcg PO DAILY
9. Calcium Carbonate 500 mg PO BID
10. Cilostazol 25 mg PO QPM
11. Cilostazol 50 mg PO QAM
12. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
13. Ferrous Sulfate 325 mg PO DAILY
14. FoLIC Acid 1 mg PO DAILY
15. Furosemide 20 mg PO DAILY
16. Levothyroxine Sodium 125 mcg PO DAILY
17. Lidocaine 5% Patch 1 PTCH TD QAM
18. Multivitamins 1 TAB PO DAILY
19. Mycophenolate Mofetil 500 mg PO BID
20. Omeprazole 40 mg PO BID
21. PredniSONE 5 mg PO DAILY
22. Promethazine 25 mg PO TID:PRN nausea
23. Ranolazine ER 500 mg PO BID
24. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
25. ___ SoloStar U-300 Insulin (insulin glargine) 24 units
subcutaneous QAM
26. trimethobenzamide 300 mg oral TID:PRN nausea
27. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Aspirin 81 mg PO DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. Calcium Carbonate 500 mg PO BID
6. Cilostazol 25 mg PO QPM
7. Cilostazol 50 mg PO QAM
8. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
9. Ferrous Sulfate 325 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Levothyroxine Sodium 125 mcg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. melatonin 10 mg oral QHS
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Mycophenolate Mofetil 500 mg PO BID
17. naftifine 2 % topical BID To soles of feet and between toe
webs
18. Omeprazole 40 mg PO BID
19. PredniSONE 5 mg PO DAILY
20. Promethazine 25 mg PO TID:PRN nausea
21. Ranolazine ER 500 mg PO BID
22. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
23. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
24. Toujeo SoloStar U-300 Insulin (insulin glargine) 24 units
subcutaneous QAM
25. trimethobenzamide 300 mg oral TID:PRN nausea
26. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Anemia of chronic inflammation
Secondary diagnosis:
- End stage renal disease s/p renal transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because:
- You were having episodes of passing out
- Your blood counts were very low
While you were admitted:
- You had blood transfusions which improved your blood counts
- Your blood pressure was checked with sitting and standing to
make sure it was not dropping
- Your home blood pressure medications were adjusted
- You worked with our physical therapists
- When your blood counts were stable, you were discharged home
with close follow up with your cardiologist and blood doctor
___ you leave:
- Please take all of your medications as prescribed
- Please attend all of your follow up appointments as scheduled
It was a pleasure to care for you during you hospitalization!
Your ___ care team
Followup Instructions:
___
|
[
"I951",
"I21A1",
"Z940",
"I5022",
"I130",
"Z681",
"R17",
"K862",
"D638",
"D631",
"E1022",
"E1065",
"N189",
"I2510",
"M341",
"G901",
"E039",
"E1040",
"E10319",
"N319",
"E785",
"G4733",
"R300",
"M109",
"R339",
"R634",
"R6881",
"I252",
"Z794",
"Z87440",
"Z955",
"Z8673",
"Z86711",
"Z7902",
"Z87891"
] |
Allergies: Penicillins / Ativan / carvedilol / amlodipine Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] Female with ESRD (s/p LURT [MASKED] on immunosuppression), anemia (weekly transusions and epo injections), CAD s/p [MASKED] 4 (most recently [MASKED], HFrEF (55% EF [MASKED], HTN, T1DM (A1c 9.9% [MASKED], and h/o multiple MDR UTIs (Klebsiella, E.coli, Enterococcus), sclerodermda/CREST and chart history antiphospholipid antibody syndrome (but on evaluation by hematology does not appear to meet diagnostic criteria) with h/o remote PE in [MASKED], presenting with 3 witnessed pre-syncopal episodes. Reports was sitting on the couch - feeling nauseated, and tired, and lightheaded. Reports most of the afternoon wasn't feeling well. Report tried to get up to go to the bathroom but couldn't make it bc was getting really disoriented and dizzy and felt like she was going to pass out. Reports around 5 pm daughter was trying to help her. Tried on rollator and kept slumping over, feeling transiently out of it, not responding. She denies losing consciousness during these episodes. Reports 3 episodes of slumping over. Denies chest pain, palpitations. Reports feels similar to when had orthostatic episodes in the past. Reports was feeling SOB when was trying to get into bed. She did not feel chest tightness or pain. She was not diaphoretic. Reports when woke up this morning took BP and was 130/65 which is low for her. Reports skipped metoprolol this morning from the low bp and all day every time stood up was so lightheaded. Denies cough. Reports has issue with vomiting but this has been at her baseline; she has not seen blood in her vomitus. Denies BRBPR or melena. Reports saw cardiology on [MASKED] and was put back on 20 mg lasix daily. Denies SOB now, chest pain. Of note, the pt reports she is also being worked up for a 4 cm pancreatic mass with plans for biopsy in [MASKED] once she can stop taking DAPT (6 mos after her DES). She also reports that she has been increasingly pruritic and that family members have noted that she appears to have a more yellow complexion. She has also had a 20 pound unintentional weight loss. Past Medical History: -CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED] DES to LAD [MASKED] PCI of Cx and OM with [MASKED] -[MASKED] renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] -Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) -Hypertension -Dyslipidemia -Scleroderma w/ CREST syndrome -Gastroparesis/GERD/Hiatal hernia -Gout diagnosed [MASKED] years ago -OSA Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION EXAM: ============== GENERAL: Yellow complexion, NAD HEENT: AT/NC, EOMI, PERRL, scleral icterus present, pink conjunctiva, MMM, no sublingual icterus noted NECK: supple, no LAD, no JVD HEART: RRR, normal S1 and S2, II/VI holosystolic murmur, no gallops or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: BS+, distended abdomen without fluid wave, mildly TTP in supraumbilical and suprapubic regions, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ radial pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: Jaundiced, warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM; ============= Temp: 98.9 (Tm 98.9), BP: 160/75 (96-175/60-107), HR: 94 (80-96), RR: 20 ([MASKED]), O2 sat: 97% (96-100) GENERAL: Lying comfortably in bed HEENT: AT/NC, EOMI, PERRL, scleral icterus present, pink conjunctiva, MMM, no sublingual icterus noted NECK: supple, no LAD, no JVD HEART: RRR, normal S1 and S2, II/VI holosystolic murmur, no gallops or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: BS+, distended abdomen without fluid wave, mildly TTP in supraumbilical and suprapubic regions, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ radial pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose Pertinent Results: ADMISSION LABS: ------------------- [MASKED] 07:05PM BLOOD WBC-8.1 RBC-1.91* Hgb-5.8* Hct-17.9* MCV-94 MCH-30.4 MCHC-32.4 RDW-18.6* RDWSD-61.7* Plt [MASKED] [MASKED] 07:05PM BLOOD Glucose-288* UreaN-68* Creat-2.3* Na-138 K-3.6 Cl-109* HCO3-16* AnGap-13 [MASKED] 07:05PM BLOOD CK-MB-4 [MASKED] [MASKED] 07:05PM BLOOD Calcium-7.7* Phos-3.6 Mg-1.5* RADIOLOGY: Transplant US [MASKED]: The left iliac fossa transplant renal morphology is normal. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. No diastolic flow is detected within the intrarenal arteries with a resistive index of 1.0. The main renal artery shows an abnormal waveform, with prompt systolic upstroke but without continuous diastolic flow. Peak systolic velocity of 51.8 centimeters/second is seen in the main renal artery. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: 1. No diastolic flow within the intrarenal arteries with resistive index of 1, new since [MASKED] with lack of continuous diastolic flow within the main renal artery. 2. Patent main renal vein. 3. No hydronephrosis or perinephric fluid collection. MICRO: Urine culture: No growth DISCHARGE LABS: [MASKED] 05:00AM BLOOD WBC-6.4 RBC-2.86* Hgb-8.8* Hct-26.2* MCV-92 MCH-30.8 MCHC-33.6 RDW-18.1* RDWSD-59.3* Plt [MASKED] [MASKED] 05:00AM BLOOD [MASKED] PTT-28.6 [MASKED] [MASKED] 05:00AM BLOOD Glucose-433* UreaN-71* Creat-2.5* Na-138 K-4.8 Cl-109* HCO3-18* AnGap-11 [MASKED] 05:00AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.7 [MASKED] 09:35AM BLOOD Cyclspr-68* Brief Hospital Course: [MASKED] woman with transfusion-dependent anemia on epo, CAD s/p DESx4 (most recent [MASKED], HFrEF (EF now 55%), ESRD [MASKED] T1DM s/p LURT PMH HFrEF (EF 41%), ESRD [MASKED] T1DM s/p LURT [MASKED] (on cellcept, prednisone, and cyclosporine), CREST/systemic sclerosis and dysautonomia with orthostatic hypotension who presented with presyncope, found to be profoundly anemic. She was transfused and volume resuscitated with normalization of her orthostatic vital signs and was discharged home with close heme/onc follow up. ACUTE ISSUES: =============== #Syncope: The patient's symptoms and presentation all seemed most consistent with orthostasis, particularly given orthostatic VS on check [MASKED]. However, given her extensive cardiac history including a recent MI, she was a monitored on telemetry for evidence of arrhythmia. Her telemetry remained without any events. She was volume resuscitated gently given her history of heart failure. Her orthostatic vital signs were trended and ultimately normalized after IVF and PRBCs. # Type II NSTEMI: The patient had a troponin of 0.2 on admission which downtrended to 0. K-MB. She did not complain of any chest pain or anginal symptoms on admission. In the setting of her acute anemia (discussed below) she did have some EKG changes including ST segment depressions in her lateral precordial leads. However, with the resolution of her underlying anemia her EKG changes resolved. Her home regimen consisting of ASA 81mg daily, Ticagrelor 90mg BID, Ranolazine 500mg ER BID, cilostazole 100mg qAM, 50mg qPM was continued on discharge. No statin due to interaction with immunosuppression. #Anemia: The patient's baseline Hgb is [MASKED]. Iron studies conducted on previous admission suggest anemia of chronic inflammation; reduced renal function and low epo also likely cause. She is being followed closely as an outpatient by heme/onc, and is currently getting weekly transfusions of one unit of packed red blood cells and epo. She had no signs of active bleeding during her hospitalization, and her Hgb remained stable following the transfusion of two units of pRBCs. #Pancreatic mass The patient has a known pancreatic mass detected on abd CT [MASKED] s/p fall. Pt awaiting biopsy in [MASKED] mos s/p [MASKED] [MASKED] when she can stop DAPT. Very concerning for malignancy given pt reporting full body pruritus, unintentional weight loss, malaise, early satiety, and gnawing abdominal pain. LFTs not concerning right now for any obstructive process. #HFrEF: LVEF 55% on admission in [MASKED], recovered from 40%. At that time discharged on Lasix 40mg PO BID, Metoprolol succinate 50mg PO daily, Hydralazine 50mg PO BID. Her weight on discharge was 56.97, which is her current admit weight. On this admission, she displayed no signs/sx of volume overload. Her lasix was held on admission given her recent syncopal episodes. Ultimately, her discharge heart failure regimen was as follows: #Pyuria The patient has a history of MDR UTIs. Her urine culture was negative on admission and she was not treated with antibiotics. CHRONIC ISSUES: =============== #ESRD s/p Transplant: Ongoing CKD likely related to poorly controlled T1DM. Discharge creatinine was 2.5. # DM1: Poorly controlled, most recent A1c 9.9% at [MASKED] on [MASKED], with multiple sequelae. Patient was hyperglycemic during her hospital stay while off her home [MASKED], however on the day prior to discharge was transitioned to 25u of glargine with better control of her sugars. At discharge her home insulin regimen was continued. # Hypothyroidism: Continued on home levothyroxine # Gout: Continued on home allopurinol TRANSITIONAL ISSUES: ================== [ ] follow up CBC and transfusion per heme/onc, next scheduled for [MASKED] [ ] Lasix was held in setting of hypovolemia on presentation [ ] renal transplant showed no diastolic flow within the intrarenal arteries with resistive index of 1, new since [MASKED] with lack of continuous diastolic flow within the main renal artery. This was discussed with radiology who reported the artery remained patent. [ ] consider uptitration of home [MASKED] given hyperglycemia while in the hospital # CODE: Presumed FULL # CONTACT: [MASKED] (SISTER) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. melatonin 10 mg oral QHS 2. naftifine 2 % topical BID To soles of feet and between toe webs 3. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Allopurinol [MASKED] mg PO DAILY 6. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 7. Aspirin 81 mg PO DAILY 8. Calcitriol 0.25 mcg PO DAILY 9. Calcium Carbonate 500 mg PO BID 10. Cilostazol 25 mg PO QPM 11. Cilostazol 50 mg PO QAM 12. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 13. Ferrous Sulfate 325 mg PO DAILY 14. FoLIC Acid 1 mg PO DAILY 15. Furosemide 20 mg PO DAILY 16. Levothyroxine Sodium 125 mcg PO DAILY 17. Lidocaine 5% Patch 1 PTCH TD QAM 18. Multivitamins 1 TAB PO DAILY 19. Mycophenolate Mofetil 500 mg PO BID 20. Omeprazole 40 mg PO BID 21. PredniSONE 5 mg PO DAILY 22. Promethazine 25 mg PO TID:PRN nausea 23. Ranolazine ER 500 mg PO BID 24. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 25. [MASKED] SoloStar U-300 Insulin (insulin glargine) 24 units subcutaneous QAM 26. trimethobenzamide 300 mg oral TID:PRN nausea 27. Vitamin D [MASKED] UNIT PO DAILY Discharge Medications: 1. Allopurinol [MASKED] mg PO DAILY 2. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 3. Aspirin 81 mg PO DAILY 4. Calcitriol 0.25 mcg PO DAILY 5. Calcium Carbonate 500 mg PO BID 6. Cilostazol 25 mg PO QPM 7. Cilostazol 50 mg PO QAM 8. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 9. Ferrous Sulfate 325 mg PO DAILY 10. FoLIC Acid 1 mg PO DAILY 11. Levothyroxine Sodium 125 mcg PO DAILY 12. Lidocaine 5% Patch 1 PTCH TD QAM 13. melatonin 10 mg oral QHS 14. Metoprolol Succinate XL 50 mg PO DAILY 15. Multivitamins 1 TAB PO DAILY 16. Mycophenolate Mofetil 500 mg PO BID 17. naftifine 2 % topical BID To soles of feet and between toe webs 18. Omeprazole 40 mg PO BID 19. PredniSONE 5 mg PO DAILY 20. Promethazine 25 mg PO TID:PRN nausea 21. Ranolazine ER 500 mg PO BID 22. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 23. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 24. Toujeo SoloStar U-300 Insulin (insulin glargine) 24 units subcutaneous QAM 25. trimethobenzamide 300 mg oral TID:PRN nausea 26. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary diagnosis: - Anemia of chronic inflammation Secondary diagnosis: - End stage renal disease s/p renal transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You were admitted to the hospital because: - You were having episodes of passing out - Your blood counts were very low While you were admitted: - You had blood transfusions which improved your blood counts - Your blood pressure was checked with sitting and standing to make sure it was not dropping - Your home blood pressure medications were adjusted - You worked with our physical therapists - When your blood counts were stable, you were discharged home with close follow up with your cardiologist and blood doctor [MASKED] you leave: - Please take all of your medications as prescribed - Please attend all of your follow up appointments as scheduled It was a pleasure to care for you during you hospitalization! Your [MASKED] care team Followup Instructions: [MASKED]
|
[] |
[
"I130",
"N189",
"I2510",
"E039",
"E785",
"G4733",
"M109",
"I252",
"Z794",
"Z955",
"Z8673",
"Z7902",
"Z87891"
] |
[
"I951: Orthostatic hypotension",
"I21A1: Myocardial infarction type 2",
"Z940: Kidney transplant status",
"I5022: Chronic systolic (congestive) heart failure",
"I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"Z681: Body mass index [BMI] 19.9 or less, adult",
"R17: Unspecified jaundice",
"K862: Cyst of pancreas",
"D638: Anemia in other chronic diseases classified elsewhere",
"D631: Anemia in chronic kidney disease",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"E1065: Type 1 diabetes mellitus with hyperglycemia",
"N189: Chronic kidney disease, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"M341: CR(E)ST syndrome",
"G901: Familial dysautonomia [Riley-Day]",
"E039: Hypothyroidism, unspecified",
"E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"N319: Neuromuscular dysfunction of bladder, unspecified",
"E785: Hyperlipidemia, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"R300: Dysuria",
"M109: Gout, unspecified",
"R339: Retention of urine, unspecified",
"R634: Abnormal weight loss",
"R6881: Early satiety",
"I252: Old myocardial infarction",
"Z794: Long term (current) use of insulin",
"Z87440: Personal history of urinary (tract) infections",
"Z955: Presence of coronary angioplasty implant and graft",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"Z86711: Personal history of pulmonary embolism",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"Z87891: Personal history of nicotine dependence"
] |
10,030,753
| 21,151,005
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan
Attending: ___
Chief Complaint:
Lower extremity edema, acute kidney injury
Major Surgical or Invasive Procedure:
Renal transplant punch biopsy (___)
History of Present Illness:
Ms. ___ is a ___ with a PMH of ___ s/p living kidney
transplant ___ on cyclosporine, cellcept, prednisone, CREST,
PE previously on warfarin, CAD (s/p ___ and OM ___ who
p/w rising Cr and volume overload characterized by increasing ___
edema, orthopnea, and PND.
Of note, Ms. ___ was recently admitted to ___ ___
for AMS, work up was extensive but no conclusive cause was
identified and AMS resolved during admission (ruled out for
seizure, infection, electrolyte abnormality, possibly due to
tacrolimus which was stopped or vascular dementia).
After her discharge in late ___, Ms. ___
started to notice increasing ___ edema bilaterally, orthopnea
(previously could lay flat, now requires 2 pillows to sleep) and
PND (wakes up at night panting for breath). She also reports
intermittent dull/aching right sided CP that occurs at rest and
lasts for only a few minutes. Out of concern for fluid build up
in her legs she called her nephrologist and was prescribed 5D of
Lasix (dose unknown) from ___. During diuresis weight
decreased from 152.3 on ___ to 148.8 on ___. Her SBPs have
ranged from 120s-150s at home. Despite her weight dropping and
some decrease in the fluid in her legs her symptoms of orthopnea
and PND persisted and so she visited her nephrologist on ___.
She was seen by nephrologist Dr. ___ on ___ and was noted
to have proteinuria and a rising creatinine to 2.6. Of note, pt
has no antidonor HLA antibodies (last checked ___ year ago) and
proteinuria has been attributed to progressive diabetic kidney
injury. Pt has not undergone kidney biopsy given she was on
warfarin. Out of concern for rising Cr, Dr. ___
that pt be admitted to ___. Repeat labs on ___ notable for
BUN/Cr of 43/2.2 and cyclosporine level of 107.
On arrival the floor vitals were 97.7 PO, 156/66, 94, 18, 95%/RA
and pt was in no distress.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___,
DES to LAD and Cx/OM ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
- End-stage renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
- Scleroderma w/ CREST syndrome
- Gastroparesis/GERD/Hiatal hernia
- Gout diagnosed ___ years ago
- OSA
NOT ACCURATE: - Antiphospholipid antibody syndrome and remote PE
history on Coumadin ___ - this diagnosis viewed unlikely per
___ hematology/oncology note
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
================================
VS: 97.7 PO 156 / 66 R Sitting 94 18 95 ROOM AIR
GENERAL: NAD, sitting up comfortably in bed
HEENT: PERRL, MMM, EOMI
NECK: Neck supple, no LAD, no TM
CARDIAC: RRR, S1 + S2 present, systolic flow murmur present
PULMONARY: crackles at bases R>L, no wheezes
ABDOMEN: Soft, nontender, mildly distended, +BS, no HSM noted
GENITOURINARY: no foley
EXTREMITIES: 3+ pitting edema bilaterally, WWP
SKIN: no rashes/lesions
NEUROLOGIC: AOx3, CNII-XII intact, strength grossly intact in
all extremities
DISCHARGE PHYSICAL EXAM:
==========================
VITALS: 97.6, 122/72, 82, 18, 98% RA
GENERAL: NAD, sitting up comfortably in bed
HEENT: PERRL, MMM, EOMI
NECK: Neck supple, no LAD, no TM
CARDIAC: RRR, S1 + S2 present, systolic flow murmur present
PULMONARY: CTAB
ABDOMEN: Soft, nontender, mildly distended, +BS, no HSM noted
GENITOURINARY: no foley
EXTREMITIES: 1+ pitting edema bilaterally, WWP
SKIN: no rashes/lesions
NEUROLOGIC: AOx3, CNII-XII intact, strength grossly intact in
all extremities
Pertinent Results:
ADMISSION LABS:
================
___ 10:05AM BLOOD WBC-7.3 RBC-2.79* Hgb-8.6* Hct-26.8*
MCV-96 MCH-30.8 MCHC-32.1 RDW-14.5 RDWSD-50.9* Plt ___
___ 07:20PM BLOOD ___ PTT-31.0 ___
___ 10:05AM BLOOD UreaN-43* Creat-2.2* Na-136 K-5.0 Cl-100
HCO3-21* AnGap-20
___ 10:05AM BLOOD Albumin-3.8 Calcium-9.7 Phos-4.0
___ 10:05AM BLOOD Cyclspr-107
IMPORTANT INTERVAL LABS:
========================
___ 05:39AM BLOOD %HbA1c-7.4* eAG-166*
___ 07:20PM BLOOD CK-MB-6 cTropnT-0.09* proBNP-2524*
___ 05:39AM BLOOD CK-MB-3 cTropnT-0.09*
___ 07:20PM BLOOD TSH-0.69
___ 12:28AM URINE Hours-RANDOM Creat-40 Na-71 K-29
TotProt-186 Phos-18.1 Prot/Cr-4.7*
___ 03:51PM URINE Hours-RANDOM Creat-23 TotProt-100
Prot/Cr-4.3*
___ 12:13PM URINE Hours-RANDOM Creat-25 TotProt-148
Prot/Cr-5.9*
___ 12:28AM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 03:51PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
MICRO:
=======
___ 2:15 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 12:28 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
========
TTE ___:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is ___ mmHg. Mild symmetric left
ventricular hypertrophy with normal cavity size, and
regional/global systolic function (biplane LVEF = 63 %). The
estimated cardiac index is normal (>=2.5L/min/m2). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is mild pulmonary artery
systolic hypertension. There is a very small inferolateral
pericardial effusion without echocardiographic signs of
tamponade.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Mild pulmonary artery systolic hypertension.
Compared with the report of the prior study (images unavailable
for review) of ___, the pericardial effusion is slighlty
larger and mild pulmonary artery systolic hypertension is now
identified.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Renal U/S ___:
Absent diastolic blood flow in the interpolar region of the
transplant kidney, though diastolic flow appears preserved in
the upper and lower poles with RIs ranging from 0.8-0.82. Close
followup advised.
CXR ___:
Small pleural effusions, bibasilar atelectasis. Borderline
heart size,
pulmonary vascularity.
DISCHARGE LABS:
================
___ 06:10AM BLOOD WBC-7.3 RBC-2.76* Hgb-8.3* Hct-25.9*
MCV-94 MCH-30.1 MCHC-32.0 RDW-13.5 RDWSD-46.5* Plt ___
___ 06:10AM BLOOD Glucose-85 UreaN-49* Creat-2.0* Na-138
K-3.9 Cl-94* HCO3-31 AnGap-17
___ 06:10AM BLOOD Calcium-9.0 Phos-4.3 Mg-1.9
Brief Hospital Course:
Ms. ___ is a ___ with a PMH of ___ s/p living kidney
transplant ___ on cyclosporine, cellcept, prednisone; CREST,
PE previously on warfarin, CAD (s/p ___ and OM ___ who
presented from home rising Cr and volume overload characterized
by increasing edema, orthopnea, and PND.
___, s/p living unrelated donor kidney transplant ___: On
admission, Cr 2.6 (baseline 1.5-2.0) in the setting of
increasing proteinuria and volume overload. Initial concern for
cardiorenal syndrome vs. UTI given significant WBC/bacteria in
the urine. The patient was diuresed with Lasix 40mg IV and
started on ceftriaxone. Her Cr improved back to baseline with
diuresis and the patient was transitioned to Lasix 20mg PO BID.
Of note, troponins and MB were flat and EKG without ST changes.
TTE unchanged from prior with LVEF >60%. Review of patient's
prior UAs revealed that she has persistent pyuria and bacteria
in her urine. UCx returned with mixed bacterial flora consistent
with several other prior urine cultures. Therefore, we obtained
a straight cath specimen which was again notable for mixed
bacterial flora. Given that the patient was asymptomatic prior
to admission with low suspicion of UTI, her ceftriaxone was
discontinued on ___. Of note, while the patient's Cr returned
to baseline, she had persistent proteinuria and therefore she
underwent kidney biopsy on ___. Initial pathology concerning
for diabetic changes without signs of rejection; final path
pending at time of discharge. The patient's cyclosporine was
increased to 75mg BID for goal level 75-100 and she was
continued on her prednisone 5mg daily and MMF 500mg BID.
# Volume overload: As detailed above, the patient presented with
several weeks ___ edema, orthopnea and PND. She was diuresed
with Lasix 40mg IV later transitioned to Lasix 20mg PO BID upon
discharge. ACS work-up reassuringly negative and TTE unchanged
from prior. ___ managed as above. Plan to follow-up with
cardiology and kidney transplant team for further management.
# DM1, hyperglycemia: A1C 7.5% (___) however persistently
hyperglycemic in the hospital likely to poor dietary compliance.
___ was consulted and recommended:
-Lantus 22 units qAM and 15 units qhs
-Humalog 4 units TID with meals
-Humalog sliding scale TID with meals, give 2 units for
BG>150mg/dl, can increase by 2 units for every increase in BG by
50mg/dl
- Humalog sliding scale qhs, starting at BG>200mg/dl give 2
units, can increase by 2 units for every increase in BG by
50mg/dl
# HTN: The patient had elevated SBPs in the setting of recently
discontinuing her home amlodipine (stopped in the setting of
worsening ___ edema). For BP management, the patient's metoprolol
was changed to carvedilol 25mg BID and she was initiated Lasix
40mg PO and nifedipine 30mg daily. Will need close follow-up as
out-patient.
TRANSITIONAL ISSUES:
====================
NEW MEDICATIONS:
-Carvedilol 25mg BID
-Furosemide 20mg BID
-Nifedipine 30mg daily
CHANGED MEDICATIONS:
-Cyclosporin increased to 75mg BID
-Lantus 22 units qAM and 15 units qhs
-Humalog 4 units TID with meals
-Humalog sliding scale TID with meals, give 2 units for
BG>150mg/dl, can increase by 2 units for every increase in BG by
50mg/dl
- Humalog sliding scale qhs, starting at BG>200mg/dl give 2
units, can increase by 2 units for every increase in BG by
50mg/dl
STOPPED MEDICATIONS:
-Metoprolol (changed to carvedilol for better BP control)
[ ] Follow-up final pathology from kidney biopsy (initial path
notable for diabetic changes without evidence of rejection)
[ ] Follow-up blood glucose and adjust lantus/SSI accordingly
[ ] Follow-up blood pressure and titrate BP medications as
needed
[ ] Repeat labs on ___
Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Calcitriol 0.25 mcg PO DAILY
4. Cilostazol 100 mg PO QAM
5. Cilostazol 50 mg PO QHS
6. esomeprazole magnesium 40 mg oral BID
7. Metoprolol Succinate XL 25 mg PO DAILY
8. PredniSONE 5 mg PO DAILY
9. Ranolazine ER 500 mg PO BID
10. Ascorbic Acid Dose is Unknown PO DAILY
11. Calcium Carbonate Dose is Unknown PO BID
12. Vitamin D ___ UNIT PO DAILY
13. Aspirin 81 mg PO DAILY
14. Mycophenolate Mofetil 500 mg PO BID
15. Levothyroxine Sodium 125 mcg PO DAILY
16. Ferrous Sulfate Dose is Unknown PO DAILY
17. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
Discharge Medications:
1. Carvedilol 25 mg PO BID
RX *carvedilol [Coreg] 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Furosemide 20 mg PO BID
RX *furosemide [Lasix] 20 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
3. Glargine 22 Units Breakfast
Glargine 15 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. NIFEdipine CR 30 mg PO DAILY
RX *nifedipine [Procardia XL] 30 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
5. Ascorbic Acid ___ mg PO DAILY
6. Calcium Carbonate 500 mg PO BID
7. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
RX *cyclosporine modified 25 mg 3 capsule(s) by mouth daily Disp
#*90 Capsule Refills:*0
8. Ferrous Sulfate 325 mg PO DAILY
9. Allopurinol ___ mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 20 mg PO QPM
12. Calcitriol 0.25 mcg PO DAILY
13. Cilostazol 100 mg PO QAM
14. Cilostazol 50 mg PO QHS
15. Esomeprazole Magnesium 40 mg oral BID
16. Levothyroxine Sodium 125 mcg PO DAILY
17. Mycophenolate Mofetil 500 mg PO BID
18. PredniSONE 5 mg PO DAILY
19. Ranolazine ER 500 mg PO BID
20. Vitamin D ___ UNIT PO DAILY
21.Outpatient Lab Work
ICD 10: ___.0
Please check BMP and cyclosporine level and fax to Dr. ___
___ Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
-Acute Kidney Injury
-Insulin dependent diabetes mellitus
SECONDARY DIAGNOSES:
=====================
-Living unrelated donor kidney transplant
-Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you. You were admitted to the
___ because your creatinine was
increasing and you had gained weight because you had a lot of
extra fluid that your body was not getting rid of. We started
you on water pills (diuretics) to take off the extra fluid. We
also found that you had a possible urinary tract infection which
we treated with antibiotics. Unfortunately, despite improvement
of your creatinine, you were still having protein in your urine.
To better understand what was going on with the transplanted
kidney, we did a biopsy, the results of which are pending. You
should follow-up in the kidney transplant clinic within a week
of leaving the hospital.
You were also found to have very poorly controlled blood sugars,
so we increased your insulin regimen. You should refrain from
eating foods or beverages that are high in sugars to ensure that
your blood sugars are better controlled. If your blood sugars
remain very high, this can cause you to lose your transplanted
kidney.
Wishing you a speedy recovery,
Your ___ Care Team
Followup Instructions:
___
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Allergies: Penicillins / Ativan Chief Complaint: Lower extremity edema, acute kidney injury Major Surgical or Invasive Procedure: Renal transplant punch biopsy ([MASKED]) History of Present Illness: Ms. [MASKED] is a [MASKED] with a PMH of [MASKED] s/p living kidney transplant [MASKED] on cyclosporine, cellcept, prednisone, CREST, PE previously on warfarin, CAD (s/p [MASKED] and OM [MASKED] who p/w rising Cr and volume overload characterized by increasing [MASKED] edema, orthopnea, and PND. Of note, Ms. [MASKED] was recently admitted to [MASKED] [MASKED] for AMS, work up was extensive but no conclusive cause was identified and AMS resolved during admission (ruled out for seizure, infection, electrolyte abnormality, possibly due to tacrolimus which was stopped or vascular dementia). After her discharge in late [MASKED], Ms. [MASKED] started to notice increasing [MASKED] edema bilaterally, orthopnea (previously could lay flat, now requires 2 pillows to sleep) and PND (wakes up at night panting for breath). She also reports intermittent dull/aching right sided CP that occurs at rest and lasts for only a few minutes. Out of concern for fluid build up in her legs she called her nephrologist and was prescribed 5D of Lasix (dose unknown) from [MASKED]. During diuresis weight decreased from 152.3 on [MASKED] to 148.8 on [MASKED]. Her SBPs have ranged from 120s-150s at home. Despite her weight dropping and some decrease in the fluid in her legs her symptoms of orthopnea and PND persisted and so she visited her nephrologist on [MASKED]. She was seen by nephrologist Dr. [MASKED] on [MASKED] and was noted to have proteinuria and a rising creatinine to 2.6. Of note, pt has no antidonor HLA antibodies (last checked [MASKED] year ago) and proteinuria has been attributed to progressive diabetic kidney injury. Pt has not undergone kidney biopsy given she was on warfarin. Out of concern for rising Cr, Dr. [MASKED] that pt be admitted to [MASKED]. Repeat labs on [MASKED] notable for BUN/Cr of 43/2.2 and cyclosporine level of 107. On arrival the floor vitals were 97.7 PO, 156/66, 94, 18, 95%/RA and pt was in no distress. Past Medical History: 1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA [MASKED], DES to LAD and Cx/OM [MASKED] - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) - End-stage renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] - Scleroderma w/ CREST syndrome - Gastroparesis/GERD/Hiatal hernia - Gout diagnosed [MASKED] years ago - OSA NOT ACCURATE: - Antiphospholipid antibody syndrome and remote PE history on Coumadin [MASKED] - this diagnosis viewed unlikely per [MASKED] hematology/oncology note Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION PHYSICAL EXAMINATION: ================================ VS: 97.7 PO 156 / 66 R Sitting 94 18 95 ROOM AIR GENERAL: NAD, sitting up comfortably in bed HEENT: PERRL, MMM, EOMI NECK: Neck supple, no LAD, no TM CARDIAC: RRR, S1 + S2 present, systolic flow murmur present PULMONARY: crackles at bases R>L, no wheezes ABDOMEN: Soft, nontender, mildly distended, +BS, no HSM noted GENITOURINARY: no foley EXTREMITIES: 3+ pitting edema bilaterally, WWP SKIN: no rashes/lesions NEUROLOGIC: AOx3, CNII-XII intact, strength grossly intact in all extremities DISCHARGE PHYSICAL EXAM: ========================== VITALS: 97.6, 122/72, 82, 18, 98% RA GENERAL: NAD, sitting up comfortably in bed HEENT: PERRL, MMM, EOMI NECK: Neck supple, no LAD, no TM CARDIAC: RRR, S1 + S2 present, systolic flow murmur present PULMONARY: CTAB ABDOMEN: Soft, nontender, mildly distended, +BS, no HSM noted GENITOURINARY: no foley EXTREMITIES: 1+ pitting edema bilaterally, WWP SKIN: no rashes/lesions NEUROLOGIC: AOx3, CNII-XII intact, strength grossly intact in all extremities Pertinent Results: ADMISSION LABS: ================ [MASKED] 10:05AM BLOOD WBC-7.3 RBC-2.79* Hgb-8.6* Hct-26.8* MCV-96 MCH-30.8 MCHC-32.1 RDW-14.5 RDWSD-50.9* Plt [MASKED] [MASKED] 07:20PM BLOOD [MASKED] PTT-31.0 [MASKED] [MASKED] 10:05AM BLOOD UreaN-43* Creat-2.2* Na-136 K-5.0 Cl-100 HCO3-21* AnGap-20 [MASKED] 10:05AM BLOOD Albumin-3.8 Calcium-9.7 Phos-4.0 [MASKED] 10:05AM BLOOD Cyclspr-107 IMPORTANT INTERVAL LABS: ======================== [MASKED] 05:39AM BLOOD %HbA1c-7.4* eAG-166* [MASKED] 07:20PM BLOOD CK-MB-6 cTropnT-0.09* proBNP-2524* [MASKED] 05:39AM BLOOD CK-MB-3 cTropnT-0.09* [MASKED] 07:20PM BLOOD TSH-0.69 [MASKED] 12:28AM URINE Hours-RANDOM Creat-40 Na-71 K-29 TotProt-186 Phos-18.1 Prot/Cr-4.7* [MASKED] 03:51PM URINE Hours-RANDOM Creat-23 TotProt-100 Prot/Cr-4.3* [MASKED] 12:13PM URINE Hours-RANDOM Creat-25 TotProt-148 Prot/Cr-5.9* [MASKED] 12:28AM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG [MASKED] 03:51PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG MICRO: ======= [MASKED] 2:15 am URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] 12:28 am URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: ======== TTE [MASKED]: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is [MASKED] mmHg. Mild symmetric left ventricular hypertrophy with normal cavity size, and regional/global systolic function (biplane LVEF = 63 %). The estimated cardiac index is normal (>=2.5L/min/m2). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is a very small inferolateral pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Mild pulmonary artery systolic hypertension. Compared with the report of the prior study (images unavailable for review) of [MASKED], the pericardial effusion is slighlty larger and mild pulmonary artery systolic hypertension is now identified. CLINICAL IMPLICATIONS: Based on [MASKED] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Renal U/S [MASKED]: Absent diastolic blood flow in the interpolar region of the transplant kidney, though diastolic flow appears preserved in the upper and lower poles with RIs ranging from 0.8-0.82. Close followup advised. CXR [MASKED]: Small pleural effusions, bibasilar atelectasis. Borderline heart size, pulmonary vascularity. DISCHARGE LABS: ================ [MASKED] 06:10AM BLOOD WBC-7.3 RBC-2.76* Hgb-8.3* Hct-25.9* MCV-94 MCH-30.1 MCHC-32.0 RDW-13.5 RDWSD-46.5* Plt [MASKED] [MASKED] 06:10AM BLOOD Glucose-85 UreaN-49* Creat-2.0* Na-138 K-3.9 Cl-94* HCO3-31 AnGap-17 [MASKED] 06:10AM BLOOD Calcium-9.0 Phos-4.3 Mg-1.9 Brief Hospital Course: Ms. [MASKED] is a [MASKED] with a PMH of [MASKED] s/p living kidney transplant [MASKED] on cyclosporine, cellcept, prednisone; CREST, PE previously on warfarin, CAD (s/p [MASKED] and OM [MASKED] who presented from home rising Cr and volume overload characterized by increasing edema, orthopnea, and PND. [MASKED], s/p living unrelated donor kidney transplant [MASKED]: On admission, Cr 2.6 (baseline 1.5-2.0) in the setting of increasing proteinuria and volume overload. Initial concern for cardiorenal syndrome vs. UTI given significant WBC/bacteria in the urine. The patient was diuresed with Lasix 40mg IV and started on ceftriaxone. Her Cr improved back to baseline with diuresis and the patient was transitioned to Lasix 20mg PO BID. Of note, troponins and MB were flat and EKG without ST changes. TTE unchanged from prior with LVEF >60%. Review of patient's prior UAs revealed that she has persistent pyuria and bacteria in her urine. UCx returned with mixed bacterial flora consistent with several other prior urine cultures. Therefore, we obtained a straight cath specimen which was again notable for mixed bacterial flora. Given that the patient was asymptomatic prior to admission with low suspicion of UTI, her ceftriaxone was discontinued on [MASKED]. Of note, while the patient's Cr returned to baseline, she had persistent proteinuria and therefore she underwent kidney biopsy on [MASKED]. Initial pathology concerning for diabetic changes without signs of rejection; final path pending at time of discharge. The patient's cyclosporine was increased to 75mg BID for goal level 75-100 and she was continued on her prednisone 5mg daily and MMF 500mg BID. # Volume overload: As detailed above, the patient presented with several weeks [MASKED] edema, orthopnea and PND. She was diuresed with Lasix 40mg IV later transitioned to Lasix 20mg PO BID upon discharge. ACS work-up reassuringly negative and TTE unchanged from prior. [MASKED] managed as above. Plan to follow-up with cardiology and kidney transplant team for further management. # DM1, hyperglycemia: A1C 7.5% ([MASKED]) however persistently hyperglycemic in the hospital likely to poor dietary compliance. [MASKED] was consulted and recommended: -Lantus 22 units qAM and 15 units qhs -Humalog 4 units TID with meals -Humalog sliding scale TID with meals, give 2 units for BG>150mg/dl, can increase by 2 units for every increase in BG by 50mg/dl - Humalog sliding scale qhs, starting at BG>200mg/dl give 2 units, can increase by 2 units for every increase in BG by 50mg/dl # HTN: The patient had elevated SBPs in the setting of recently discontinuing her home amlodipine (stopped in the setting of worsening [MASKED] edema). For BP management, the patient's metoprolol was changed to carvedilol 25mg BID and she was initiated Lasix 40mg PO and nifedipine 30mg daily. Will need close follow-up as out-patient. TRANSITIONAL ISSUES: ==================== NEW MEDICATIONS: -Carvedilol 25mg BID -Furosemide 20mg BID -Nifedipine 30mg daily CHANGED MEDICATIONS: -Cyclosporin increased to 75mg BID -Lantus 22 units qAM and 15 units qhs -Humalog 4 units TID with meals -Humalog sliding scale TID with meals, give 2 units for BG>150mg/dl, can increase by 2 units for every increase in BG by 50mg/dl - Humalog sliding scale qhs, starting at BG>200mg/dl give 2 units, can increase by 2 units for every increase in BG by 50mg/dl STOPPED MEDICATIONS: -Metoprolol (changed to carvedilol for better BP control) [ ] Follow-up final pathology from kidney biopsy (initial path notable for diabetic changes without evidence of rejection) [ ] Follow-up blood glucose and adjust lantus/SSI accordingly [ ] Follow-up blood pressure and titrate BP medications as needed [ ] Repeat labs on [MASKED] Code: Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Calcitriol 0.25 mcg PO DAILY 4. Cilostazol 100 mg PO QAM 5. Cilostazol 50 mg PO QHS 6. esomeprazole magnesium 40 mg oral BID 7. Metoprolol Succinate XL 25 mg PO DAILY 8. PredniSONE 5 mg PO DAILY 9. Ranolazine ER 500 mg PO BID 10. Ascorbic Acid Dose is Unknown PO DAILY 11. Calcium Carbonate Dose is Unknown PO BID 12. Vitamin D [MASKED] UNIT PO DAILY 13. Aspirin 81 mg PO DAILY 14. Mycophenolate Mofetil 500 mg PO BID 15. Levothyroxine Sodium 125 mcg PO DAILY 16. Ferrous Sulfate Dose is Unknown PO DAILY 17. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H Discharge Medications: 1. Carvedilol 25 mg PO BID RX *carvedilol [Coreg] 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Furosemide 20 mg PO BID RX *furosemide [Lasix] 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Glargine 22 Units Breakfast Glargine 15 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner Insulin SC Sliding Scale using HUM Insulin 4. NIFEdipine CR 30 mg PO DAILY RX *nifedipine [Procardia XL] 30 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Ascorbic Acid [MASKED] mg PO DAILY 6. Calcium Carbonate 500 mg PO BID 7. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H RX *cyclosporine modified 25 mg 3 capsule(s) by mouth daily Disp #*90 Capsule Refills:*0 8. Ferrous Sulfate 325 mg PO DAILY 9. Allopurinol [MASKED] mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. Atorvastatin 20 mg PO QPM 12. Calcitriol 0.25 mcg PO DAILY 13. Cilostazol 100 mg PO QAM 14. Cilostazol 50 mg PO QHS 15. Esomeprazole Magnesium 40 mg oral BID 16. Levothyroxine Sodium 125 mcg PO DAILY 17. Mycophenolate Mofetil 500 mg PO BID 18. PredniSONE 5 mg PO DAILY 19. Ranolazine ER 500 mg PO BID 20. Vitamin D [MASKED] UNIT PO DAILY 21.Outpatient Lab Work ICD 10: [MASKED].0 Please check BMP and cyclosporine level and fax to Dr. [MASKED] [MASKED] Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSES: ================== -Acute Kidney Injury -Insulin dependent diabetes mellitus SECONDARY DIAGNOSES: ===================== -Living unrelated donor kidney transplant -Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you. You were admitted to the [MASKED] because your creatinine was increasing and you had gained weight because you had a lot of extra fluid that your body was not getting rid of. We started you on water pills (diuretics) to take off the extra fluid. We also found that you had a possible urinary tract infection which we treated with antibiotics. Unfortunately, despite improvement of your creatinine, you were still having protein in your urine. To better understand what was going on with the transplanted kidney, we did a biopsy, the results of which are pending. You should follow-up in the kidney transplant clinic within a week of leaving the hospital. You were also found to have very poorly controlled blood sugars, so we increased your insulin regimen. You should refrain from eating foods or beverages that are high in sugars to ensure that your blood sugars are better controlled. If your blood sugars remain very high, this can cause you to lose your transplanted kidney. Wishing you a speedy recovery, Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
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"Y929",
"Z794",
"I2510",
"I10",
"E785",
"Z955",
"K219",
"M109",
"G4733",
"Z87891",
"E039",
"D649",
"I252"
] |
[
"T8619: Other complication of kidney transplant",
"N179: Acute kidney failure, unspecified",
"J90: Pleural effusion, not elsewhere classified",
"E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified",
"K3184: Gastroparesis",
"E46: Unspecified protein-calorie malnutrition",
"E1021: Type 1 diabetes mellitus with diabetic nephropathy",
"M341: CR(E)ST syndrome",
"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",
"Z794: Long term (current) use of insulin",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z86711: Personal history of pulmonary embolism",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"Z955: Presence of coronary angioplasty implant and graft",
"E1065: Type 1 diabetes mellitus with hyperglycemia",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"N319: Neuromuscular dysfunction of bladder, unspecified",
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"K219: Gastro-esophageal reflux disease without esophagitis",
"K449: Diaphragmatic hernia without obstruction or gangrene",
"M109: Gout, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"Z87891: Personal history of nicotine dependence",
"R8271: Bacteriuria",
"B9689: Other specified bacterial agents as the cause of diseases classified elsewhere",
"Z9111: Patient's noncompliance with dietary regimen",
"E1051: Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene",
"E039: Hypothyroidism, unspecified",
"R110: Nausea",
"Z6827: Body mass index [BMI] 27.0-27.9, adult",
"R0789: Other chest pain",
"D649: Anemia, unspecified",
"E8770: Fluid overload, unspecified",
"I252: Old myocardial infarction"
] |
10,030,753
| 21,257,920
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female with ESRD s/p LRRT ___, (bl Cr 1.5-2.0; bx w
diabetic nephropathy and grade 2 IFTA ___, CAD s/p DES ___,
___, HTN, CREST syndrome, T1DM, who presents with shortness
of breath found to have volume overload, hyperglycemia, and
sepsis in the ED. Of note, patient was recently admitted
___ on the kidney transplant service due to shortness of
breath. This is attributed to acute decompensated systolic
heart failure in the setting of dietary noncompliance. ACS was
ruled out. She had a repeat that admission that showed a newly
depressed EF of 40%. Cardiology was consulted and her meds were
altered. Specifically, she was discontinued on metoprolol,
furosemide, carvedilol; nitro patch, and hydralazine were added,
and home cyclosporine was increased. She subsequently followed
up with cardiology since that visit and Lasix 40 mg twice daily
was added.
In ED initial VS: T ___ 26 96% Nasal Cannula
Exam: none
Labs significant for:
Patient was given:
IV Ondansetron 4 mg
IV Vancomycin
IV DRIPNitroglycerin (0.35-3.5 mcg/kg/min ordered)Started 0.4
IV Piperacillin-Tazobactam
PO Acetaminophen 1000 mg
IV Vancomycin 1000 mg
IV Levofloxacin 750 mg(chosen given pcn allergy)
IV insulin regular 10
Imaging notable for:
CXR 1. Compared to ___, persistent moderate
cardiomegaly and increased vascular congestion, now with
moderate bilateral pulmonary edema. 2. Small bilateral pleural
effusions.
Consults:
VS prior to transfer: T 102.1 122 177/78 26 96% Nasal Cannula
On arrival to the MICU, patient reports her breathing is mildly
improved
Past Medical History:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___
DES to LAD and Cx/OM ___
3. OTHER PAST MEDICAL HISTORY. End-stage renal disease ___
diabetes s/p L-sided living kidney transplant in ___
- Scleroderma w/ CREST syndrome
- Gastroparesis/GERD/Hiatal hernia
- Gout diagnosed ___ years ago
- OSA
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
Admission exam:
VITALS: T 98.2 108 156/24 26 96% Nasal Cannula
GENERAL: Alert, oriented, moderately uncomfortable appearing
HEENT: Sclera anicteric, dry MM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: bilateral rales in bases bilaterally; no rhonchi or
wheeze
CV: tachycardic, regular rhythm, no 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 rash
NEURO: no tremor, no asterixis, CNII-XII intact, no neck
stiffness, neg Kernig's
Discharge exam:
VS: 109 / 69
Standing 113 98
GENERAL: NAD
HEENT: AT/NC, MMM, no JVD
HEART: RRR, S1/S2, II/VI systolic murmur heard best at USB and
apex
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: grossly intact
PSYCH: Alert, responsive, appropriate responses
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission labs:
___ 05:06AM BLOOD WBC-11.9* RBC-3.09* Hgb-9.5* Hct-28.4*
MCV-92 MCH-30.7 MCHC-33.5 RDW-12.8 RDWSD-42.5 Plt ___
___ 05:06AM BLOOD Neuts-86.7* Lymphs-4.5* Monos-7.1
Eos-0.9* Baso-0.3 Im ___ AbsNeut-10.28* AbsLymp-0.53*
AbsMono-0.84* AbsEos-0.11 AbsBaso-0.04
___ 05:06AM BLOOD ___ PTT-28.4 ___
___ 05:06AM BLOOD Glucose-738* UreaN-48* Creat-2.3* Na-135
K-3.9 Cl-93* HCO3-25 AnGap-17*
___ 05:06AM BLOOD ALT-9 AST-8 AlkPhos-116* TotBili-0.4
___ 10:21AM BLOOD ALT-7 AST-10 LD(LDH)-367* AlkPhos-84
TotBili-0.5
___ 05:06AM BLOOD ___
___ 05:06AM BLOOD cTropnT-0.16*
___ 05:06AM BLOOD Lipase-10
___ 05:06AM BLOOD Albumin-3.4* Calcium-9.8 Phos-3.4 Mg-1.7
___ 05:25AM BLOOD Cyclspr-129
___ 05:53AM BLOOD Cyclspr-181
___ 02:50PM BLOOD freeCa-1.04*
___ 05:17AM BLOOD ___ pO2-47* pCO2-41 pH-7.43
calTCO2-28 Base XS-2
___ 06:45AM URINE RBC-4* WBC-19* Bacteri-FEW* Yeast-NONE
Epi-0
___ 06:45AM URINE Color-Straw Appear-Clear Sp ___
Notable labs:
___ 10:21AM BLOOD WBC-10.4* RBC-2.74* Hgb-8.7* Hct-25.5*
MCV-93 MCH-31.8 MCHC-34.1 RDW-13.1 RDWSD-44.2 Plt ___
___ 05:25AM BLOOD WBC-7.0 RBC-2.91* Hgb-9.0* Hct-27.5*
MCV-95 MCH-30.9 MCHC-32.7 RDW-13.3 RDWSD-45.5 Plt ___
___ 05:12AM BLOOD WBC-8.1 RBC-3.06* Hgb-9.4* Hct-29.6*
MCV-97 MCH-30.7 MCHC-31.8* RDW-13.2 RDWSD-46.5* Plt ___
___ 12:22AM BLOOD ___ PTT-30.7 ___
___ 05:00AM BLOOD ___ PTT-29.9 ___
___ 10:21AM BLOOD ALT-7 AST-10 LD(LDH)-367* AlkPhos-84
TotBili-0.5
___ 10:21AM BLOOD Glucose-431* UreaN-47* Creat-2.5* Na-138
K-3.6 Cl-97 HCO3-22 AnGap-19___ 05:25AM BLOOD Glucose-158* UreaN-51* Creat-2.8* Na-143
K-3.6 Cl-101 HCO3-29 AnGap-13
___ 05:00AM BLOOD Glucose-188* UreaN-46* Creat-2.3* Na-144
K-3.6 Cl-103 HCO3-31 AnGap-10
___ 05:12AM BLOOD Glucose-65* UreaN-43* Creat-2.3* Na-144
K-4.3 Cl-102 HCO3-33* AnGap-9
___ 05:42AM BLOOD Cyclspr-198
___ 05:50AM BLOOD Cyclspr-73*
___ 09:52AM BLOOD Cyclspr-70*
___ 09:04AM BLOOD Cyclspr-228
Discharge labs:
___ 06:00AM BLOOD WBC-7.6 RBC-3.00* Hgb-9.4* Hct-28.7*
MCV-96 MCH-31.3 MCHC-32.8 RDW-13.0 RDWSD-44.7 Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-196* UreaN-38* Creat-2.4* Na-141
K-4.4 Cl-97 HCO3-34* AnGap-10
___ 06:00AM BLOOD Calcium-10.1 Phos-3.5 Mg-1.8
___ 09:00AM BLOOD Cyclspr-79*
MICROBIOLOGY:
___ 6:45 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
REPORTS: CXR ___
FINDINGS:
The size of the cardiac silhouette is enlarged. There is a
small left pleural effusion with subjacent
atelectasis/pneumonia. The right lung is grossly clear. There
is no pneumothorax or right pleural effusion.
IMPRESSION:
New opacities at the left lung base are reflective of a pleural
effusion with subjacent atelectasis/pneumonia.
CXR ___
FINDINGS:
Compared to ___, the cardiac silhouette remains
moderately
enlarged. There is increased vascular congestion with moderate
bilateral
pulmonary edema. Small bilateral pleural effusions are again
seen. No focal infiltrates or pneumothorax.
IMPRESSION:
1. Compared to ___, persistent moderate cardiomegaly
and increased vascular congestion, now with moderate bilateral
pulmonary edema.
2. Small bilateral pleural effusions.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a PMHx of ESRD s/p
living renal transplant in ___, DM, and h/o multiple MDR UTIs
(Klebsiella, E.coli, Enterococcus), sclerodermda/CREST and chart
history antiphospholipid antibody syndrome with h/o remote PE in
___, CAD s/p MI x 2 and DES ___ who presents to the
hospital with dyspnea and hypertensive emergency as well as
fever.
Acute issues:
# Hypertensive emergency: Patient presented with progressive
dyspnea since recent discharge, weight gain, and orthopnea, and
she was found to have hypertensive emergency, acute cardiogenic
pulmonary edema, causing hypoxemic respiratory distress. Her
respiratory status improved with control of blood pressure.
Ineffective control of blood pressure and hypervolemia were the
driving factors for her presentation. Her BP is very elevated
while supine but difficult to control due to worsening of
orthostasis when on antihypertensives. Her diuretic and blood
pressure regimen was titrated while in-house and she was
discharged with SBPs in 170s-180s while supine, 80s-100s while
standing. She occasionally still got dizzy with these low blood
pressures. Physical therapy worked with her and felt that other
than her symptomatic hypotension, her strength and mobility was
stable but did recommend home physical therapy.
#Fever: Patient was febrile to 102.5 on the day of admission but
was otherwise asymptomatic without signs of infection.
Antibiotics were discontinued in light of cultures without
complications. She did not have any further fevers.
# ESRD s/p renal transplant ___, Cr baseline of 1.5-2.0,
indicating allograft CKD. Creatinine was slightly elevated at
2.5 compared to baseline ~2.0. Her ___ is likely related to
hypertensive urgency and improved with BP control. Her discharge
creatinine was 2.4.
Chronic issues:
#Immunosuppression: Patient was maintained on her home dosages
of prednisone and MMF. Her cyclosporine regimen was titrated so
that her blood cyclosporine level was within goal. She was
discharged on 25mg qAM and 50mg qPM.
# Type 1 Diabetes: Maintained on insulin regimen which was
titrated while in-house in setting of hypoglycemia. ___
followed her as an inpatient. She was discharged on 15U Toujeo
in the AM and ___ (twice daily) as well as 6U Humalog with meals
and sliding scale, per ___ recommendations, with follow-up
within a week.
# Hypothyroidism: Maintained on home synthroid
# CAD s/p DES: Maintained on home aspirin, atorvastatin, and
ranolazine
# Peripheral arterial disease: Maintained on home cilostazol
# Gout: Maintained on home allopurinol
# Health Maintenance: Maintained on home calcium carbonate and
vitamin D
Transitional issues:
STOPPED MEDICATIONS:
- Amlodipine
- Carvedilol- patient reported fatigue with this medication and
would like to avoid beta blockers in the future
- Losartan (holding)
CHANGED MEDICATIONS:
- Hydralazine
- Cyclosporine
- Furosemide
- Insulin
[ ] Discharge weight 130.5 lbs. Weigh patient and assess for
adequacy of diuretic regimen at next appointment.
[ ] Patient has been instructed that she can take one additional
dosage of 20mg Lasix PO if needed for significant weight gain,
shortness of breath, or swelling in her legs. However, she
should call her doctor immediately.
[ ] Losartan was held due to symptomatic hypotension as well as
elevated creatinine. Consider restarting at discharge at next
PCP or cardiology appointment if additional antihypertensive is
needed.
[ ] Patient was discharged with home ___ and ___
[ ] Measure BP and assess for continued autonomic lability. Of
note, patient continues to be symptomatic (dizzy, lightheaded)
with sitting/standing.
# Communication:
- ___ (HCP/sister): h ___ c ___
# Code: Full, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Calcitriol 0.25 mcg PO DAILY
7. Calcium Carbonate 500 mg PO BID
8. Ferrous Sulfate 325 mg PO DAILY
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Mycophenolate Mofetil 500 mg PO BID
11. PredniSONE 5 mg PO DAILY
12. Ranolazine ER 500 mg PO BID
13. Vitamin D ___ UNIT PO DAILY
14. Cilostazol 100 mg PO QAM
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. Promethazine 25 mg PO DAILY PRN nausea
17. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
18. Esomeprazole 40 mg Other BID
19. Carvedilol 3.125 mg PO BID
20. HydrALAZINE 25 mg PO QHS
21. Furosemide 40 mg PO BID
22. Losartan Potassium 25 mg PO DAILY
Discharge Medications:
1. Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Toujeo 15 Units Breakfast
Toujeo 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM
RX *cyclosporine modified 25 mg 1 capsule(s) by mouth Twice a
day Disp #*90 Capsule Refills:*0
3. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM
4. Furosemide 20 mg PO BID
RX *furosemide 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. HydrALAZINE 50 mg PO QHS
RX *hydralazine 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
6. Allopurinol ___ mg PO DAILY
7. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
8. Ascorbic Acid ___ mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 20 mg PO QPM
11. Calcitriol 0.25 mcg PO DAILY
12. Calcium Carbonate 500 mg PO BID
13. Cilostazol 100 mg PO QAM
14. Cilostazol 50 mg PO QPM
15. Esomeprazole 40 mg Other BID
16. Ferrous Sulfate 325 mg PO DAILY
17. Levothyroxine Sodium 125 mcg PO DAILY
18. Mycophenolate Mofetil 500 mg PO BID
19. Ondansetron 4 mg PO Q8H:PRN nausea
20. PredniSONE 5 mg PO DAILY
21. Promethazine 25 mg PO DAILY PRN nausea
22. Ranolazine ER 500 mg PO BID
23. Vitamin D ___ UNIT PO DAILY
24. HELD- Losartan Potassium 25 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until your doctor tells
you to
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Hypertensive emergency
- Autonomic lability
Secondary diagnosis:
- Type 1 Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. ___,
Why were you admitted?
- You were admitted for elevated blood pressures that were
causing you to have trouble breathing
What happened in the hospital?
- We adjusted your medications to better control your blood
pressures
- We also adjusted your water pill regimen (diuretics) so that
your weight was back to normal at discharge
What should you do when you leave the hospital?
- Please remember to take precautions when standing- stand
slowly and be careful about falling!
- Please wear compression stockings whenever sitting or standing
to increase your blood pressure
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs in 1 day. If needed (you notice trouble breathing,
increased swelling, or weight gain) you can take an extra dose
of your Lasix 20mg once, but please call your doctor too.
It was a pleasure taking care of you! We wish you the best.
- Your ___ Team
Followup Instructions:
___
|
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"N319",
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"Z87891",
"I252",
"Z86711",
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Allergies: Penicillins / Ativan / carvedilol Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] female with ESRD s/p LRRT [MASKED], (bl Cr 1.5-2.0; bx w diabetic nephropathy and grade 2 IFTA [MASKED], CAD s/p DES [MASKED], [MASKED], HTN, CREST syndrome, T1DM, who presents with shortness of breath found to have volume overload, hyperglycemia, and sepsis in the ED. Of note, patient was recently admitted [MASKED] on the kidney transplant service due to shortness of breath. This is attributed to acute decompensated systolic heart failure in the setting of dietary noncompliance. ACS was ruled out. She had a repeat that admission that showed a newly depressed EF of 40%. Cardiology was consulted and her meds were altered. Specifically, she was discontinued on metoprolol, furosemide, carvedilol; nitro patch, and hydralazine were added, and home cyclosporine was increased. She subsequently followed up with cardiology since that visit and Lasix 40 mg twice daily was added. In ED initial VS: T [MASKED] 26 96% Nasal Cannula Exam: none Labs significant for: Patient was given: IV Ondansetron 4 mg IV Vancomycin IV DRIPNitroglycerin (0.35-3.5 mcg/kg/min ordered)Started 0.4 IV Piperacillin-Tazobactam PO Acetaminophen 1000 mg IV Vancomycin 1000 mg IV Levofloxacin 750 mg(chosen given pcn allergy) IV insulin regular 10 Imaging notable for: CXR 1. Compared to [MASKED], persistent moderate cardiomegaly and increased vascular congestion, now with moderate bilateral pulmonary edema. 2. Small bilateral pleural effusions. Consults: VS prior to transfer: T 102.1 122 177/78 26 96% Nasal Cannula On arrival to the MICU, patient reports her breathing is mildly improved Past Medical History: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED] 3. OTHER PAST MEDICAL HISTORY. End-stage renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] - Scleroderma w/ CREST syndrome - Gastroparesis/GERD/Hiatal hernia - Gout diagnosed [MASKED] years ago - OSA Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: Admission exam: VITALS: T 98.2 108 156/24 26 96% Nasal Cannula GENERAL: Alert, oriented, moderately uncomfortable appearing HEENT: Sclera anicteric, dry MM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: bilateral rales in bases bilaterally; no rhonchi or wheeze CV: tachycardic, regular rhythm, no 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 rash NEURO: no tremor, no asterixis, CNII-XII intact, no neck stiffness, neg Kernig's Discharge exam: VS: 109 / 69 Standing 113 98 GENERAL: NAD HEENT: AT/NC, MMM, no JVD HEART: RRR, S1/S2, II/VI systolic murmur heard best at USB and apex LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose NEURO: grossly intact PSYCH: Alert, responsive, appropriate responses SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: Admission labs: [MASKED] 05:06AM BLOOD WBC-11.9* RBC-3.09* Hgb-9.5* Hct-28.4* MCV-92 MCH-30.7 MCHC-33.5 RDW-12.8 RDWSD-42.5 Plt [MASKED] [MASKED] 05:06AM BLOOD Neuts-86.7* Lymphs-4.5* Monos-7.1 Eos-0.9* Baso-0.3 Im [MASKED] AbsNeut-10.28* AbsLymp-0.53* AbsMono-0.84* AbsEos-0.11 AbsBaso-0.04 [MASKED] 05:06AM BLOOD [MASKED] PTT-28.4 [MASKED] [MASKED] 05:06AM BLOOD Glucose-738* UreaN-48* Creat-2.3* Na-135 K-3.9 Cl-93* HCO3-25 AnGap-17* [MASKED] 05:06AM BLOOD ALT-9 AST-8 AlkPhos-116* TotBili-0.4 [MASKED] 10:21AM BLOOD ALT-7 AST-10 LD(LDH)-367* AlkPhos-84 TotBili-0.5 [MASKED] 05:06AM BLOOD [MASKED] [MASKED] 05:06AM BLOOD cTropnT-0.16* [MASKED] 05:06AM BLOOD Lipase-10 [MASKED] 05:06AM BLOOD Albumin-3.4* Calcium-9.8 Phos-3.4 Mg-1.7 [MASKED] 05:25AM BLOOD Cyclspr-129 [MASKED] 05:53AM BLOOD Cyclspr-181 [MASKED] 02:50PM BLOOD freeCa-1.04* [MASKED] 05:17AM BLOOD [MASKED] pO2-47* pCO2-41 pH-7.43 calTCO2-28 Base XS-2 [MASKED] 06:45AM URINE RBC-4* WBC-19* Bacteri-FEW* Yeast-NONE Epi-0 [MASKED] 06:45AM URINE Color-Straw Appear-Clear Sp [MASKED] Notable labs: [MASKED] 10:21AM BLOOD WBC-10.4* RBC-2.74* Hgb-8.7* Hct-25.5* MCV-93 MCH-31.8 MCHC-34.1 RDW-13.1 RDWSD-44.2 Plt [MASKED] [MASKED] 05:25AM BLOOD WBC-7.0 RBC-2.91* Hgb-9.0* Hct-27.5* MCV-95 MCH-30.9 MCHC-32.7 RDW-13.3 RDWSD-45.5 Plt [MASKED] [MASKED] 05:12AM BLOOD WBC-8.1 RBC-3.06* Hgb-9.4* Hct-29.6* MCV-97 MCH-30.7 MCHC-31.8* RDW-13.2 RDWSD-46.5* Plt [MASKED] [MASKED] 12:22AM BLOOD [MASKED] PTT-30.7 [MASKED] [MASKED] 05:00AM BLOOD [MASKED] PTT-29.9 [MASKED] [MASKED] 10:21AM BLOOD ALT-7 AST-10 LD(LDH)-367* AlkPhos-84 TotBili-0.5 [MASKED] 10:21AM BLOOD Glucose-431* UreaN-47* Creat-2.5* Na-138 K-3.6 Cl-97 HCO3-22 AnGap-19 05:25AM BLOOD Glucose-158* UreaN-51* Creat-2.8* Na-143 K-3.6 Cl-101 HCO3-29 AnGap-13 [MASKED] 05:00AM BLOOD Glucose-188* UreaN-46* Creat-2.3* Na-144 K-3.6 Cl-103 HCO3-31 AnGap-10 [MASKED] 05:12AM BLOOD Glucose-65* UreaN-43* Creat-2.3* Na-144 K-4.3 Cl-102 HCO3-33* AnGap-9 [MASKED] 05:42AM BLOOD Cyclspr-198 [MASKED] 05:50AM BLOOD Cyclspr-73* [MASKED] 09:52AM BLOOD Cyclspr-70* [MASKED] 09:04AM BLOOD Cyclspr-228 Discharge labs: [MASKED] 06:00AM BLOOD WBC-7.6 RBC-3.00* Hgb-9.4* Hct-28.7* MCV-96 MCH-31.3 MCHC-32.8 RDW-13.0 RDWSD-44.7 Plt [MASKED] [MASKED] 06:00AM BLOOD Plt [MASKED] [MASKED] 06:00AM BLOOD Glucose-196* UreaN-38* Creat-2.4* Na-141 K-4.4 Cl-97 HCO3-34* AnGap-10 [MASKED] 06:00AM BLOOD Calcium-10.1 Phos-3.5 Mg-1.8 [MASKED] 09:00AM BLOOD Cyclspr-79* MICROBIOLOGY: [MASKED] 6:45 am URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. REPORTS: CXR [MASKED] FINDINGS: The size of the cardiac silhouette is enlarged. There is a small left pleural effusion with subjacent atelectasis/pneumonia. The right lung is grossly clear. There is no pneumothorax or right pleural effusion. IMPRESSION: New opacities at the left lung base are reflective of a pleural effusion with subjacent atelectasis/pneumonia. CXR [MASKED] FINDINGS: Compared to [MASKED], the cardiac silhouette remains moderately enlarged. There is increased vascular congestion with moderate bilateral pulmonary edema. Small bilateral pleural effusions are again seen. No focal infiltrates or pneumothorax. IMPRESSION: 1. Compared to [MASKED], persistent moderate cardiomegaly and increased vascular congestion, now with moderate bilateral pulmonary edema. 2. Small bilateral pleural effusions. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old woman with a PMHx of ESRD s/p living renal transplant in [MASKED], DM, and h/o multiple MDR UTIs (Klebsiella, E.coli, Enterococcus), sclerodermda/CREST and chart history antiphospholipid antibody syndrome with h/o remote PE in [MASKED], CAD s/p MI x 2 and DES [MASKED] who presents to the hospital with dyspnea and hypertensive emergency as well as fever. Acute issues: # Hypertensive emergency: Patient presented with progressive dyspnea since recent discharge, weight gain, and orthopnea, and she was found to have hypertensive emergency, acute cardiogenic pulmonary edema, causing hypoxemic respiratory distress. Her respiratory status improved with control of blood pressure. Ineffective control of blood pressure and hypervolemia were the driving factors for her presentation. Her BP is very elevated while supine but difficult to control due to worsening of orthostasis when on antihypertensives. Her diuretic and blood pressure regimen was titrated while in-house and she was discharged with SBPs in 170s-180s while supine, 80s-100s while standing. She occasionally still got dizzy with these low blood pressures. Physical therapy worked with her and felt that other than her symptomatic hypotension, her strength and mobility was stable but did recommend home physical therapy. #Fever: Patient was febrile to 102.5 on the day of admission but was otherwise asymptomatic without signs of infection. Antibiotics were discontinued in light of cultures without complications. She did not have any further fevers. # ESRD s/p renal transplant [MASKED], Cr baseline of 1.5-2.0, indicating allograft CKD. Creatinine was slightly elevated at 2.5 compared to baseline ~2.0. Her [MASKED] is likely related to hypertensive urgency and improved with BP control. Her discharge creatinine was 2.4. Chronic issues: #Immunosuppression: Patient was maintained on her home dosages of prednisone and MMF. Her cyclosporine regimen was titrated so that her blood cyclosporine level was within goal. She was discharged on 25mg qAM and 50mg qPM. # Type 1 Diabetes: Maintained on insulin regimen which was titrated while in-house in setting of hypoglycemia. [MASKED] followed her as an inpatient. She was discharged on 15U Toujeo in the AM and [MASKED] (twice daily) as well as 6U Humalog with meals and sliding scale, per [MASKED] recommendations, with follow-up within a week. # Hypothyroidism: Maintained on home synthroid # CAD s/p DES: Maintained on home aspirin, atorvastatin, and ranolazine # Peripheral arterial disease: Maintained on home cilostazol # Gout: Maintained on home allopurinol # Health Maintenance: Maintained on home calcium carbonate and vitamin D Transitional issues: STOPPED MEDICATIONS: - Amlodipine - Carvedilol- patient reported fatigue with this medication and would like to avoid beta blockers in the future - Losartan (holding) CHANGED MEDICATIONS: - Hydralazine - Cyclosporine - Furosemide - Insulin [ ] Discharge weight 130.5 lbs. Weigh patient and assess for adequacy of diuretic regimen at next appointment. [ ] Patient has been instructed that she can take one additional dosage of 20mg Lasix PO if needed for significant weight gain, shortness of breath, or swelling in her legs. However, she should call her doctor immediately. [ ] Losartan was held due to symptomatic hypotension as well as elevated creatinine. Consider restarting at discharge at next PCP or cardiology appointment if additional antihypertensive is needed. [ ] Patient was discharged with home [MASKED] and [MASKED] [ ] Measure BP and assess for continued autonomic lability. Of note, patient continues to be symptomatic (dizzy, lightheaded) with sitting/standing. # Communication: - [MASKED] (HCP/sister): h [MASKED] c [MASKED] # Code: Full, confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 3. Ascorbic Acid [MASKED] mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Calcitriol 0.25 mcg PO DAILY 7. Calcium Carbonate 500 mg PO BID 8. Ferrous Sulfate 325 mg PO DAILY 9. Levothyroxine Sodium 125 mcg PO DAILY 10. Mycophenolate Mofetil 500 mg PO BID 11. PredniSONE 5 mg PO DAILY 12. Ranolazine ER 500 mg PO BID 13. Vitamin D [MASKED] UNIT PO DAILY 14. Cilostazol 100 mg PO QAM 15. Ondansetron 4 mg PO Q8H:PRN nausea 16. Promethazine 25 mg PO DAILY PRN nausea 17. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H 18. Esomeprazole 40 mg Other BID 19. Carvedilol 3.125 mg PO BID 20. HydrALAZINE 25 mg PO QHS 21. Furosemide 40 mg PO BID 22. Losartan Potassium 25 mg PO DAILY Discharge Medications: 1. Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 6 Units Dinner Toujeo 15 Units Breakfast Toujeo 15 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 2. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM RX *cyclosporine modified 25 mg 1 capsule(s) by mouth Twice a day Disp #*90 Capsule Refills:*0 3. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM 4. Furosemide 20 mg PO BID RX *furosemide 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. HydrALAZINE 50 mg PO QHS RX *hydralazine 50 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 6. Allopurinol [MASKED] mg PO DAILY 7. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 8. Ascorbic Acid [MASKED] mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Atorvastatin 20 mg PO QPM 11. Calcitriol 0.25 mcg PO DAILY 12. Calcium Carbonate 500 mg PO BID 13. Cilostazol 100 mg PO QAM 14. Cilostazol 50 mg PO QPM 15. Esomeprazole 40 mg Other BID 16. Ferrous Sulfate 325 mg PO DAILY 17. Levothyroxine Sodium 125 mcg PO DAILY 18. Mycophenolate Mofetil 500 mg PO BID 19. Ondansetron 4 mg PO Q8H:PRN nausea 20. PredniSONE 5 mg PO DAILY 21. Promethazine 25 mg PO DAILY PRN nausea 22. Ranolazine ER 500 mg PO BID 23. Vitamin D [MASKED] UNIT PO DAILY 24. HELD- Losartan Potassium 25 mg PO DAILY This medication was held. Do not restart Losartan Potassium until your doctor tells you to Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary diagnosis: - Hypertensive emergency - Autonomic lability Secondary diagnosis: - Type 1 Diabetes Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Ms. [MASKED], Why were you admitted? - You were admitted for elevated blood pressures that were causing you to have trouble breathing What happened in the hospital? - We adjusted your medications to better control your blood pressures - We also adjusted your water pill regimen (diuretics) so that your weight was back to normal at discharge What should you do when you leave the hospital? - Please remember to take precautions when standing- stand slowly and be careful about falling! - Please wear compression stockings whenever sitting or standing to increase your blood pressure - Weigh yourself every morning, call MD if weight goes up more than 3 lbs in 1 day. If needed (you notice trouble breathing, increased swelling, or weight gain) you can take an extra dose of your Lasix 20mg once, but please call your doctor too. It was a pleasure taking care of you! We wish you the best. - Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"I130",
"J9601",
"N179",
"N189",
"E785",
"E039",
"M109",
"I2510",
"K5900",
"D649",
"Z955",
"Z794",
"Z87891",
"I252",
"Y929"
] |
[
"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",
"J9601: Acute respiratory failure with hypoxia",
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"T8612: Kidney transplant failure",
"N179: Acute kidney failure, unspecified",
"K3184: Gastroparesis",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"E1051: Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene",
"M341: CR(E)ST syndrome",
"I161: Hypertensive emergency",
"N189: Chronic kidney disease, unspecified",
"E1065: Type 1 diabetes mellitus with hyperglycemia",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"N319: Neuromuscular dysfunction of bladder, unspecified",
"E785: Hyperlipidemia, unspecified",
"E039: Hypothyroidism, unspecified",
"I951: Orthostatic hypotension",
"R509: Fever, unspecified",
"M109: Gout, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"K5900: Constipation, unspecified",
"D649: Anemia, unspecified",
"E10649: Type 1 diabetes mellitus with hypoglycemia without coma",
"Z955: Presence of coronary angioplasty implant and graft",
"Z794: Long term (current) use of insulin",
"Z87891: Personal history of nicotine dependence",
"I252: Old myocardial infarction",
"Z86711: Personal history of pulmonary embolism",
"Z9111: Patient's noncompliance with dietary regimen",
"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"
] |
10,030,753
| 21,862,232
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___.
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo woman with history of ESRD (s/p LURT
___ on cyclosporine, prednisone 5 mg daily), anemia, CAD s/p
___ 4 (most recently ___, HFrEF (EF ~40%), IPMN (___), HTN,
T1DM complicated by neuropathy, retinopathy, neurogenic bladder
(intermittent straight catheterization), autonomic dysfunction
and h/o multiple UTIs
(Klebsiella, E.coli, Enterococcus), OSA, cryptogenic stroke, and
scleroderma/CREST who presents with an episode of hypotension
during Procrit infusion.
Patient reports being in ___ this AM when she
experienced an episode of decreased responsiveness. Per referral
note, patient suffered an episode of decreased responsiveness
and
lethargy during infusion and was found to be hypotensive with a
blood pressure of 70. The patient noted that she felt dizzy at
that time as well. She states she felt similarly to how she has
in the past
when her blood pressure has dropped in setting of known
orthostasis. She reported to ED staff that she recently was
started "on an aggressive Lasix regimen" 1 week prior to
presentation and has lost roughly 9 lbs. Patient's aid stated
that patient was acting normal prior to the event and has had
similar events in the past. She was first taken to the ED at ___ where straight cath urine specimen was notable for 1000
mg/dL glucose, 25 RBCs, + Leuk esterase, ___ WBCs/hpf, 3 +
bact.
EKG with T wave inversions laterally "which is similar to
previous and some possible submillimeter ST depressions V4 and
V5
which is nonspecific and trop T .499, lower than previous." CXR
clear. She was given a 1x dose of CTX 1 g and sent to the ___
ED for further care.
Past Medical History:
-CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___ DES to LAD ___
PCI of Cx and OM with ___
-___ renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
-Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
-Dysautonomia
-Hypertension
-Dyslipidemia
-Scleroderma w/ CREST syndrome
-Gastroparesis/GERD/Hiatal hernia
-Gout diagnosed ___ years ago
-OSA
-Pancreatic cyst
-Non convulsive status epilepticus
-stroke
-BPPV
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
Admission exam:
===============
GENERAL: Chronically ill-appearing woman. NAD, alert and
interactive. Oriented to self, ___ in ___
and ___ but states year is ___.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: No cervical lymphadenopathy. No JVD appreciated.
CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally with bibasilar crackles
noted. No wheezes. No increased work of breathing on RA.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: +BS, soft, slightly distended, but non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: 1+ edema bilaterally to mid-shins. No clubbing or
cyanosis. Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. No rash.
NEUROLOGIC: A&Ox3, no focal neurologic deficits. CN2-12 grossly
intact. ___ strength throughout.
Discharge exam:
===============
___ 1140 Temp: 97.8 PO BP: 150/78 L Lying HR: 66 RR: 16 O2
sat: 97% O2 delivery: RA
GENERAL: Chronically ill-appearing woman. Lying in bed. Alert
and
conversant; A&O to year, self, location
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM. No facial droop.
NECK: No JVD appreciated.
CARDIAC: RRR. Audible S1 and S2. Crescendo-descrendo systolic
ejection murmur ___ at LUSB, No gallops or rubs.
LUNGS: Clear to auscultation bilaterally. No wheezes or crackles
appreciated. No increased work of breathing on RA.
BACK: No CVA tenderness.
ABDOMEN: Normal bowel sound; Abdomen is soft, remains slightly
distended, hyperresonant, but non-tender to deep palpation in
all
four
quadrants.
EXTREMITIES: 1+ edema bilaterally to lower ankles. No clubbing
or
cyanosis.
SKIN: Warm. No rash.
NEUROLOGIC: No focal neurologic deficits. No asterixis. No gaze
preference. CNII-XII intact.
Pertinent Results:
Admission labs:
===============
___ 12:46PM BLOOD WBC-5.1 RBC-2.86* Hgb-10.0* Hct-32.2*
MCV-113* MCH-35.0* MCHC-31.1* RDW-14.2 RDWSD-59.1* Plt ___
___ 09:34PM BLOOD WBC-5.6 RBC-2.77* Hgb-9.4* Hct-30.7*
MCV-111* MCH-33.9* MCHC-30.6* RDW-14.0 RDWSD-56.5* Plt ___
___ 12:46PM BLOOD Plt ___
___ 09:34PM BLOOD Plt ___
___ 09:34PM BLOOD Glucose-309* UreaN-118* Creat-3.6* Na-146
K-4.8 Cl-102 HCO3-28 AnGap-16
___ 09:34PM BLOOD ALT-26 AST-18 AlkPhos-84 TotBili-<0.2
___ 09:34PM BLOOD Lipase-7
___ 09:34PM BLOOD Albumin-2.6* Calcium-8.4 Phos-6.6* Mg-2.1
___ 09:34PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
Studies:
========
CT Heat without contrast ___
No acute findings. Moderate paranasal sinus disease, slightly
improved compared to prior noncontrast head CT from ___.
Age advanced involutional changes, with sequela of chronic small
vessel
ischemic disease and stable appearance of few areas of chronic
infarction.
U/S Renal Transplant ___. Further elevation of resistive indices and absence of
diastolic flow within the left iliac fossa transplant kidney,
findings highly concerning for renal transplant
dysfunction/failure, acute tubular necrosis.
2. No hydronephrosis.
CT Heat without contrast ___. No acute intracranial abnormality on noncontrast CT head.
2. Redemonstration of multiple chronic infarcts, global
parenchymal volume loss and sequela of chronic microangiopathy
3. Moderate paranasal sinus disease is mildly worse.
Microbiology:
=============
Urine Culture ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Urine Culture ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
Blood Culture ___ (1 of 2)
Blood Culture, Routine (Pending): No growth to date.
Blood Culture ___ (2 of 2)
Blood Culture, Routine (Pending): No growth to date.
Discharge labs:
===============
___ 07:10AM BLOOD WBC-4.3 RBC-2.46* Hgb-8.4* Hct-26.5*
MCV-108* MCH-34.1* MCHC-31.7* RDW-14.0 RDWSD-55.1* Plt ___
___ 07:10AM BLOOD Glucose-43* UreaN-80* Creat-3.5* Na-145
K-4.7 Cl-108 HCO3-24 AnGap-13
___ 07:10AM BLOOD Calcium-8.2* Phos-6.3* Mg-2.___rief Hospital Course:
========================
___ year-old woman with history of ESRD (s/p LURT ___ on
cyclosporine, prednisone 5 mg daily), anemia, CAD s/p ___ 4
(most recently ___, HFrEF (EF ~40%), IPMN (___), HTN,
T1DM complicated by neuropathy, retinopathy, neurogenic bladder
(intermittent straight catheterization), and h/o multiple MDR
UTIs (Klebsiella, E.coli, Enterococcus), OSA, cryptogenic
stroke, and scleroderma/CREST who presented with an episode of
hypotension during Procrit infusion, now improved since
admission. Additionally, patient found to have elevation of Cr
up to 4.2, which responded to supplemental IVF and increased PO
intake; likely elevated and altered due to overdiuresis.
Hospital course complicated by acute complicate cystitis.
Treated with linezolid for VRE. Her BP medications were adjusted
given persistent SBP >180s with some improvement in BPs. She
became orthostatic and her BP medications were decreased. Home
diuretics were held at discharge.
TRANSITIONAL ISSUES:
====================
[] GOC: continue GOC discussion. on ___, spoke with ___
(HCP) regarding ___ wishes when she was clinically
worsening. ___ stated that ___ wanted to be DNR/DNI and
not want long term dialysis. Was transitioned to DNR/DNI on
___. However, ___ mentioned she is hoping to reverse the
DNR/DNI and go back to full code for subsequent
hospitalizations. Once ___ returned to her baseline, had a
discussion on ___: DNR but OK to intubate.
[] Volume status: While inpatient, her home diuretics were held
in setting of hypotension and prerenal ___. Should measure
weight daily at home once discharged, set this as her dry
weight; if weight goes up more than 3lb above this weight,
should do pill in pocket approach. Take 40 PO torsemide that
day; if weight not 3lb above that dry weight, should not take
diuretics that day. Should have close follow up with cardiology
[] Dry weight: 59.9 kg (132.05 lb)
[] Hypertension: continues to be labile; will need close
titration of hydralazine, clonidine, imdur, and metoprolol.
Likely should tolerate higher BP goal ~160 systolics given that
she is significantly orthostatic when she sits up/stands/walks
at lower BPs. Recommend compression stockings daily.
[] T1DM: while inpatient, glucose ranged from low ___ up to
500s. She is being discharged on 6u Lantus and ISS and will
require follow up with her outpatient endocrinologist.
[] ___: likely new baseline Cr is ~3.6, and transient increase
in Cr to 4.2 while inpatient was secondary to hypovolemia/poor
PO intake. Once patient taking in 1.5L of fluids, Cr stabilized
near 3.6. Encourage daily fluid intake of 1.5L.
[] Patient should have her BMP within a week of discharge to
ensure Cr stability and normal K. Cr on discharge was 3.5
[] While hospitalized, patient did not receive Procrit. Her
Hgb/Hct at admission were 10.0/32.2, and at discharge was
8.4/26.5. She should follow-up w/ Hematology on further Procrit
injections
[] Patient had urine culture, which grew VRE. Treated with a 7
day course of linezolid (last day of medications on ___
[] Continue glucerna BID given poor PO intake
[] Had one day of hyperkalemia which resolved once transitioned
to potassium 2gm diet. Should continue on this diet given near
ESRD.
ACUTE PROBLEMS:
==============
# Goals of Care
Has had multiple goals of care discussions in the past with
involvement of palliative care as well. On this admission when
___ was clinically deteriorating, ___ (HCP and sister)
stated that when ___ was at her mental baseline and lucid a
couple days prior, ___ stated she wished to be DNR/DNI.
___ also noted at that time (on ___ that ___ only wished
to be on dialysis short term if needed but would not want to be
on dialysis long term. On ___, was transitioned to DNR/DNI to
honor those wishes, which ___ agreed with. On ___, had a
discussion with ___ regarding her goals of care: she wishes
to be DNR but OK to intubate (for short trial on order of ___
weeks).
# Acute encephalopathy
# Episodic hypotension (resolved): Patient presented with
episode of decreased responsiveness with Procrit infusion at
clinic ___. She described lightheadedness and dizziness on
Procrit infusion, which she said was similar to her episodes of
orthostasis. Upon arrival to ___ ED, hypotension had resolved
but patient was noted to be more confused compared to
baseline(see acute encephalopathy below). The most likely cause
of hypotension was uptitration of torsemide as outpatient
leading to volume deficit. Patient's mental status returned to
baseline after IVF and holding torsemide.
# Acute complicated cystitis
Patient with pyuria on UA both at ___ and ___ in
setting of multiple MDRs UTIs in the past. She received CTX
(___), and Vancomycin (___). She grew VRE at ___.
Given patient clinically improved without new evidence of
urinary symptoms (has urinary retention at baseline for years
___ long standing diabetes) and without effective antibiotics,
we did not pursue further antibiosis until ___ when she became
acutely altered. U/A and urine culture on ___ grew out VRE.
Linezolid was started and her mental status returned to baseline
of alert and oriented x3. Will continue for a 7 day course
(___) for acute complicated cystitis.
___
#ESRD ___ T1DM and HTN s/p LURT (___)
#Nephrotic syndrome
At presentation, patient had elevated Cr 3.6 up from 3.3 on
___. Patient has chronic allograft dysfunction due to diabetic
nephropathy, partial rejection with baseline Cr ~ 3.0. Patient
has long history of nephrotic syndrome, biopsy proven ___ T1DM;
latest Grade 2 IFTA. Renal ultrasound at ED was without
hydronephrosis, but showed absence of diastolic flow, and
further elevation of resistive indices. Per renal transplant
team, it was very unlikely the rise in Cr represented acute
graft rejection and stated her new baseline Cr was likely 3.6.
Her initial increase in Cr above baseline was likely secondary
to pre-renal ___ due to overdiuresis. Cr stabilized at 3.5 once
patient was able to take in 1.5L of fluids daily.
# Hypertension
# Old infarcts
Patient with labile blood pressures, previous admissions for
hypertensive urgency and prior MRI/MRA head with new infarcts
c/f hypertension as etiology. Neurology inpatient service
previously recommended ASA and high dose statin. While
inpatient, she had remained hypertensive SBP >180 without
symptoms, requiring additional doses of hydralazine over several
nights. Initially increased her hydralazine to 75mg TID and
clonidine to 0.2mg/24h with improvement in overnight BPs. On
___, patient triggered given nursing concern. On evaluation,
patient had orthostatic hypotension (SBP 160 lying-> SBP 124
sitting) and no focal neurological deficits. Given significant
orthostasis, hydralazine was decreased to 25mg TID. Patient was
discharged on clonidine 0.2mg/24h, metoprolol succinate 50mg
daily, imdur 120mg qhs, and hydralazine 25mg TID in addition to
compression stockings. Labile BPs likely ___ severe dysautonomia
from long standing diabetes. More liberal BPs were tolerated
given her significant positional orthostatics.
#T1DM
Patient with initial glucose in the 400-500 range but without
anion gap. While in house, glucose widely fluctuated from ___ to
400s. ___ closely followed given labile glucose levels. Upon
discharge, patient will be on lantus 6u qam + gentle sliding
scale.
#Nutrition
Nutrition was consulted on ___ given poor oral intake. She was
started Glucerna BID, which she tolerated well.
CHRONIC PROBLEMS:
=================
# HFrEF (LVEF 40%-45% ___
Chronically overloaded. Recently lost 9 lbs in setting of
increasing diuretics. weight. Last TTE with EF 40-45%, mild MR,
mild AR ___. Home torsemide was held in setting of
hypotension. Her home metoprolol was reduced in hopes of
allowing her to augment her cardiac output more efficiently
during activity as she becomes quite orthostatic and lightheaded
upon standing, due to have severe dysautonomia. Given patient's
poor PO intake and sensitivity to prerenal insult, held
torsemide and will do pill in pocket approach. Will only take
torsemide 40mg daily when 3lbs above her dry weight. Dry weight
59.9 kg (132.05 lb)
# Chronic nausea:
Her promethazine was continued during hospitalization.
#Scleroderma w/ CREST syndrome:
Her immunosuppression was continued as above.
#Gastroparesis/GERD/hiatal hernia:
Patient was continued on home esomeprazole upon discharge.
#Seizure disorder:
Nonconvulsive status diagnosed during previous admission and
started on divalproate and levetiracetam at that time. She was
continued on home divalproex, and levetiracetam.
#Macrocytic anemia:
Chronic, secondary to ESRD, immunosuppression. Possibly a
dilutional component from fluids. Was initially maintained on
EPO, and per outpatient discussion via email with hematologist,
will likely continue this regimen on outpatient basis.
#Gout:
Patient was continued home allopurinol.
#Hypothyroidism:
Patient was continued on home levothyroxine.
#Hyperlipidemia:
Patient was continued on home pravastatin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM
3. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM
4. Divalproex (DELayed Release) 750 mg PO BID
5. HydrALAZINE 50 mg PO BID
6. Isosorbide Mononitrate (Extended Release) 120 mg PO QHS
7. LevETIRAcetam 250 mg PO BID
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Metoprolol Succinate XL 100 mg PO QHS
10. Mycophenolate Mofetil 500 mg PO BID
11. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
12. Pravastatin 30 mg PO QPM
13. PredniSONE 5 mg PO DAILY
14. Promethazine 25 mg PO Q8H:PRN nausea
15. Senna 8.6 mg PO BID
16. Sodium Bicarbonate 650 mg PO BID
17. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QSAT
18. melatonin 10 mg oral QHS
19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
20. Aspirin 81 mg PO DAILY
21. Calcitriol 0.25 mcg PO DAILY
22. Levothyroxine Sodium 125 mcg PO DAILY
23. Torsemide 60 mg PO QAM
24. Levemir 16 Units Breakfast
Levemir 16 Units Dinner
Novolog 5 Units Breakfast
Novolog 5 Units Dinner
25. Torsemide 40 mg PO QPM
Discharge Medications:
1. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QTUES
2. Linezolid ___ mg PO Q12H
3. Multivitamins 1 TAB PO DAILY
4. Torsemide 40 mg PO DAILY:PRN weight gain >3lbs from baseline
5. HydrALAZINE 25 mg PO TID
6. Glargine 6 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Allopurinol ___ mg PO EVERY OTHER DAY
9. Aspirin 81 mg PO DAILY
10. Calcitriol 0.25 mcg PO DAILY
11. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QSAT
12. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM
13. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM
14. Divalproex (DELayed Release) 750 mg PO BID
15. Esomeprazole 40 mg Other Q12H
16. Isosorbide Mononitrate (Extended Release) 120 mg PO QHS
17. LevETIRAcetam 250 mg PO BID
18. Levothyroxine Sodium 125 mcg PO DAILY
19. Lidocaine 5% Patch 1 PTCH TD QAM
20. melatonin 10 mg oral QHS
21. Mycophenolate Mofetil 500 mg PO BID
22. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
23. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
24. Pravastatin 30 mg PO QPM
25. PredniSONE 5 mg PO DAILY
26. Promethazine 25 mg PO Q8H:PRN nausea
27. Ranolazine ER 500 mg PO BID
28. Senna 8.6 mg PO BID
29. Sodium Bicarbonate 650 mg PO BID
30. HELD- Torsemide 40 mg PO QPM This medication was held. Do
not restart Torsemide until doing prn dosing
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Hypotension
Altered Mental Status
Urinary Tract Infection
Acute Kidney Injury
SECONDARY DIAGNOSIS:
====================
Hypertension
Type 1 Diabetes
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
================================================
MEDICINE Discharge Worksheet
================================================
Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
You were admitted because you had low blood pressure and
appeared to be confused.
What was done for me while I was in the hospital?
You received intravenous fluids because you were dehydrated. A
renal ultrasound showed no significant change to your kidney
transplant. You were also found to have an urinary tract
infection, for which you received antibiotics. Your kidney
function improved as you drank more water.
What should I do when I leave the hospital?
-Please note any new or changes in your medications in your
discharge worksheet.
-Please weigh yourself every morning. You weighed ***** on
discharge from the hospital: this is your dry weight. If you
gain more than 3lbs from this dry weight, please take torsemide
40mg daily until you are within 3 lbs from your dry weight. When
you do this, please let your primary care physician or
cardiologist know as you will likely need to get your kidney
function checked as well.
-Please note any new or changes in your medications in your
discharge worksheet.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
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Allergies: Penicillins / Ativan / carvedilol / amlodipine Chief Complaint: Hypotension Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [MASKED] is a [MASKED] yo woman with history of ESRD (s/p LURT [MASKED] on cyclosporine, prednisone 5 mg daily), anemia, CAD s/p [MASKED] 4 (most recently [MASKED], HFrEF (EF ~40%), IPMN ([MASKED]), HTN, T1DM complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization), autonomic dysfunction and h/o multiple UTIs (Klebsiella, E.coli, Enterococcus), OSA, cryptogenic stroke, and scleroderma/CREST who presents with an episode of hypotension during Procrit infusion. Patient reports being in [MASKED] this AM when she experienced an episode of decreased responsiveness. Per referral note, patient suffered an episode of decreased responsiveness and lethargy during infusion and was found to be hypotensive with a blood pressure of 70. The patient noted that she felt dizzy at that time as well. She states she felt similarly to how she has in the past when her blood pressure has dropped in setting of known orthostasis. She reported to ED staff that she recently was started "on an aggressive Lasix regimen" 1 week prior to presentation and has lost roughly 9 lbs. Patient's aid stated that patient was acting normal prior to the event and has had similar events in the past. She was first taken to the ED at [MASKED] where straight cath urine specimen was notable for 1000 mg/dL glucose, 25 RBCs, + Leuk esterase, [MASKED] WBCs/hpf, 3 + bact. EKG with T wave inversions laterally "which is similar to previous and some possible submillimeter ST depressions V4 and V5 which is nonspecific and trop T .499, lower than previous." CXR clear. She was given a 1x dose of CTX 1 g and sent to the [MASKED] ED for further care. Past Medical History: -CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED] DES to LAD [MASKED] PCI of Cx and OM with [MASKED] -[MASKED] renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] -Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) -Dysautonomia -Hypertension -Dyslipidemia -Scleroderma w/ CREST syndrome -Gastroparesis/GERD/Hiatal hernia -Gout diagnosed [MASKED] years ago -OSA -Pancreatic cyst -Non convulsive status epilepticus -stroke -BPPV Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: Admission exam: =============== GENERAL: Chronically ill-appearing woman. NAD, alert and interactive. Oriented to self, [MASKED] in [MASKED] and [MASKED] but states year is [MASKED]. HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD appreciated. CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally with bibasilar crackles noted. No wheezes. No increased work of breathing on RA. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: +BS, soft, slightly distended, but non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: 1+ edema bilaterally to mid-shins. No clubbing or cyanosis. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. No rash. NEUROLOGIC: A&Ox3, no focal neurologic deficits. CN2-12 grossly intact. [MASKED] strength throughout. Discharge exam: =============== [MASKED] 1140 Temp: 97.8 PO BP: 150/78 L Lying HR: 66 RR: 16 O2 sat: 97% O2 delivery: RA GENERAL: Chronically ill-appearing woman. Lying in bed. Alert and conversant; A&O to year, self, location HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. MMM. No facial droop. NECK: No JVD appreciated. CARDIAC: RRR. Audible S1 and S2. Crescendo-descrendo systolic ejection murmur [MASKED] at LUSB, No gallops or rubs. LUNGS: Clear to auscultation bilaterally. No wheezes or crackles appreciated. No increased work of breathing on RA. BACK: No CVA tenderness. ABDOMEN: Normal bowel sound; Abdomen is soft, remains slightly distended, hyperresonant, but non-tender to deep palpation in all four quadrants. EXTREMITIES: 1+ edema bilaterally to lower ankles. No clubbing or cyanosis. SKIN: Warm. No rash. NEUROLOGIC: No focal neurologic deficits. No asterixis. No gaze preference. CNII-XII intact. Pertinent Results: Admission labs: =============== [MASKED] 12:46PM BLOOD WBC-5.1 RBC-2.86* Hgb-10.0* Hct-32.2* MCV-113* MCH-35.0* MCHC-31.1* RDW-14.2 RDWSD-59.1* Plt [MASKED] [MASKED] 09:34PM BLOOD WBC-5.6 RBC-2.77* Hgb-9.4* Hct-30.7* MCV-111* MCH-33.9* MCHC-30.6* RDW-14.0 RDWSD-56.5* Plt [MASKED] [MASKED] 12:46PM BLOOD Plt [MASKED] [MASKED] 09:34PM BLOOD Plt [MASKED] [MASKED] 09:34PM BLOOD Glucose-309* UreaN-118* Creat-3.6* Na-146 K-4.8 Cl-102 HCO3-28 AnGap-16 [MASKED] 09:34PM BLOOD ALT-26 AST-18 AlkPhos-84 TotBili-<0.2 [MASKED] 09:34PM BLOOD Lipase-7 [MASKED] 09:34PM BLOOD Albumin-2.6* Calcium-8.4 Phos-6.6* Mg-2.1 [MASKED] 09:34PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG Studies: ======== CT Heat without contrast [MASKED] No acute findings. Moderate paranasal sinus disease, slightly improved compared to prior noncontrast head CT from [MASKED]. Age advanced involutional changes, with sequela of chronic small vessel ischemic disease and stable appearance of few areas of chronic infarction. U/S Renal Transplant [MASKED]. Further elevation of resistive indices and absence of diastolic flow within the left iliac fossa transplant kidney, findings highly concerning for renal transplant dysfunction/failure, acute tubular necrosis. 2. No hydronephrosis. CT Heat without contrast [MASKED]. No acute intracranial abnormality on noncontrast CT head. 2. Redemonstration of multiple chronic infarcts, global parenchymal volume loss and sequela of chronic microangiopathy 3. Moderate paranasal sinus disease is mildly worse. Microbiology: ============= Urine Culture [MASKED] URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL. Urine Culture [MASKED] URINE CULTURE (Final [MASKED]: ENTEROCOCCUS SP.. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 128 R TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R Blood Culture [MASKED] (1 of 2) Blood Culture, Routine (Pending): No growth to date. Blood Culture [MASKED] (2 of 2) Blood Culture, Routine (Pending): No growth to date. Discharge labs: =============== [MASKED] 07:10AM BLOOD WBC-4.3 RBC-2.46* Hgb-8.4* Hct-26.5* MCV-108* MCH-34.1* MCHC-31.7* RDW-14.0 RDWSD-55.1* Plt [MASKED] [MASKED] 07:10AM BLOOD Glucose-43* UreaN-80* Creat-3.5* Na-145 K-4.7 Cl-108 HCO3-24 AnGap-13 [MASKED] 07:10AM BLOOD Calcium-8.2* Phos-6.3* Mg-2. rief Hospital Course: ======================== [MASKED] year-old woman with history of ESRD (s/p LURT [MASKED] on cyclosporine, prednisone 5 mg daily), anemia, CAD s/p [MASKED] 4 (most recently [MASKED], HFrEF (EF ~40%), IPMN ([MASKED]), HTN, T1DM complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization), and h/o multiple MDR UTIs (Klebsiella, E.coli, Enterococcus), OSA, cryptogenic stroke, and scleroderma/CREST who presented with an episode of hypotension during Procrit infusion, now improved since admission. Additionally, patient found to have elevation of Cr up to 4.2, which responded to supplemental IVF and increased PO intake; likely elevated and altered due to overdiuresis. Hospital course complicated by acute complicate cystitis. Treated with linezolid for VRE. Her BP medications were adjusted given persistent SBP >180s with some improvement in BPs. She became orthostatic and her BP medications were decreased. Home diuretics were held at discharge. TRANSITIONAL ISSUES: ==================== [] GOC: continue GOC discussion. on [MASKED], spoke with [MASKED] (HCP) regarding [MASKED] wishes when she was clinically worsening. [MASKED] stated that [MASKED] wanted to be DNR/DNI and not want long term dialysis. Was transitioned to DNR/DNI on [MASKED]. However, [MASKED] mentioned she is hoping to reverse the DNR/DNI and go back to full code for subsequent hospitalizations. Once [MASKED] returned to her baseline, had a discussion on [MASKED]: DNR but OK to intubate. [] Volume status: While inpatient, her home diuretics were held in setting of hypotension and prerenal [MASKED]. Should measure weight daily at home once discharged, set this as her dry weight; if weight goes up more than 3lb above this weight, should do pill in pocket approach. Take 40 PO torsemide that day; if weight not 3lb above that dry weight, should not take diuretics that day. Should have close follow up with cardiology [] Dry weight: 59.9 kg (132.05 lb) [] Hypertension: continues to be labile; will need close titration of hydralazine, clonidine, imdur, and metoprolol. Likely should tolerate higher BP goal ~160 systolics given that she is significantly orthostatic when she sits up/stands/walks at lower BPs. Recommend compression stockings daily. [] T1DM: while inpatient, glucose ranged from low [MASKED] up to 500s. She is being discharged on 6u Lantus and ISS and will require follow up with her outpatient endocrinologist. [] [MASKED]: likely new baseline Cr is ~3.6, and transient increase in Cr to 4.2 while inpatient was secondary to hypovolemia/poor PO intake. Once patient taking in 1.5L of fluids, Cr stabilized near 3.6. Encourage daily fluid intake of 1.5L. [] Patient should have her BMP within a week of discharge to ensure Cr stability and normal K. Cr on discharge was 3.5 [] While hospitalized, patient did not receive Procrit. Her Hgb/Hct at admission were 10.0/32.2, and at discharge was 8.4/26.5. She should follow-up w/ Hematology on further Procrit injections [] Patient had urine culture, which grew VRE. Treated with a 7 day course of linezolid (last day of medications on [MASKED] [] Continue glucerna BID given poor PO intake [] Had one day of hyperkalemia which resolved once transitioned to potassium 2gm diet. Should continue on this diet given near ESRD. ACUTE PROBLEMS: ============== # Goals of Care Has had multiple goals of care discussions in the past with involvement of palliative care as well. On this admission when [MASKED] was clinically deteriorating, [MASKED] (HCP and sister) stated that when [MASKED] was at her mental baseline and lucid a couple days prior, [MASKED] stated she wished to be DNR/DNI. [MASKED] also noted at that time (on [MASKED] that [MASKED] only wished to be on dialysis short term if needed but would not want to be on dialysis long term. On [MASKED], was transitioned to DNR/DNI to honor those wishes, which [MASKED] agreed with. On [MASKED], had a discussion with [MASKED] regarding her goals of care: she wishes to be DNR but OK to intubate (for short trial on order of [MASKED] weeks). # Acute encephalopathy # Episodic hypotension (resolved): Patient presented with episode of decreased responsiveness with Procrit infusion at clinic [MASKED]. She described lightheadedness and dizziness on Procrit infusion, which she said was similar to her episodes of orthostasis. Upon arrival to [MASKED] ED, hypotension had resolved but patient was noted to be more confused compared to baseline(see acute encephalopathy below). The most likely cause of hypotension was uptitration of torsemide as outpatient leading to volume deficit. Patient's mental status returned to baseline after IVF and holding torsemide. # Acute complicated cystitis Patient with pyuria on UA both at [MASKED] and [MASKED] in setting of multiple MDRs UTIs in the past. She received CTX ([MASKED]), and Vancomycin ([MASKED]). She grew VRE at [MASKED]. Given patient clinically improved without new evidence of urinary symptoms (has urinary retention at baseline for years [MASKED] long standing diabetes) and without effective antibiotics, we did not pursue further antibiosis until [MASKED] when she became acutely altered. U/A and urine culture on [MASKED] grew out VRE. Linezolid was started and her mental status returned to baseline of alert and oriented x3. Will continue for a 7 day course ([MASKED]) for acute complicated cystitis. [MASKED] #ESRD [MASKED] T1DM and HTN s/p LURT ([MASKED]) #Nephrotic syndrome At presentation, patient had elevated Cr 3.6 up from 3.3 on [MASKED]. Patient has chronic allograft dysfunction due to diabetic nephropathy, partial rejection with baseline Cr ~ 3.0. Patient has long history of nephrotic syndrome, biopsy proven [MASKED] T1DM; latest Grade 2 IFTA. Renal ultrasound at ED was without hydronephrosis, but showed absence of diastolic flow, and further elevation of resistive indices. Per renal transplant team, it was very unlikely the rise in Cr represented acute graft rejection and stated her new baseline Cr was likely 3.6. Her initial increase in Cr above baseline was likely secondary to pre-renal [MASKED] due to overdiuresis. Cr stabilized at 3.5 once patient was able to take in 1.5L of fluids daily. # Hypertension # Old infarcts Patient with labile blood pressures, previous admissions for hypertensive urgency and prior MRI/MRA head with new infarcts c/f hypertension as etiology. Neurology inpatient service previously recommended ASA and high dose statin. While inpatient, she had remained hypertensive SBP >180 without symptoms, requiring additional doses of hydralazine over several nights. Initially increased her hydralazine to 75mg TID and clonidine to 0.2mg/24h with improvement in overnight BPs. On [MASKED], patient triggered given nursing concern. On evaluation, patient had orthostatic hypotension (SBP 160 lying-> SBP 124 sitting) and no focal neurological deficits. Given significant orthostasis, hydralazine was decreased to 25mg TID. Patient was discharged on clonidine 0.2mg/24h, metoprolol succinate 50mg daily, imdur 120mg qhs, and hydralazine 25mg TID in addition to compression stockings. Labile BPs likely [MASKED] severe dysautonomia from long standing diabetes. More liberal BPs were tolerated given her significant positional orthostatics. #T1DM Patient with initial glucose in the 400-500 range but without anion gap. While in house, glucose widely fluctuated from [MASKED] to 400s. [MASKED] closely followed given labile glucose levels. Upon discharge, patient will be on lantus 6u qam + gentle sliding scale. #Nutrition Nutrition was consulted on [MASKED] given poor oral intake. She was started Glucerna BID, which she tolerated well. CHRONIC PROBLEMS: ================= # HFrEF (LVEF 40%-45% [MASKED] Chronically overloaded. Recently lost 9 lbs in setting of increasing diuretics. weight. Last TTE with EF 40-45%, mild MR, mild AR [MASKED]. Home torsemide was held in setting of hypotension. Her home metoprolol was reduced in hopes of allowing her to augment her cardiac output more efficiently during activity as she becomes quite orthostatic and lightheaded upon standing, due to have severe dysautonomia. Given patient's poor PO intake and sensitivity to prerenal insult, held torsemide and will do pill in pocket approach. Will only take torsemide 40mg daily when 3lbs above her dry weight. Dry weight 59.9 kg (132.05 lb) # Chronic nausea: Her promethazine was continued during hospitalization. #Scleroderma w/ CREST syndrome: Her immunosuppression was continued as above. #Gastroparesis/GERD/hiatal hernia: Patient was continued on home esomeprazole upon discharge. #Seizure disorder: Nonconvulsive status diagnosed during previous admission and started on divalproate and levetiracetam at that time. She was continued on home divalproex, and levetiracetam. #Macrocytic anemia: Chronic, secondary to ESRD, immunosuppression. Possibly a dilutional component from fluids. Was initially maintained on EPO, and per outpatient discussion via email with hematologist, will likely continue this regimen on outpatient basis. #Gout: Patient was continued home allopurinol. #Hypothyroidism: Patient was continued on home levothyroxine. #Hyperlipidemia: Patient was continued on home pravastatin. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO EVERY OTHER DAY 2. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM 3. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM 4. Divalproex (DELayed Release) 750 mg PO BID 5. HydrALAZINE 50 mg PO BID 6. Isosorbide Mononitrate (Extended Release) 120 mg PO QHS 7. LevETIRAcetam 250 mg PO BID 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Metoprolol Succinate XL 100 mg PO QHS 10. Mycophenolate Mofetil 500 mg PO BID 11. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 12. Pravastatin 30 mg PO QPM 13. PredniSONE 5 mg PO DAILY 14. Promethazine 25 mg PO Q8H:PRN nausea 15. Senna 8.6 mg PO BID 16. Sodium Bicarbonate 650 mg PO BID 17. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QSAT 18. melatonin 10 mg oral QHS 19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 20. Aspirin 81 mg PO DAILY 21. Calcitriol 0.25 mcg PO DAILY 22. Levothyroxine Sodium 125 mcg PO DAILY 23. Torsemide 60 mg PO QAM 24. Levemir 16 Units Breakfast Levemir 16 Units Dinner Novolog 5 Units Breakfast Novolog 5 Units Dinner 25. Torsemide 40 mg PO QPM Discharge Medications: 1. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QTUES 2. Linezolid [MASKED] mg PO Q12H 3. Multivitamins 1 TAB PO DAILY 4. Torsemide 40 mg PO DAILY:PRN weight gain >3lbs from baseline 5. HydrALAZINE 25 mg PO TID 6. Glargine 6 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Allopurinol [MASKED] mg PO EVERY OTHER DAY 9. Aspirin 81 mg PO DAILY 10. Calcitriol 0.25 mcg PO DAILY 11. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QSAT 12. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM 13. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM 14. Divalproex (DELayed Release) 750 mg PO BID 15. Esomeprazole 40 mg Other Q12H 16. Isosorbide Mononitrate (Extended Release) 120 mg PO QHS 17. LevETIRAcetam 250 mg PO BID 18. Levothyroxine Sodium 125 mcg PO DAILY 19. Lidocaine 5% Patch 1 PTCH TD QAM 20. melatonin 10 mg oral QHS 21. Mycophenolate Mofetil 500 mg PO BID 22. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 23. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 24. Pravastatin 30 mg PO QPM 25. PredniSONE 5 mg PO DAILY 26. Promethazine 25 mg PO Q8H:PRN nausea 27. Ranolazine ER 500 mg PO BID 28. Senna 8.6 mg PO BID 29. Sodium Bicarbonate 650 mg PO BID 30. HELD- Torsemide 40 mg PO QPM This medication was held. Do not restart Torsemide until doing prn dosing Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Hypotension Altered Mental Status Urinary Tract Infection Acute Kidney Injury SECONDARY DIAGNOSIS: ==================== Hypertension Type 1 Diabetes Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: ================================================ MEDICINE Discharge Worksheet ================================================ Dear Ms. [MASKED], It was a pleasure taking part in your care here at [MASKED]! Why was I admitted to the hospital? You were admitted because you had low blood pressure and appeared to be confused. What was done for me while I was in the hospital? You received intravenous fluids because you were dehydrated. A renal ultrasound showed no significant change to your kidney transplant. You were also found to have an urinary tract infection, for which you received antibiotics. Your kidney function improved as you drank more water. What should I do when I leave the hospital? -Please note any new or changes in your medications in your discharge worksheet. -Please weigh yourself every morning. You weighed ***** on discharge from the hospital: this is your dry weight. If you gain more than 3lbs from this dry weight, please take torsemide 40mg daily until you are within 3 lbs from your dry weight. When you do this, please let your primary care physician or cardiologist know as you will likely need to get your kidney function checked as well. -Please note any new or changes in your medications in your discharge worksheet. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"I2510",
"G4733",
"E785",
"K219",
"M109",
"E039",
"Z955",
"Z8673",
"Z87891",
"Z66",
"Z515",
"Z794"
] |
[
"I952: Hypotension due to drugs",
"N186: End stage renal disease",
"G92: Toxic encephalopathy",
"I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease",
"I5022: Chronic systolic (congestive) heart failure",
"K862: Cyst of pancreas",
"N178: Other acute kidney failure",
"N3000: Acute cystitis without hematuria",
"T8612: Kidney transplant failure",
"E870: Hyperosmolality and hypernatremia",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"N319: Neuromuscular dysfunction of bladder, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"E785: Hyperlipidemia, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"K449: Diaphragmatic hernia without obstruction or gangrene",
"M341: CR(E)ST syndrome",
"M109: Gout, unspecified",
"N141: Nephropathy induced by other drugs, medicaments and biological substances",
"T502X5A: Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, initial encounter",
"I951: Orthostatic hypotension",
"H8110: Benign paroxysmal vertigo, unspecified ear",
"E875: Hyperkalemia",
"E1021: Type 1 diabetes mellitus with diabetic nephropathy",
"G40909: Epilepsy, unspecified, not intractable, without status epilepticus",
"D631: Anemia in chronic kidney disease",
"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",
"E039: Hypothyroidism, unspecified",
"Z7982: Long term (current) use of aspirin",
"Z992: Dependence on renal dialysis",
"Z955: Presence of coronary angioplasty implant and graft",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"Z87891: Personal history of nicotine dependence",
"Z66: Do not resuscitate",
"Z515: Encounter for palliative care",
"Z794: Long term (current) use of insulin"
] |
10,030,753
| 22,045,511
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___.
Chief Complaint:
Weight gain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with DM1, CAD and dysautonomia presents from rehab with
sudden onset of lower extremity swelling and pain.
Yesterday evening, the patient noticed the sudden onset ___
pain and swelling that is described as throbbing. She does not
note any exacerbating factors but does not alleviation with
movement. This morning, she noticed progression of the pain to
her lower back.
She ___ no fevers or chills. She notes no chest pain,
palpitations or dyspnea. She ___ no cough, wheezing or
orthopnea.
+n/v for over ___ year. She ___ had large, loose, watery bowel
movements ___ times per day for the last week. She stats her
blood glucose ___ been under good control.
Of note, the patient was hospitalized at ___ from ___
after suffering a SAH after a mechanical fall. The etiology of
the fall was attributed to labile blood sugars and blood
pressures due to dysautonomia. Her hospital course was
complicated by HHS and labile blood pressures. She was seen by
___ and ___ blood sugars were controlled with an insulin gtt
and eventually transitioned to Lantus 8u qAM and 2U Humalog at
meals with sliding scale. . Regarding her labile blood
pressures,
this was thought to be from dysautonomia due to her poorly
controlled DM1. She was started on metoprolol succinate and
hydralazine
In the ED, initial VS were:
T 97.5 HR 83 BP 147/63 R 16 SpO2 99% RA
Exam notable for:
2+ pitting edema to mid calf, swelling diffuse up legs with
scattered petechiae, no CVA tenderness, no midline tenderness
ECG: NSR Rate 83. L-axis Normal Intervals, QTc 450. No
significant change from prior
Labs showed:
145|106|53
-----------<84
4.2|24|2.1
Ca: 7.8 Mg: 1.0 P: 3.3
ALT: 17 AP: 86 Tbili: 0.3 Alb: 2.7
AST: 20 Lip: 9
Lactate:1.6
Trop-T: 0.14 CK: 130 MB: 3
___: ___
7.3
8.2>----<382
23.4
Imaging showed:
___ Liver Or Gallbladder Us
No evidence of biliary obstruction or portal vein thrombosis
___ Chest (Pa & Lat)
IMPRESSION:
No acute cardiopulmonary abnormality.
Consults:
Per Renal Transplant: cyclosporine(neoral) 25 mg bid. Goal
75-125. Cyclosporine AM trough level daily MMF 500 mg bid.
Prednisone 6 mg daily.
Patient received:
___ 17:25 IV Magnesium Sulfate
___ 17:51 IV Furosemide 20 mg
___ 18:30 IV Magnesium Sulfate 2 gm
___ 20:00 SC Insulin Not Given per Sliding Scale
___ 20:17 PO/NG Ondansetron 4 mg
On arrival to the floor, patient reports no dyspnea and
improvement of her leg pain.
Past Medical History:
Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
Hypertension
Dyslipidemia
CAD with PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___. Then DES to LAD in ___ and ___ PCI of Cx and OM with ___
___ w/ CREST syndrome
Gastroparesis
GERD
Hiatal hernia
Gout
OSA
End-stage renal disease due diabetes s/p L-sided living kidney
transplant in ___
anemia
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION EXAM
VS: T 97.9 BP 137/59 HR 87 R 16 SpO2 97 Ra
GEN: NAD, speaking comfortably lying flat in bed
HEENT: Clear OP, moist mucous membranes
___: Regular, II/VI SEM, JVP at mid-neck at 45 degrees
+Hepatojugular reflex
RESP: RRR, no wheezing, crackles or rhonchi. No increased WOB
ABD: NTND, no HSM
EXT: Warm, Pitting edema to mid thigh bilaterally.
NEURO: CN IV-XII intact. Pupils dilated and minimally-reactive
to
light (baseline).
SKIN: Fine, scattered erythematous erosions L medial thigh, R
lateral thigh with overlying crusting. No excoriations. No
lesions in web spaces. Small 1cm linear abrasion over L small
toe
and 1cm, circular, erythematous macule with overlying scab over
L
great toe.
DISCHARGE EXAM
Pertinent Results:
ADMISSION LABS
=================
___ 04:00PM BLOOD WBC-8.2 RBC-2.52* Hgb-7.3* Hct-23.4*
MCV-93 MCH-29.0 MCHC-31.2* RDW-21.2* RDWSD-70.5* Plt ___
___ 04:00PM BLOOD Glucose-84 UreaN-53* Creat-2.1* Na-145
K-4.2 Cl-106 HCO3-24 AnGap-15
___ 04:00PM BLOOD CK-MB-3 cTropnT-0.15* ___
___ 04:00PM BLOOD Albumin-2.7* Calcium-7.8* Phos-3.3
Mg-1.0*
___ 04:00PM BLOOD Cortsol-3.1
___ 04:22PM BLOOD Lactate-1.6
___ 09:16AM URINE Blood-NEG Nitrite-NEG Protein-100*
Glucose-150* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 09:16AM URINE Hours-RANDOM Creat-39 Na-85 Mg-<1.4
Albumin-242.0 Alb/Cre-6205.1*
___ 09:16AM URINE Osmolal-395
INTERVAL LABS
=================
DISCHARGE LABS
=================
MICROBIOLOGY
=================
CMV IgG ANTIBODY (Final ___:
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
<4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING
=================
RUQUS ___:
No evidence of biliary obstruction or portal vein thrombosis.
CXR ___
No acute cardiopulmonary abnormality.
Rib Series ___
1. Right lower lobe atelectasis versus early infiltrate,
slightly worse.
Follow up to resolution is recommended to exclude pneumonia.
2. No displaced rib fracture.
Renal US ___
1. Elevated resistive indices similar to the prior study with
differential
which may include acute tubular necrosis and rejection.
2. Patent vasculature, no hydronephrosis.
TTE ___
The left atrium is elongated. 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.
The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). 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) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] There is
moderate pulmonary artery systolic hypertension. There is a
small pericardial effusion. The effusion appears
circumferential.
IMPRESSION: Moderate left ventricular hypertrophy with low
normal global systolic function. Small pericardial effusion
without echo evidence of tamponade. Moderate pulmonary
hypertension.
Compared with the prior study (images reviewed) of ___
global left ventricular systolic function is improved. Moderate
pulmonary hypertension is seen. As before amyloid cardiomyopathy
should be considered).
CXR ___
Cardiomegaly is severe, minimally improved since previous
examination. Right
pleural effusion ___ increased. There is no overt pulmonary
edema, mild
vascular congestion is better than on ___. No
pneumothorax.
Brief Hospital Course:
Ms. ___ is a ___ female with history of HFrEF (EF
41%) ESRD s/p LURT ___ longstanding DMI on CellCept,
Neoral, and prednisone, CAD s/p multiple ___ recently on
___ on aspirin and ticagrelor, CREST, remote PE,
dysautonomia with orthostatic hypotension, recent fall with
right sided SAH, recently seen new pancreatic head mass on CT
A/P, who presented with a 1 week history of lower extremity
swelling and weight gain admitted for acute on chronic HFrEF
exacerbation requiring IV diureses subsequently transitioned to
PO lasix 20 with a contingency for an extram 20mg for lower
extremity edema, with plan for GI follow-up for ongoing work-up
of incidental pancreatic mass. Of note patient requested to be
discharged despite remaining volume overloaded with ___ on CKD
with plan for outpatient ongoing diuresis and renal monitoring.
On the day of discharge the patient was very insistent on being
discharged so that she could be able to attend to very special
family ___. We discussed this with the renal transplant team
as well. Together we both felt that was ongoing medical
management and optimization that should be done but in an
attempt to meet her wishes and give her some quality life time
we were willing to make a compromise on a plan to discharge her
with full disclosure to her that she was not quite as optimized
as possible. We also created a plan to treat her UTI in the
outpatient setting for a total 14 days of treatment end of
treatment would be ___. She will also need to eat a very low
sodium diet of 2gram max per day and have her renal function
assessed and have her results faxed to the BI renal team. We
will also gave her a rx for Lasix 20mg daily with extra 20mg for
leg swelling.
ACUTE ISSUES
===================
#Acute on chronic HFrEF - Patient ___ a history of HFrEF EF 41%
who initially presented with a one week history of worsening
lower extremity swelling and weight gain found to be volume
overloaded on exam with BNP 22,235 on admission. The trigger for
her acute on chronic HFrEF exacerbation was unclear. Her EKG
showed no ischemic changes, troponins were at baseline with flat
CK-MB. She was initially diuresed with intermittent IV lasix 80
boluses, however subsequently had worsening renal function.
Diureses was subsequently held however renal functioned
continued to worsen, thought to be attributed to cardiorenal
syndrome and concomitant UTI per below. CXR showed worsening
right sided pleural effusion. In consultation with transplant
nephrology, she was subsequently diuresed with 80mg IV Lasix X2
which did not show a large improvement in the Cr. and she was
transitioned to PO 20mg lasix daily with contingency for extra
dose of 20mg for ___ edema. Discharge weight was 60.4kg and
discharge creatinine was 3.4. Plan for ongoing outpatient
diuresis with PO regimen and continued renal monitoring.
___ on CKD
#ESRD s/p renal transplant:
With history of ESRD in the setting of long standing DMI, s/p
LURT ___ maintained on cellcept, cyclosporine and prednisone.
Baseline Cr over the last 6 months ranged between 2.0-2.5. Renal
US showed elevated resistive indices, stable from prior with no
evidence of hydronephrosis. Per above, she had worsening renal
function despite periods of aggressive diuresis as well as
rising Cr when holding diuretics. Upon discharge, it seemed as
though her ___ was most likely due to over diuresis as she was
nearly back to her baseline weight w/very little ___ edema. This
being the case in her fluid status was incongruent with her
worsening creatinine to 3.4 on day of discharge. Ultimately we
felt that a large component of her increasing creatinine was not
solely based on a pre-renal picture or CRS but likely a
component of chronic renal graft rejection. There was no
evidence of ATN on urinalysis. She was continued on MMF 500mg
BID, neoral 25mg BID with goal cyclosporin level 40-100, and
continued on prednisone 6mg daily.
#Incidental Pancreatic Mass: Recent Non-con CT Torso at ___
___ was significant for a 2.1 x 1.4 cm hypodense mass in the
region of the pancreatic head and a 1 cm exophytic hypodensity
off anterior aspect of the pancreatic body, suspicious for
malignancy. She was initially planned for an outpatient EUS on
___. GI was consulted for possible inpatient EUS, however
after multi-disciplinary meeting involving radiology, per GI
mass appeared more consistent with IPMN. Plan for interval MRCP
in 4 weeks from now (6 weeks from original CT to evaluate for
interval change. Of note, any additional advanced imaging will
be limited by current renal function given inability to use
contrast, and if biopsy is pursued, will have to consider
holding ticagrelor given she is on DAPT for recent ___
in ___. Follow-up will be arranged with Dr. ___ in
___ weeks.
#UTI - Urine culture ___ growing E. Coli. She was initially
started on ceftriaxone and subsequently transitioned to p.o.
cefpodoxime, with plan for 14 day total course given her history
of renal transplant end of treatment for ___.
#Anemia - History of chronic anemia with baseline Hb 7.0-8.0.
Initial Hb on admission was 6.8 and she recieved 1U PRBC with
post-transfusion Hb 9.5. There was no evidence of hemolysis.
Anemia was thought to be inflammatory also in the setting of her
CKD. She was started on IV ferric gluconate x 4 doses given her
transferrin saturation of 19%. Plan to follow-up with GI per
above.
#Subarachnoid hemorrhage
#Intracranial stenosis - Patient had a recent admission for
mechanical fall and subsequent SAH. No neurosurgical
intervention was performed and goal SBP remains <160. She ___
had very difficult to control blood pressure given her history
of chronic orthostatic hypotension and dysautonomia. She was
continued on aspirin 81 mg daily, atorvastatin 20 mg daily, home
hydralazine was uptitrated from 50mg PO QHS to 75mg TID given
frequent SBP ranging 160-200, and continued on home metoprolol
succinate 125 mg daily.
#Orthostatic Hypotension
#Dysautonomia - Patient ___ a well-documented history of severe
orthostatic hypotension and dysautonomia. On previous discharge
in consultation with renal transplant, she was maintained on a
regimen of hydralazine 50 mg daily, and metoprolol succinate 125
mg daily. Her blood pressure was better controlled on longer
acting agents, and she previously ___ not tolerated CCB,
captopril due to her severe orthostatic hypotension. Her
antihypertensives were uptitrated to hydralazine 75 mg TID and
continued metoprolol succinate 125 mg daily per above. We were
unable to start an ___ given her ___ on CKD per above.
#Skin findings - Patient was found to have multiple skin
findings including an erythematous erosions on L medial thigh
and R lateral thigh with overlying crusting. RUQUS was initially
obtained on admission in the setting of her petechial appearing
rash, ___ swelling to evaluate for PVT which was negative. She
also had a left MTP
erythematous macule which was non-cellulitic appearing and
unlikely to be an abscess. She initially came in on levofloxacin
for this possibly infected diabetic ulcer per her rehab,
antibiotics were not continued given low suspicion for
underlying infection.
# Diarrhea - Patient initially endorsed a one week history of
diarrhea approximately ___ episodes daily, last episode 2 days
prior to admission. She had received a 2 day history of levaquin
for possible diabetic foot ulcer per above. Stool cultures and
CMV were negative.
CHRONIC ISSUES
==========================
#CAD - History of CAD s/p multiple ___ recently ___.
Prior data reveal EF 41% and s/p Cath on ___ showed normal
LM, 40% proximal LAD, 80% distal lesion beyond previous stent.
She also had a 80% mid LCx lesion with planned staged cath. She
underwent successful PTCA and DES x1 to distal LAD lesion in
___. She was continued on aspirin 81 mg daily, ticagrelor
90mg BID, ranolazine 500mg ER BID, atorvastatin 20mg daily. Home
cilostazol was resumed on discharge.
#DM1: Long-standing history of diabetes mellitus type 1,
complicated by dysautonomia, neurogenic bladder and
gastroparesis. She was maintained on home glargine 24 units QAM.
Home Humalog 2 units TID with meals was discontinued given
hypoglycemia during hospitalization. Was also placed on insulin
sliding scale.
#Neurogenic Bladder - Patient ___ neurogenic bladder secondary
to DM Type 1, and intermittently straight caths at home. She had
a Foley placed for a brief period of time during hospitalization
given subjective urinary hesitancy and inability to obtain
accurate I/O's, which was later pulled.
#Hypothyroidism: She was continued on home levothyroxine 125mcg
daily.
TRANSITIONAL ISSUES
===========================
[ ] New/Changed Medications
- Hydralazine increased from 50 QHS to 75 mg TID given
hypertension
- Started on cefpodoxime for UTI to continue for 14 day total
course (end date ___
- Sodium bicarbonate 1300mg PO TID discontinued metabolic
alkalosis
[ ] Repeat BMP, Cr in 3 days to monitor creatinine trend and fax
results to outpatient renal team at ___
[ ] discharged to complete a 14 day course of PO abx last day of
treatment for UTI in a renal transplant patient will be ___
of cefpodoxime
[ ] Consider ongoing up titration of PO diuretic as indicated
given remains volume overloaded
[ ] MRCP in 4 weeks to further evaluate pancreatic mass,
possible IPMN, and follow-up with Dr. ___ in ___ weeks
[ ] If pursuing pancreatic biopsy, will need to consider holding
ticagrelor in consultation with cardiology given recent DES in
___
[ ] Goal SBP <160 given recent SAH, consider outpatient up
titration of antihypertensives as indicated
[ ] Consider re-starting sodium bicarbonate at transplant
nephrology follow-up if indicated
[ ] Discharge diuretic 20mg Lasix po daily plus additional PRN
dose 20mg for lower extremity edema
[ ] Discharge weight 60.4 kg
[ ] Discharge creatinine 3.4
#CONTACT:
Name of health care proxy: ___: SISTER
Phone number: ___
Cell phone: ___
#CODE: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Cilostazol 50 mg PO QPM
4. Cilostazol 100 mg PO QAM
5. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
6. HydrALAZINE 50 mg PO QHS
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Metoprolol Succinate XL 125 mg PO DAILY
10. Mycophenolate Mofetil 500 mg PO BID
11. PredniSONE 6 mg PO DAILY
12. Promethazine 25 mg PO DAILY PRN nausea
13. Ranolazine ER 500 mg PO BID
14. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
15. Acetaminophen 1000 mg PO Q6H
16. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
17. FoLIC Acid 1 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Severe
20. Polyethylene Glycol 17 g PO DAILY:PRN constipation
21. Sodium Bicarbonate 1300 mg PO TID
22. Trimethobenzamide 300 mg oral BID
23. Vitamin D ___ UNIT PO DAILY
24. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
25. Atorvastatin 20 mg PO QPM
26. Ferrous Sulfate 325 mg PO DAILY
27. Furosemide 20 mg PO DAILY
28. melatonin 10 mg oral QHS
29. naftifine 2 % topical BID To soles of feet and between toe
webs
30. Calcium Carbonate 500 mg PO BID
31. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
32. Allopurinol ___ mg PO DAILY
33. Glargine 24 Units Breakfast
aspart 2 Units Breakfast
aspart 2 Units Lunch
aspart 2 Units Dinner
Insulin SC Sliding Scale using aspart Insulin
34. Omeprazole 40 mg PO BID
35. Ondansetron 4 mg PO Q8H:PRN nausea
36. Toujeo SoloStar U-300 Insulin (insulin glargine) 300 unit/mL
(1.5 mL) subcutaneous QAM
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO Q24H urinary tract infection
Duration: 10 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth once daily Disp #*10
Tablet Refills:*0
2. Furosemide 20 mg PO DAILY
take an additional pill of 20mg in addition to your daily dose
if your legs become swollen
RX *furosemide 20 mg 1 tablet(s) by mouth one tablet daily Disp
#*60 Tablet Refills:*1
3. HydrALAZINE 75 mg PO TID
RX *hydralazine 25 mg 3 tablet(s) by mouth three times a day
Disp #*126 Tablet Refills:*0
4. Glargine 24 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Acetaminophen 1000 mg PO Q6H
6. Allopurinol ___ mg PO DAILY
7. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 20 mg PO QPM
10. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
11. Calcitriol 0.25 mcg PO DAILY
12. Calcium Carbonate 500 mg PO BID
13. Cilostazol 50 mg PO QPM
14. Cilostazol 100 mg PO QAM
15. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
16. Ferrous Sulfate 325 mg PO DAILY
17. FoLIC Acid 1 mg PO DAILY
18. Levothyroxine Sodium 125 mcg PO DAILY
19. Lidocaine 5% Patch 1 PTCH TD QAM
20. melatonin 10 mg oral QHS
21. Metoprolol Succinate XL 125 mg PO DAILY
22. Multivitamins 1 TAB PO DAILY
23. Mycophenolate Mofetil 500 mg PO BID
24. naftifine 2 % topical BID To soles of feet and between toe
webs
25. Omeprazole 40 mg PO BID
26. Ondansetron 4 mg PO Q8H:PRN nausea
27. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Severe
28. Polyethylene Glycol 17 g PO DAILY:PRN constipation
29. PredniSONE 6 mg PO DAILY
30. Promethazine 25 mg PO DAILY PRN nausea
31. Ranolazine ER 500 mg PO BID
32. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
33. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
34. Toujeo SoloStar U-300 Insulin (insulin glargine) 300
unit/mL (1.5 mL) subcutaneous QAM
35. Trimethobenzamide 300 mg oral BID
36. Vitamin D ___ UNIT PO DAILY
37. HELD- Sodium Bicarbonate 1300 mg PO TID This medication was
held. Do not restart Sodium Bicarbonate until you follow-up with
your transplant nephrologist
38.Outpatient Lab Work
Please check a BMP (Na, K, Cl, HC03, BUN and Creatinine) for
this patient on ___ and fax these results to ___.
Thank you.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Acute on chronic HFrEF
- ___ on CKD
- UTI
- Incidental Pancreatic Mass
SECONDARY DIAGNOSIS
- ESRD s/p LURT
- SAH
- DM1
- Orthostatic hypotension
- Dysautonomia
- Anemia
- CAD
- Neurogenic Bladder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Was a pleasure taking care of your ___
___.
Why did you come to the hospital?
-You initially came to the hospital because of worsening lower
extremity swelling and weight gain
What happened during your hospitalization?
-You were given medications through your IV in order to help
remove extra fluid because of your heart failure exacerbation
-You were given antibiotics for a UTI
-You were evaluated by the gastroenterology team to further
workup your possible pancreatic mass, you will obtain a MRI in 4
weeks and follow-up with Dr. ___ in ___ weeks
What should you do when you leave the hospital?
-Continue to take all your medications as prescribed
- It is very important that you stick to a very strict low
sodium diet.
- This is of utmost importance, you should try to eat less
than 2 grams of sodium per day. 1 piece of toast ___ about 500mg
of sodium or a quarter of the total daily salt that you should
eat in your diet.
- please avoid canned foods, processed foods or meats and
restaurant foods.
- Get blood work checked in 3 days and have your labs sent to
you kidney doctors at ___ at ___
-Weigh yourself daily, if your weight goes up by more than 2
pounds in 1 day or 5 pounds in 1 week, call your PCP
-___ with your primary care physician ___ 1 week
-Keep all your other scheduled healthcare appointments listed
below
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
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Allergies: Penicillins / Ativan / carvedilol / amlodipine Chief Complaint: Weight gain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with DM1, CAD and dysautonomia presents from rehab with sudden onset of lower extremity swelling and pain. Yesterday evening, the patient noticed the sudden onset [MASKED] pain and swelling that is described as throbbing. She does not note any exacerbating factors but does not alleviation with movement. This morning, she noticed progression of the pain to her lower back. She [MASKED] no fevers or chills. She notes no chest pain, palpitations or dyspnea. She [MASKED] no cough, wheezing or orthopnea. +n/v for over [MASKED] year. She [MASKED] had large, loose, watery bowel movements [MASKED] times per day for the last week. She stats her blood glucose [MASKED] been under good control. Of note, the patient was hospitalized at [MASKED] from [MASKED] after suffering a SAH after a mechanical fall. The etiology of the fall was attributed to labile blood sugars and blood pressures due to dysautonomia. Her hospital course was complicated by HHS and labile blood pressures. She was seen by [MASKED] and [MASKED] blood sugars were controlled with an insulin gtt and eventually transitioned to Lantus 8u qAM and 2U Humalog at meals with sliding scale. . Regarding her labile blood pressures, this was thought to be from dysautonomia due to her poorly controlled DM1. She was started on metoprolol succinate and hydralazine In the ED, initial VS were: T 97.5 HR 83 BP 147/63 R 16 SpO2 99% RA Exam notable for: 2+ pitting edema to mid calf, swelling diffuse up legs with scattered petechiae, no CVA tenderness, no midline tenderness ECG: NSR Rate 83. L-axis Normal Intervals, QTc 450. No significant change from prior Labs showed: 145|106|53 -----------<84 4.2|24|2.1 Ca: 7.8 Mg: 1.0 P: 3.3 ALT: 17 AP: 86 Tbili: 0.3 Alb: 2.7 AST: 20 Lip: 9 Lactate:1.6 Trop-T: 0.14 CK: 130 MB: 3 [MASKED]: [MASKED] 7.3 8.2>----<382 23.4 Imaging showed: [MASKED] Liver Or Gallbladder Us No evidence of biliary obstruction or portal vein thrombosis [MASKED] Chest (Pa & Lat) IMPRESSION: No acute cardiopulmonary abnormality. Consults: Per Renal Transplant: cyclosporine(neoral) 25 mg bid. Goal 75-125. Cyclosporine AM trough level daily MMF 500 mg bid. Prednisone 6 mg daily. Patient received: [MASKED] 17:25 IV Magnesium Sulfate [MASKED] 17:51 IV Furosemide 20 mg [MASKED] 18:30 IV Magnesium Sulfate 2 gm [MASKED] 20:00 SC Insulin Not Given per Sliding Scale [MASKED] 20:17 PO/NG Ondansetron 4 mg On arrival to the floor, patient reports no dyspnea and improvement of her leg pain. Past Medical History: Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) Hypertension Dyslipidemia CAD with PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED]. Then DES to LAD in [MASKED] and [MASKED] PCI of Cx and OM with [MASKED] [MASKED] w/ CREST syndrome Gastroparesis GERD Hiatal hernia Gout OSA End-stage renal disease due diabetes s/p L-sided living kidney transplant in [MASKED] anemia Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION EXAM VS: T 97.9 BP 137/59 HR 87 R 16 SpO2 97 Ra GEN: NAD, speaking comfortably lying flat in bed HEENT: Clear OP, moist mucous membranes [MASKED]: Regular, II/VI SEM, JVP at mid-neck at 45 degrees +Hepatojugular reflex RESP: RRR, no wheezing, crackles or rhonchi. No increased WOB ABD: NTND, no HSM EXT: Warm, Pitting edema to mid thigh bilaterally. NEURO: CN IV-XII intact. Pupils dilated and minimally-reactive to light (baseline). SKIN: Fine, scattered erythematous erosions L medial thigh, R lateral thigh with overlying crusting. No excoriations. No lesions in web spaces. Small 1cm linear abrasion over L small toe and 1cm, circular, erythematous macule with overlying scab over L great toe. DISCHARGE EXAM Pertinent Results: ADMISSION LABS ================= [MASKED] 04:00PM BLOOD WBC-8.2 RBC-2.52* Hgb-7.3* Hct-23.4* MCV-93 MCH-29.0 MCHC-31.2* RDW-21.2* RDWSD-70.5* Plt [MASKED] [MASKED] 04:00PM BLOOD Glucose-84 UreaN-53* Creat-2.1* Na-145 K-4.2 Cl-106 HCO3-24 AnGap-15 [MASKED] 04:00PM BLOOD CK-MB-3 cTropnT-0.15* [MASKED] [MASKED] 04:00PM BLOOD Albumin-2.7* Calcium-7.8* Phos-3.3 Mg-1.0* [MASKED] 04:00PM BLOOD Cortsol-3.1 [MASKED] 04:22PM BLOOD Lactate-1.6 [MASKED] 09:16AM URINE Blood-NEG Nitrite-NEG Protein-100* Glucose-150* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG* [MASKED] 09:16AM URINE Hours-RANDOM Creat-39 Na-85 Mg-<1.4 Albumin-242.0 Alb/Cre-6205.1* [MASKED] 09:16AM URINE Osmolal-395 INTERVAL LABS ================= DISCHARGE LABS ================= MICROBIOLOGY ================= CMV IgG ANTIBODY (Final [MASKED]: NEGATIVE FOR CMV IgG ANTIBODY BY EIA. <4 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final [MASKED]: NEGATIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: NO ANTIBODY DETECTED. Greatly elevated serum protein with IgG levels [MASKED] mg/dl may cause interference with CMV IgM results. URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. FECAL CULTURE (Final [MASKED]: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [MASKED]: NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O VIBRIO (Final [MASKED]: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final [MASKED]: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [MASKED]: No E. coli O157:H7 found. URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R IMAGING ================= RUQUS [MASKED]: No evidence of biliary obstruction or portal vein thrombosis. CXR [MASKED] No acute cardiopulmonary abnormality. Rib Series [MASKED] 1. Right lower lobe atelectasis versus early infiltrate, slightly worse. Follow up to resolution is recommended to exclude pneumonia. 2. No displaced rib fracture. Renal US [MASKED] 1. Elevated resistive indices similar to the prior study with differential which may include acute tubular necrosis and rejection. 2. Patent vasculature, no hydronephrosis. TTE [MASKED] The left atrium is elongated. 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. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). 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) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. IMPRESSION: Moderate left ventricular hypertrophy with low normal global systolic function. Small pericardial effusion without echo evidence of tamponade. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [MASKED] global left ventricular systolic function is improved. Moderate pulmonary hypertension is seen. As before amyloid cardiomyopathy should be considered). CXR [MASKED] Cardiomegaly is severe, minimally improved since previous examination. Right pleural effusion [MASKED] increased. There is no overt pulmonary edema, mild vascular congestion is better than on [MASKED]. No pneumothorax. Brief Hospital Course: Ms. [MASKED] is a [MASKED] female with history of HFrEF (EF 41%) ESRD s/p LURT [MASKED] longstanding DMI on CellCept, Neoral, and prednisone, CAD s/p multiple [MASKED] recently on [MASKED] on aspirin and ticagrelor, CREST, remote PE, dysautonomia with orthostatic hypotension, recent fall with right sided SAH, recently seen new pancreatic head mass on CT A/P, who presented with a 1 week history of lower extremity swelling and weight gain admitted for acute on chronic HFrEF exacerbation requiring IV diureses subsequently transitioned to PO lasix 20 with a contingency for an extram 20mg for lower extremity edema, with plan for GI follow-up for ongoing work-up of incidental pancreatic mass. Of note patient requested to be discharged despite remaining volume overloaded with [MASKED] on CKD with plan for outpatient ongoing diuresis and renal monitoring. On the day of discharge the patient was very insistent on being discharged so that she could be able to attend to very special family [MASKED]. We discussed this with the renal transplant team as well. Together we both felt that was ongoing medical management and optimization that should be done but in an attempt to meet her wishes and give her some quality life time we were willing to make a compromise on a plan to discharge her with full disclosure to her that she was not quite as optimized as possible. We also created a plan to treat her UTI in the outpatient setting for a total 14 days of treatment end of treatment would be [MASKED]. She will also need to eat a very low sodium diet of 2gram max per day and have her renal function assessed and have her results faxed to the BI renal team. We will also gave her a rx for Lasix 20mg daily with extra 20mg for leg swelling. ACUTE ISSUES =================== #Acute on chronic HFrEF - Patient [MASKED] a history of HFrEF EF 41% who initially presented with a one week history of worsening lower extremity swelling and weight gain found to be volume overloaded on exam with BNP 22,235 on admission. The trigger for her acute on chronic HFrEF exacerbation was unclear. Her EKG showed no ischemic changes, troponins were at baseline with flat CK-MB. She was initially diuresed with intermittent IV lasix 80 boluses, however subsequently had worsening renal function. Diureses was subsequently held however renal functioned continued to worsen, thought to be attributed to cardiorenal syndrome and concomitant UTI per below. CXR showed worsening right sided pleural effusion. In consultation with transplant nephrology, she was subsequently diuresed with 80mg IV Lasix X2 which did not show a large improvement in the Cr. and she was transitioned to PO 20mg lasix daily with contingency for extra dose of 20mg for [MASKED] edema. Discharge weight was 60.4kg and discharge creatinine was 3.4. Plan for ongoing outpatient diuresis with PO regimen and continued renal monitoring. [MASKED] on CKD #ESRD s/p renal transplant: With history of ESRD in the setting of long standing DMI, s/p LURT [MASKED] maintained on cellcept, cyclosporine and prednisone. Baseline Cr over the last 6 months ranged between 2.0-2.5. Renal US showed elevated resistive indices, stable from prior with no evidence of hydronephrosis. Per above, she had worsening renal function despite periods of aggressive diuresis as well as rising Cr when holding diuretics. Upon discharge, it seemed as though her [MASKED] was most likely due to over diuresis as she was nearly back to her baseline weight w/very little [MASKED] edema. This being the case in her fluid status was incongruent with her worsening creatinine to 3.4 on day of discharge. Ultimately we felt that a large component of her increasing creatinine was not solely based on a pre-renal picture or CRS but likely a component of chronic renal graft rejection. There was no evidence of ATN on urinalysis. She was continued on MMF 500mg BID, neoral 25mg BID with goal cyclosporin level 40-100, and continued on prednisone 6mg daily. #Incidental Pancreatic Mass: Recent Non-con CT Torso at [MASKED] [MASKED] was significant for a 2.1 x 1.4 cm hypodense mass in the region of the pancreatic head and a 1 cm exophytic hypodensity off anterior aspect of the pancreatic body, suspicious for malignancy. She was initially planned for an outpatient EUS on [MASKED]. GI was consulted for possible inpatient EUS, however after multi-disciplinary meeting involving radiology, per GI mass appeared more consistent with IPMN. Plan for interval MRCP in 4 weeks from now (6 weeks from original CT to evaluate for interval change. Of note, any additional advanced imaging will be limited by current renal function given inability to use contrast, and if biopsy is pursued, will have to consider holding ticagrelor given she is on DAPT for recent [MASKED] in [MASKED]. Follow-up will be arranged with Dr. [MASKED] in [MASKED] weeks. #UTI - Urine culture [MASKED] growing E. Coli. She was initially started on ceftriaxone and subsequently transitioned to p.o. cefpodoxime, with plan for 14 day total course given her history of renal transplant end of treatment for [MASKED]. #Anemia - History of chronic anemia with baseline Hb 7.0-8.0. Initial Hb on admission was 6.8 and she recieved 1U PRBC with post-transfusion Hb 9.5. There was no evidence of hemolysis. Anemia was thought to be inflammatory also in the setting of her CKD. She was started on IV ferric gluconate x 4 doses given her transferrin saturation of 19%. Plan to follow-up with GI per above. #Subarachnoid hemorrhage #Intracranial stenosis - Patient had a recent admission for mechanical fall and subsequent SAH. No neurosurgical intervention was performed and goal SBP remains <160. She [MASKED] had very difficult to control blood pressure given her history of chronic orthostatic hypotension and dysautonomia. She was continued on aspirin 81 mg daily, atorvastatin 20 mg daily, home hydralazine was uptitrated from 50mg PO QHS to 75mg TID given frequent SBP ranging 160-200, and continued on home metoprolol succinate 125 mg daily. #Orthostatic Hypotension #Dysautonomia - Patient [MASKED] a well-documented history of severe orthostatic hypotension and dysautonomia. On previous discharge in consultation with renal transplant, she was maintained on a regimen of hydralazine 50 mg daily, and metoprolol succinate 125 mg daily. Her blood pressure was better controlled on longer acting agents, and she previously [MASKED] not tolerated CCB, captopril due to her severe orthostatic hypotension. Her antihypertensives were uptitrated to hydralazine 75 mg TID and continued metoprolol succinate 125 mg daily per above. We were unable to start an [MASKED] given her [MASKED] on CKD per above. #Skin findings - Patient was found to have multiple skin findings including an erythematous erosions on L medial thigh and R lateral thigh with overlying crusting. RUQUS was initially obtained on admission in the setting of her petechial appearing rash, [MASKED] swelling to evaluate for PVT which was negative. She also had a left MTP erythematous macule which was non-cellulitic appearing and unlikely to be an abscess. She initially came in on levofloxacin for this possibly infected diabetic ulcer per her rehab, antibiotics were not continued given low suspicion for underlying infection. # Diarrhea - Patient initially endorsed a one week history of diarrhea approximately [MASKED] episodes daily, last episode 2 days prior to admission. She had received a 2 day history of levaquin for possible diabetic foot ulcer per above. Stool cultures and CMV were negative. CHRONIC ISSUES ========================== #CAD - History of CAD s/p multiple [MASKED] recently [MASKED]. Prior data reveal EF 41% and s/p Cath on [MASKED] showed normal LM, 40% proximal LAD, 80% distal lesion beyond previous stent. She also had a 80% mid LCx lesion with planned staged cath. She underwent successful PTCA and DES x1 to distal LAD lesion in [MASKED]. She was continued on aspirin 81 mg daily, ticagrelor 90mg BID, ranolazine 500mg ER BID, atorvastatin 20mg daily. Home cilostazol was resumed on discharge. #DM1: Long-standing history of diabetes mellitus type 1, complicated by dysautonomia, neurogenic bladder and gastroparesis. She was maintained on home glargine 24 units QAM. Home Humalog 2 units TID with meals was discontinued given hypoglycemia during hospitalization. Was also placed on insulin sliding scale. #Neurogenic Bladder - Patient [MASKED] neurogenic bladder secondary to DM Type 1, and intermittently straight caths at home. She had a Foley placed for a brief period of time during hospitalization given subjective urinary hesitancy and inability to obtain accurate I/O's, which was later pulled. #Hypothyroidism: She was continued on home levothyroxine 125mcg daily. TRANSITIONAL ISSUES =========================== [ ] New/Changed Medications - Hydralazine increased from 50 QHS to 75 mg TID given hypertension - Started on cefpodoxime for UTI to continue for 14 day total course (end date [MASKED] - Sodium bicarbonate 1300mg PO TID discontinued metabolic alkalosis [ ] Repeat BMP, Cr in 3 days to monitor creatinine trend and fax results to outpatient renal team at [MASKED] [ ] discharged to complete a 14 day course of PO abx last day of treatment for UTI in a renal transplant patient will be [MASKED] of cefpodoxime [ ] Consider ongoing up titration of PO diuretic as indicated given remains volume overloaded [ ] MRCP in 4 weeks to further evaluate pancreatic mass, possible IPMN, and follow-up with Dr. [MASKED] in [MASKED] weeks [ ] If pursuing pancreatic biopsy, will need to consider holding ticagrelor in consultation with cardiology given recent DES in [MASKED] [ ] Goal SBP <160 given recent SAH, consider outpatient up titration of antihypertensives as indicated [ ] Consider re-starting sodium bicarbonate at transplant nephrology follow-up if indicated [ ] Discharge diuretic 20mg Lasix po daily plus additional PRN dose 20mg for lower extremity edema [ ] Discharge weight 60.4 kg [ ] Discharge creatinine 3.4 #CONTACT: Name of health care proxy: [MASKED]: SISTER Phone number: [MASKED] Cell phone: [MASKED] #CODE: Full Code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Calcitriol 0.25 mcg PO DAILY 3. Cilostazol 50 mg PO QPM 4. Cilostazol 100 mg PO QAM 5. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 6. HydrALAZINE 50 mg PO QHS 7. Levothyroxine Sodium 125 mcg PO DAILY 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Metoprolol Succinate XL 125 mg PO DAILY 10. Mycophenolate Mofetil 500 mg PO BID 11. PredniSONE 6 mg PO DAILY 12. Promethazine 25 mg PO DAILY PRN nausea 13. Ranolazine ER 500 mg PO BID 14. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 15. Acetaminophen 1000 mg PO Q6H 16. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 17. FoLIC Acid 1 mg PO DAILY 18. Multivitamins 1 TAB PO DAILY 19. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - Severe 20. Polyethylene Glycol 17 g PO DAILY:PRN constipation 21. Sodium Bicarbonate 1300 mg PO TID 22. Trimethobenzamide 300 mg oral BID 23. Vitamin D [MASKED] UNIT PO DAILY 24. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 25. Atorvastatin 20 mg PO QPM 26. Ferrous Sulfate 325 mg PO DAILY 27. Furosemide 20 mg PO DAILY 28. melatonin 10 mg oral QHS 29. naftifine 2 % topical BID To soles of feet and between toe webs 30. Calcium Carbonate 500 mg PO BID 31. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 32. Allopurinol [MASKED] mg PO DAILY 33. Glargine 24 Units Breakfast aspart 2 Units Breakfast aspart 2 Units Lunch aspart 2 Units Dinner Insulin SC Sliding Scale using aspart Insulin 34. Omeprazole 40 mg PO BID 35. Ondansetron 4 mg PO Q8H:PRN nausea 36. Toujeo SoloStar U-300 Insulin (insulin glargine) 300 unit/mL (1.5 mL) subcutaneous QAM Discharge Medications: 1. Cefpodoxime Proxetil 400 mg PO Q24H urinary tract infection Duration: 10 Days RX *cefpodoxime 200 mg 2 tablet(s) by mouth once daily Disp #*10 Tablet Refills:*0 2. Furosemide 20 mg PO DAILY take an additional pill of 20mg in addition to your daily dose if your legs become swollen RX *furosemide 20 mg 1 tablet(s) by mouth one tablet daily Disp #*60 Tablet Refills:*1 3. HydrALAZINE 75 mg PO TID RX *hydralazine 25 mg 3 tablet(s) by mouth three times a day Disp #*126 Tablet Refills:*0 4. Glargine 24 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 5. Acetaminophen 1000 mg PO Q6H 6. Allopurinol [MASKED] mg PO DAILY 7. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 11. Calcitriol 0.25 mcg PO DAILY 12. Calcium Carbonate 500 mg PO BID 13. Cilostazol 50 mg PO QPM 14. Cilostazol 100 mg PO QAM 15. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 16. Ferrous Sulfate 325 mg PO DAILY 17. FoLIC Acid 1 mg PO DAILY 18. Levothyroxine Sodium 125 mcg PO DAILY 19. Lidocaine 5% Patch 1 PTCH TD QAM 20. melatonin 10 mg oral QHS 21. Metoprolol Succinate XL 125 mg PO DAILY 22. Multivitamins 1 TAB PO DAILY 23. Mycophenolate Mofetil 500 mg PO BID 24. naftifine 2 % topical BID To soles of feet and between toe webs 25. Omeprazole 40 mg PO BID 26. Ondansetron 4 mg PO Q8H:PRN nausea 27. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - Severe 28. Polyethylene Glycol 17 g PO DAILY:PRN constipation 29. PredniSONE 6 mg PO DAILY 30. Promethazine 25 mg PO DAILY PRN nausea 31. Ranolazine ER 500 mg PO BID 32. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 33. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 34. Toujeo SoloStar U-300 Insulin (insulin glargine) 300 unit/mL (1.5 mL) subcutaneous QAM 35. Trimethobenzamide 300 mg oral BID 36. Vitamin D [MASKED] UNIT PO DAILY 37. HELD- Sodium Bicarbonate 1300 mg PO TID This medication was held. Do not restart Sodium Bicarbonate until you follow-up with your transplant nephrologist 38.Outpatient Lab Work Please check a BMP (Na, K, Cl, HC03, BUN and Creatinine) for this patient on [MASKED] and fax these results to [MASKED]. Thank you. Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS - Acute on chronic HFrEF - [MASKED] on CKD - UTI - Incidental Pancreatic Mass SECONDARY DIAGNOSIS - ESRD s/p LURT - SAH - DM1 - Orthostatic hypotension - Dysautonomia - Anemia - CAD - Neurogenic Bladder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], Was a pleasure taking care of your [MASKED] [MASKED]. Why did you come to the hospital? -You initially came to the hospital because of worsening lower extremity swelling and weight gain What happened during your hospitalization? -You were given medications through your IV in order to help remove extra fluid because of your heart failure exacerbation -You were given antibiotics for a UTI -You were evaluated by the gastroenterology team to further workup your possible pancreatic mass, you will obtain a MRI in 4 weeks and follow-up with Dr. [MASKED] in [MASKED] weeks What should you do when you leave the hospital? -Continue to take all your medications as prescribed - It is very important that you stick to a very strict low sodium diet. - This is of utmost importance, you should try to eat less than 2 grams of sodium per day. 1 piece of toast [MASKED] about 500mg of sodium or a quarter of the total daily salt that you should eat in your diet. - please avoid canned foods, processed foods or meats and restaurant foods. - Get blood work checked in 3 days and have your labs sent to you kidney doctors at [MASKED] at [MASKED] -Weigh yourself daily, if your weight goes up by more than 2 pounds in 1 day or 5 pounds in 1 week, call your PCP -[MASKED] with your primary care physician [MASKED] 1 week -Keep all your other scheduled healthcare appointments listed below Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"I130",
"N179",
"N390",
"N189",
"D649",
"I2510",
"Y929",
"Z794",
"E785",
"Z955",
"K219",
"M109",
"G4733",
"E039",
"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",
"I5043: Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure",
"N179: Acute kidney failure, unspecified",
"N390: Urinary tract infection, site not specified",
"T8611: Kidney transplant rejection",
"I248: Other forms of acute ischemic heart disease",
"N189: Chronic kidney disease, unspecified",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"T502X5A: Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, initial encounter",
"Y92239: Unspecified place in hospital as the place of occurrence of the external cause",
"I951: Orthostatic hypotension",
"D649: Anemia, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"K869: Disease of pancreas, unspecified",
"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",
"I669: Occlusion and stenosis of unspecified cerebral artery",
"S066X9D: Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, subsequent encounter",
"W010XXD: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, subsequent encounter",
"Z794: Long term (current) use of insulin",
"G901: Familial dysautonomia [Riley-Day]",
"E1065: Type 1 diabetes mellitus with hyperglycemia",
"E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"N318: Other neuromuscular dysfunction of bladder",
"E785: Hyperlipidemia, unspecified",
"Z955: Presence of coronary angioplasty implant and graft",
"M341: CR(E)ST syndrome",
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"K3184: Gastroparesis",
"K219: Gastro-esophageal reflux disease without esophagitis",
"K449: Diaphragmatic hernia without obstruction or gangrene",
"M109: Gout, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"E8342: Hypomagnesemia",
"R197: Diarrhea, unspecified",
"D638: Anemia in other chronic diseases classified elsewhere",
"E039: Hypothyroidism, unspecified",
"Z87891: Personal history of nicotine dependence"
] |
10,030,753
| 22,300,700
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___.
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with complex medical history notable for ESRD
s/p LURT ___ on immunosuppression, CAD s/p ___ 4 (most recent
___, HFrEF (EF 35-40% ___, T1DM, severe poorly
controlled
HTN, scleroderma/CREST, who was brought to the ED by EMS after
an
episode of hypoglycemia and is now admitted for altered mental
status and weakness iso a UTI.
The patient had a recent admission at ___ ___ for
decompensated heart failure. Her hospital course was complicated
by NSTEMI, ___, and non-convulsive status epilepticus with
workup that revealed acute and subacute strokes in the right
periventricular pericollosal artery territory and punctate
infarct in pons. She was discharged on Keppra and valproate and
has not had any witnessed seizures since discharge. She also
underwent RHC iso newly reduced EF to 37% and difficult volume
management. RHC showed elevated filling pressures and pHTN and
she was aggressively diuresed.
Since her discharge on ___ she has felt generally weak and has
had periods of confusion where she does not know the date or
know
where she is. The night before presentation her FSBGs were noted
to be in the 400s. She received 10u SC insulin and in the AM she
was noted to be hypoglycemic to the ___. The patient received
2mg
IM glucagon and juice with improvement in her FSBG to 170s. She
was taken by EMS to ___ for further management.
In the ED, she was afebrile, HRs ___, BPs 200/90s but decreased
to 160s/70s after home anti-HTN meds, and SpO2 98% RA. On
initial
exam she was somnolent, grade III systolic murmur, normal lung
sounds, mild abdominal tenderness of LUQ, 1+ edema of b/l LEs,
and she was AOx4 with no focal neurologic findings. Her EKG
showed new lateral ST depressions. MB 6->4, and Trop 0.28 ->
0.16, asymptomatic. WBC 20 (normal at b/l), Hgb 11, Cr 2.5
(baseline 3.0), an otherwise normal chem-10, and lactate 1.6. UA
was notable for Lg leuks, 178 WBCs, and many bact. Imaging
included a CXR without e/o pna and a renal transplant US that
showed improved intrarenal arterial flow, no hydronephrosis, and
patent main renal vein.
Renal transplant was consulted and recommended BP control with
home medications, cyclosporine trough daily, and admission to
medicine for further management of her confusion and AMS. ___
was also consulted for assistance with management of her DMI iso
recent episode of hypoglycemia.
In addition to her home antihypertensives and insulin per
___,
she was started on ceftriaxone for a UTI (previous culture data
from ___ w/ ecoli, sensitive to CTX).
Transfer VS were: 97.6 121 169/93 21 95% RA
On arrival to the floor, patient reports marked fatigue. She
denies dysuria but endorses mild lower abdominal discomfort. She
denies diarrhea or constipation. She has had nausea and poor
appetite for the past week and had one episode of non-bloody,
non-bilious vomiting the day prior to admission. She denies any
recent chest pain, palpitations, or dyspnea. She has had no
cough, rhinorrhea, fevers, or chills. She reports a mild
headache
without neck stiffness, vision changes, or photophobia.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
-CAD s/p PCI x4: LAD PTCA ___ DES to LAD and Cx/OM ___ DES
to LAD ___ DES to Cx and OM ___
-Heart failure with reduced EF (35-40% ___
-L-sided living kidney transplant in ___ complicated by
transplant nephropathy
-Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
-Autonomic dysfunction with orthostatic hypotension and supine
hypertension
-CVA ___
-Seizure disorder
-Scleroderma w/ CREST syndrome
-Gastroparesis/GERD/Hiatal hernia
-Chronic Nausea
-Gout
-OSA
-Pancreatic cyst c/w IPMN
-Dyslipidemia
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION PHYSICAL EXAM:
___ 0417 Temp: 98.1 PO BP: 168/78 R Lying HR: 118 RR: 22 O2
sat: 98% O2 delivery: Ra
GENERAL: NAD, AOx3
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: tachycardic, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, mild TTP of lower abdomen, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert/oriented x4, non-focal exam
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Temp: 98.4 PO BP: 180/77 HR: 81 RR: 16 O2 sat: 94% O2 delivery:
Ra FSBG: 187
Constitutional: NAD
HEENT: eyes anicteric, R sided pterygium, normal hearing, nose
unremarkable, MMM without exudate
CV: RRR ___ SEM, JVP 8cm
Resp: CTAB
GI: sntnd, NABS
GU: no foley
MSK: no obvious synovitis
Ext: wwp, trace ___: mild skin tightening
Neuro: A&O grossly, speech intact and fluent, CN grossly intact
___ LUE/LLE, 4+/5 RUE/RLE, SILT BUE/BLE,
Psych: normal affect, pleasant
Pertinent Results:
ADMISSION LABS:
===========
___ 11:34AM BLOOD WBC-20.8* RBC-3.47* Hgb-11.1* Hct-34.6
MCV-100* MCH-32.0 MCHC-32.1 RDW-14.7 RDWSD-53.4* Plt ___
___ 11:34AM BLOOD Neuts-92.0* Lymphs-1.3* Monos-5.8
Eos-0.1* Baso-0.1 Im ___ AbsNeut-19.13* AbsLymp-0.27*
AbsMono-1.21* AbsEos-0.02* AbsBaso-0.03
___ 11:34AM BLOOD Glucose-178* UreaN-57* Creat-2.5* Na-141
K-4.9 Cl-101 HCO3-27 AnGap-13
___ 11:34AM BLOOD Glucose-178* UreaN-57* Creat-2.5* Na-141
K-4.9 Cl-101 HCO3-27 AnGap-13
___ 11:34AM BLOOD ALT-11 AST-33 CK(CPK)-110 AlkPhos-72
TotBili-0.2
___ 11:34AM BLOOD CK-MB-6
___ 11:34AM BLOOD cTropnT-0.28*
___ 04:20PM BLOOD CK-MB-4 cTropnT-0.16*
___ 11:34AM BLOOD Albumin-3.5 Calcium-9.5 Phos-3.2 Mg-2.1
___ 04:20PM BLOOD PTH-64
___:02PM BLOOD Lactate-1.6
___ 04:10PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 04:10PM URINE Blood-SM* Nitrite-NEG Protein-300*
Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5
Leuks-LG*
___ 04:10PM URINE RBC-5* WBC-178* Bacteri-MANY* Yeast-NONE
Epi-3
INTERIM LABS:
==========
___ 06:30AM BLOOD Valproa-14*
___ 09:00AM BLOOD Cyclspr-<30*
___ 04:36PM BLOOD ___ pO2-196* pCO2-42 pH-7.43
calTCO2-29 Base XS-3 Comment-GREEN TOP
___ 08:02AM BLOOD Cyclspr-92*
___ 08:02AM BLOOD Valproa-54
DISCHARGE LABS:
============
___ 05:25AM BLOOD WBC-6.3 RBC-2.95* Hgb-9.0* Hct-29.3*
MCV-99* MCH-30.5 MCHC-30.7* RDW-19.3* RDWSD-70.7* Plt ___
___ 07:26AM BLOOD Glucose-123* UreaN-51* Creat-3.2* Na-141
K-4.6 Cl-101 HCO3-32 AnGap-8*
MICROBIOLOGY:
==============
___ URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ Culture, Routine-FINAL
IMAGING:
=========
___ CXR
No focal consolidation to suggest pneumonia. Mild pulmonary
vascular congestion, improved from the prior exam.
___ RENAL U/S
1. Improved intrarenal arterial flow with continuous diastolic
flow now seen in the upper and lower pole intrarenal arteries,
but questionable lack of diastolic flow in the interpolar
region, as seen previously. Resistive indices in the upper and
lower poles are mildly elevated.
2. No hydronephrosis. Patent main renal vein.
___ EEG
This is an abnormal continuous EEG monitoring study because of
mild slowing of the background activity, indicative of mild
diffuse encephalopathy without specific etiology. Common causes
are medication effect, infections or toxic/metabolic
disturbances. There was intermittent focal attenuation and very
mild slowing over the right hemisphere, indicative of
subcortical dysfunction in that region. There were no
epileptiform discharges or electrographic seizures. Compared to
the prior day's recording, there is no significant change.
___ CT HEAD W/O CONTRAST
1. No new acute intracranial process.
2. Chronic findings, as above.
___ MRI
1. Interval evolution of subacute on chronic thromboembolic
ischemic changes in the right cerebral hemisphere and right
pons.
2. No new infarct or acute intracranial hemorrhage. No evidence
for PRES.
3. Additional findings as described above.
___ CHEST XR
In comparison with the study of ___, the there are lower
lung volumes. Moderate enlargement of the cardiac silhouette is
again seen with moderate pulmonary vascular congestion.
Opacification at the right base silhouetting hemidiaphragm is
consistent with pleural fluid and atelectatic changes at the
base. Retrocardiac opacification suggests volume loss in the
left lower lobe.
No evidence of acute focal consolidation, though this would be
difficult to unequivocally exclude in the appropriate clinical
setting, especially in the absence of a lateral view.
There is a spiculated opacification in the right upper quadrant
of the
abdomen, raising the possibility of a gallstone.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with complex
medical history notable for renal transplant in ___ on
immunosuppression, CAD s/p ___ 4 (most recent ___, HFrEF
(EF 35-40% ___, brittle T1DM, autonomic dysfunction with
poorly controlled HTN and orthostatic hypotension,
scleroderma/CREST, recent admission for acute on chronic HFrEF,
course complicated by CVA and seizures, brought to the ED ___
from rehab after an episode of hypoglycemia, admitted for
altered mental status and weakness presumed secondary to UTI.
ACUTE ISSUES:
===================
# Toxic Metabolic Encephalopathy
# Generalized Weakness / Fatigue
Since her discharge on ___ patient generally weak and reported
periods of confusion where she did not know the date or know
where she was. Sister/HCP reported she was somnolent since prior
to discharge, sleeping all the time, not herself. Worsened after
an episode of hypoglycemia, improved with treatment of UTI
below. Suspected a multifactorial process, in part related to
delirium from UTI, poor glycemic control, recent
hospitalizations superimposed on numerous chronic medical
problems and neurologic injury including seizure and strokes.
Initially also concerned for post-ictal state vs seizure I/s/o
hypoglycemia. Neurology was consulted, recommended EEG, which
from ___ was w/o any evidence of seizure. Valproate was
initially low likely i/s/o missing a dose in the ED, s/p one
load remained in normal range. Keppra level was 48, but per
neurology, this was okay and patient should continue keppra
500mg BID. CT head and MRI w/o any new acute strokes. Mental
status returned to baseline by discharge.
#DM type 1 c/b episode of hypoglycemia
Blood sugar 400 at rehab, was given 10u SC insulin, then
decreased to 50 and had AMS. Endorsed poor appetite, so was
likely receiving inappropriate amount of insulin for how much
she was taking in. Per sister, she has very brittle diabetes for
a long time. ___ was consulted. BG were very labile, swings
from low to high with minimal change to insulin regimen. Patient
had continuous glucose monitor, sensor was lost in the hospital,
replaced on ___. Discharged on lower amount of Levemir than
previously (see below for full regimen).
#E. coli UTI in transplanted kidney
UA positive, w/ lower abdominal pain, leukocytosis to 20
(previously normal). Urine culture grew E. coli sensitive to
ceftriaxone, resistant to cipro. Started IV ceftriaxone,
transitioned to cefpodoxime ___ to complete a 10 day
course.
#Hypertensive Urgency
Per outpatient nephrologist, goal SBP<180. Increased isosorbide
dinitrate to 60 mg tid, Hydralazine to 100mg q8h and increased
metoprolol XL to 50mg. SBPs remained elevated as high as 180s
but further increases in BP meds limited by orthostasis. Follow
up arranged with Cardiology and Neurology.
#Orthostatic hypotension
#Acute on chronic systolic heart failure
#Acute kidney injury
Initially had orthostasis, held diuretics, then developed
edema/pulmonary edema. Edema improved with diuretics but then
renal function worsened. Now appears dry to euvolemic, allowing
for autoregulation for now, decreased lasix to twice weekly on
discharge. Per discussion with transplant nephrology, given that
Cr has peaked, safe for discharge with close follow up.
Discontinued cilastozol (increased mortality in HF).
#Autonomic Dysfunction
Labile BPs and volume status as above. Followed by Neurology as
outpatient. Etiology thought to be due to diabetes. Prior workup
for other etiologies negative.
#CAD ___ 4 (most recent ___
#Chest Pain
Having intermittent chest pain, sometimes intermittent in
nature. Troponin have been stable. From ___ cath, still have
70% lesion in D1, but EKG have been stable.
Continued home statin, metop, asa, ranolazine. Of note, patient
had DES placed ___ but was directed to stop taking ticagrelor
in ___, which she had stopped for a procedure. Confirmed
with outpatient cardiologist that ticagrelor is not necessary to
continue.
#Akathisia / Hyperactivity
Patient noted to be moving her extremities continually after
somnolence improved, had a hard time extinguishing the movement
with volition. Likely medication effect (Phenergan most
trimethobenzamide). Valproate level within normal limits.
Symptoms improved since discontinuing phenergan and
trimethobenzamide. Phenergan restarted on ___ w/o any adverse
effects.
#Chronic nausea
Has has difficult to control nausea of unclear etiology on
phenergan and trimethobenzamide, followed by GI as outpatient.
Nausea appeared to correlate with episodes of hyperglycemia.
Nausea was controlled with initially PRN Zofran, but became
ineffective. Phenergan restarted on ___ w/o any adverse
effects. Trimethobenzamide discontinued due to akithisia.
#Blurry vision
Has known cataract, diabetic retinopathy, followed by ___.
Last seen by opthaomlogy on ___. Discussed with on-call
opthalmology, no indication to be seen inpatient, but should
have follow up with opthalmology in ___ weeks. No evidence of
new strokes on head imaging this admission.
#Anemia
Has chronic anemia and receives epogen as outpatient and
occasional blood transfusion. Hgb downtrending inpatient, likely
in setting of iatrogenic blood draw and not receiving epogen. No
melena/hematochezia or symptom to suspect acute drop. Iron
studies c/w ACD likely iso of CKD. Received 1u PRBC on ___ for
hgb of 6.6, with exaggerated response and hgb was stable. Epogen
was restarted. Goal hgb >8
#BPPV
Had vertigo on ___ with exam consistent with BPPV as diagnosed
with ___. Improved with epley maneuver and meclizine. No
concern for posterior stroke.
CHRONIC ISSUES:
============
#Seizure Disorder
Recent nonconvulsive status diagnosed on last hospitalization.
Started Divalproate and Keppra during that hospitalization. EEG
w/o any seizures as above, continued home AEDs. s/p 1 valproate
load.
#ESRD ___ T1DM and HTN s/p LURT (___)
Has known chronic allograft dysfunction. Renal US in ED w/
improved intrarenal arterial flow and patent vasculature. Renal
transplant was consulted. Continued immunosuppression as below.
# Immunosuppression
Continued Cyclosporine (25 mg q12h), MMF 500 mg bid and
prednisone 5 mg daily.
# Bone mineral ds
Per Renal, continued Vitamin D, no indication for phos binders
# Anemia
Previously receiving weekly EPO injections but did not have the
week before admission due to concern of seizure as a side
effect. No inpatient indication for ESA.
# Recent CVA
MRI showed two subacute infarcts in the right periventricular
pericollosal artery territory and punctate infarct in pons.
Given distribution, highest suspicion was for small vessel
etiology. Given this and timing related to right heart cath, TTE
with bubble was performed, which showed no e/o PFO. It was
therefore felt that the infarcts are unlikely related to the
right heart catheterization. Continued home Asa.
#Scleroderma w/ CREST syndrome. On immunosuppression as above
#Gastroparesis/GERD/Hiatal hernia. Continued Omeprazole.
#Gout. Continued allopurinol.
#IPMN. Seen on recent EUS, needs outpatient followup.
TRANSITIONAL ISSUES:
=====================
[] recheck BMP on ___ or ___ to ensure stability of Cr
[] Lasix restarted at 20mg twice weekly. Has bibasilar crackles
on discharge, but did not aggressively diurese given Cr and
predisposition to orthostasis
[] discharge weight: 130.4kg
[] Pt with brittle diabetes. Would only make small changes at a
time to insulin regimen. Discharge insulin regimen: 12u glargine
qam, Humalog ___ with meals
[] please check orthostatics before making further changes to BP
regimen, as has historically had significant orthostatic
hypotension. ___ not tolerate significantly more BP medication
[] Needs close follow up with ophthalmology and ___.
[] If having repeated episodes of vertigo, likely peripheral and
would benefit from vestibular ___
New medications:
Meclizine PRN vertigo
Changed medications:
Hydralazine 75mg TID to ___ TID
Isosorbide Dinitrate 40mg TID to 60mg TID
Metoprolol XL 25mg to 50mg
Held medications:
___
Stopped medications:
Cilastozol
#CODE: Full (presumed)
#CONTACT: ___
___: SISTER
Phone number: ___
Cell phone: ___
More than 30 minutes were spent preparing this discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
4. Ferrous Sulfate 325 mg PO DAILY
5. Levothyroxine Sodium 125 mcg PO DAILY
6. Lidocaine 5% Patch ___ PTCH TD QAM
7. Mycophenolate Mofetil 500 mg PO BID
8. Pravastatin 30 mg PO QPM
9. PredniSONE 5 mg PO DAILY
10. Promethazine 25 mg PO Q6 HR-Q8HR
11. Ranolazine ER 500 mg PO BID
12. Vitamin D ___ UNIT PO DAILY
13. Divalproex (DELayed Release) 750 mg PO BID
14. Metoprolol Succinate XL 25 mg PO DAILY
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. pen needle, diabetic 32 gauge x ___ miscellaneous Other
17. Sodium Bicarbonate 1300 mg PO BID
18. trimethobenzamide 300 mg oral Q6H:PRN
19. Allopurinol ___ mg PO DAILY
20. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
21. Calcium Carbonate 500 mg PO DAILY
22. Cilostazol 50 mg PO BID
23. Esomeprazole Magnesium 40 mg oral BID
24. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL SC
Prior to meals
25. melatonin 10 mg oral QHS
26. LevETIRAcetam 500 mg PO BID
27. HydrALAZINE 75 mg PO Q8H
28. Isosorbide Dinitrate 40 mg PO TID
29. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Meclizine 12.5 mg PO Q8H:PRN vertigo, nausea
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Polyethylene Glycol 17 g PO DAILY
4. Senna 8.6 mg PO BID
5. Furosemide 20 mg PO 2X/WEEK (MO,TH)
6. HydrALAZINE 100 mg PO Q8H
7. Glargine 12 Units Breakfast
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. Isosorbide Dinitrate 60 mg PO TID
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Promethazine 25 mg PO Q8H:PRN nausea
12. Allopurinol ___ mg PO DAILY
13. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
14. Aspirin 81 mg PO DAILY
15. Calcitriol 0.25 mcg PO DAILY
16. Calcium Carbonate 500 mg PO DAILY
17. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
18. Divalproex (DELayed Release) 750 mg PO BID
19. Esomeprazole Magnesium 40 mg oral BID
20. Ferrous Sulfate 325 mg PO DAILY
21. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL SC
Prior to meals
22. LevETIRAcetam 500 mg PO BID
23. Levothyroxine Sodium 125 mcg PO DAILY
24. melatonin 10 mg oral QHS
25. Mycophenolate Mofetil 500 mg PO BID
26. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
27. pen needle, diabetic 32 gauge x ___ miscellaneous Other
28. Pravastatin 30 mg PO QPM
29. PredniSONE 5 mg PO DAILY
30. Ranolazine ER 500 mg PO BID
31. Sodium Bicarbonate 1300 mg PO BID
32. Vitamin D ___ UNIT PO DAILY
33. HELD- trimethobenzamide 300 mg oral Q6H:PRN This medication
was held. Do not restart trimethobenzamide until told by your
doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Complicated UTI
Toxic Metabolic Encephalopathy
Akathisia ___ Phenergan
Diabetes mellitus type 1 with hyperglycemia
Autonomic dysfunction with supine hypertension and orthostatic
hypotension
Acute on chronic systolic heart failure
Acute on chronic renal failure
Renal transplant on chronic immunosuppression
Secondary:
Nausea
Benign positional vertigo
Seizure disorder
Recent stroke
Coronary artery disease status post percutaneous coronary
interventions
Chronic multifactorial anemia
Chronic urinary retention
Diabetic retinopathy and cataracts
CREST syndrome
GERD
Hiatal hernia
Gastroparesis
History of gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital because your blood sugar was very low
after receiving some insulin and you were hard to wake up.
You received antibiotics for a urinary tract infection and
became more alert.
You had more imaging of your brain including CT scan and MRI
that showed no new strokes.
The diabetes doctors worked with ___ to keep your blood sugar in
a safe range. You received a new continuous glucose monitoring.
You received a unit of blood, but became fluid overloaded and
required Lasix.
Your blood pressure medications were uptitrated.
When you return to rehab, please:
- we changed some of your medicines - see below
- see below for your followup appontments
It was a pleasure caring for you and we wish you the best,
Your ___ Team
Followup Instructions:
___
|
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"R110",
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"M349",
"M341",
"K3184",
"K219",
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"T426X5A",
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Allergies: Penicillins / Ativan / carvedilol / amlodipine Chief Complaint: Hypoglycemia Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old woman with complex medical history notable for ESRD s/p LURT [MASKED] on immunosuppression, CAD s/p [MASKED] 4 (most recent [MASKED], HFrEF (EF 35-40% [MASKED], T1DM, severe poorly controlled HTN, scleroderma/CREST, who was brought to the ED by EMS after an episode of hypoglycemia and is now admitted for altered mental status and weakness iso a UTI. The patient had a recent admission at [MASKED] [MASKED] for decompensated heart failure. Her hospital course was complicated by NSTEMI, [MASKED], and non-convulsive status epilepticus with workup that revealed acute and subacute strokes in the right periventricular pericollosal artery territory and punctate infarct in pons. She was discharged on Keppra and valproate and has not had any witnessed seizures since discharge. She also underwent RHC iso newly reduced EF to 37% and difficult volume management. RHC showed elevated filling pressures and pHTN and she was aggressively diuresed. Since her discharge on [MASKED] she has felt generally weak and has had periods of confusion where she does not know the date or know where she is. The night before presentation her FSBGs were noted to be in the 400s. She received 10u SC insulin and in the AM she was noted to be hypoglycemic to the [MASKED]. The patient received 2mg IM glucagon and juice with improvement in her FSBG to 170s. She was taken by EMS to [MASKED] for further management. In the ED, she was afebrile, HRs [MASKED], BPs 200/90s but decreased to 160s/70s after home anti-HTN meds, and SpO2 98% RA. On initial exam she was somnolent, grade III systolic murmur, normal lung sounds, mild abdominal tenderness of LUQ, 1+ edema of b/l LEs, and she was AOx4 with no focal neurologic findings. Her EKG showed new lateral ST depressions. MB 6->4, and Trop 0.28 -> 0.16, asymptomatic. WBC 20 (normal at b/l), Hgb 11, Cr 2.5 (baseline 3.0), an otherwise normal chem-10, and lactate 1.6. UA was notable for Lg leuks, 178 WBCs, and many bact. Imaging included a CXR without e/o pna and a renal transplant US that showed improved intrarenal arterial flow, no hydronephrosis, and patent main renal vein. Renal transplant was consulted and recommended BP control with home medications, cyclosporine trough daily, and admission to medicine for further management of her confusion and AMS. [MASKED] was also consulted for assistance with management of her DMI iso recent episode of hypoglycemia. In addition to her home antihypertensives and insulin per [MASKED], she was started on ceftriaxone for a UTI (previous culture data from [MASKED] w/ ecoli, sensitive to CTX). Transfer VS were: 97.6 121 169/93 21 95% RA On arrival to the floor, patient reports marked fatigue. She denies dysuria but endorses mild lower abdominal discomfort. She denies diarrhea or constipation. She has had nausea and poor appetite for the past week and had one episode of non-bloody, non-bilious vomiting the day prior to admission. She denies any recent chest pain, palpitations, or dyspnea. She has had no cough, rhinorrhea, fevers, or chills. She reports a mild headache without neck stiffness, vision changes, or photophobia. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: -CAD s/p PCI x4: LAD PTCA [MASKED] DES to LAD and Cx/OM [MASKED] DES to LAD [MASKED] DES to Cx and OM [MASKED] -Heart failure with reduced EF (35-40% [MASKED] -L-sided living kidney transplant in [MASKED] complicated by transplant nephropathy -Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) -Autonomic dysfunction with orthostatic hypotension and supine hypertension -CVA [MASKED] -Seizure disorder -Scleroderma w/ CREST syndrome -Gastroparesis/GERD/Hiatal hernia -Chronic Nausea -Gout -OSA -Pancreatic cyst c/w IPMN -Dyslipidemia Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION PHYSICAL EXAM: [MASKED] 0417 Temp: 98.1 PO BP: 168/78 R Lying HR: 118 RR: 22 O2 sat: 98% O2 delivery: Ra GENERAL: NAD, AOx3 HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD CV: tachycardic, S1/S2, no murmurs, gallops, or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles GI: abdomen soft, nondistended, mild TTP of lower abdomen, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ radial pulses bilaterally NEURO: Alert/oriented x4, non-focal exam DERM: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: Temp: 98.4 PO BP: 180/77 HR: 81 RR: 16 O2 sat: 94% O2 delivery: Ra FSBG: 187 Constitutional: NAD HEENT: eyes anicteric, R sided pterygium, normal hearing, nose unremarkable, MMM without exudate CV: RRR [MASKED] SEM, JVP 8cm Resp: CTAB GI: sntnd, NABS GU: no foley MSK: no obvious synovitis Ext: wwp, trace [MASKED]: mild skin tightening Neuro: A&O grossly, speech intact and fluent, CN grossly intact [MASKED] LUE/LLE, 4+/5 RUE/RLE, SILT BUE/BLE, Psych: normal affect, pleasant Pertinent Results: ADMISSION LABS: =========== [MASKED] 11:34AM BLOOD WBC-20.8* RBC-3.47* Hgb-11.1* Hct-34.6 MCV-100* MCH-32.0 MCHC-32.1 RDW-14.7 RDWSD-53.4* Plt [MASKED] [MASKED] 11:34AM BLOOD Neuts-92.0* Lymphs-1.3* Monos-5.8 Eos-0.1* Baso-0.1 Im [MASKED] AbsNeut-19.13* AbsLymp-0.27* AbsMono-1.21* AbsEos-0.02* AbsBaso-0.03 [MASKED] 11:34AM BLOOD Glucose-178* UreaN-57* Creat-2.5* Na-141 K-4.9 Cl-101 HCO3-27 AnGap-13 [MASKED] 11:34AM BLOOD Glucose-178* UreaN-57* Creat-2.5* Na-141 K-4.9 Cl-101 HCO3-27 AnGap-13 [MASKED] 11:34AM BLOOD ALT-11 AST-33 CK(CPK)-110 AlkPhos-72 TotBili-0.2 [MASKED] 11:34AM BLOOD CK-MB-6 [MASKED] 11:34AM BLOOD cTropnT-0.28* [MASKED] 04:20PM BLOOD CK-MB-4 cTropnT-0.16* [MASKED] 11:34AM BLOOD Albumin-3.5 Calcium-9.5 Phos-3.2 Mg-2.1 [MASKED] 04:20PM BLOOD PTH-64 [MASKED]:02PM BLOOD Lactate-1.6 [MASKED] 04:10PM URINE Color-Yellow Appear-Hazy* Sp [MASKED] [MASKED] 04:10PM URINE Blood-SM* Nitrite-NEG Protein-300* Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG* [MASKED] 04:10PM URINE RBC-5* WBC-178* Bacteri-MANY* Yeast-NONE Epi-3 INTERIM LABS: ========== [MASKED] 06:30AM BLOOD Valproa-14* [MASKED] 09:00AM BLOOD Cyclspr-<30* [MASKED] 04:36PM BLOOD [MASKED] pO2-196* pCO2-42 pH-7.43 calTCO2-29 Base XS-3 Comment-GREEN TOP [MASKED] 08:02AM BLOOD Cyclspr-92* [MASKED] 08:02AM BLOOD Valproa-54 DISCHARGE LABS: ============ [MASKED] 05:25AM BLOOD WBC-6.3 RBC-2.95* Hgb-9.0* Hct-29.3* MCV-99* MCH-30.5 MCHC-30.7* RDW-19.3* RDWSD-70.7* Plt [MASKED] [MASKED] 07:26AM BLOOD Glucose-123* UreaN-51* Creat-3.2* Na-141 K-4.6 Cl-101 HCO3-32 AnGap-8* MICROBIOLOGY: ============== [MASKED] URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R [MASKED] Culture, Routine-FINAL IMAGING: ========= [MASKED] CXR No focal consolidation to suggest pneumonia. Mild pulmonary vascular congestion, improved from the prior exam. [MASKED] RENAL U/S 1. Improved intrarenal arterial flow with continuous diastolic flow now seen in the upper and lower pole intrarenal arteries, but questionable lack of diastolic flow in the interpolar region, as seen previously. Resistive indices in the upper and lower poles are mildly elevated. 2. No hydronephrosis. Patent main renal vein. [MASKED] EEG This is an abnormal continuous EEG monitoring study because of mild slowing of the background activity, indicative of mild diffuse encephalopathy without specific etiology. Common causes are medication effect, infections or toxic/metabolic disturbances. There was intermittent focal attenuation and very mild slowing over the right hemisphere, indicative of subcortical dysfunction in that region. There were no epileptiform discharges or electrographic seizures. Compared to the prior day's recording, there is no significant change. [MASKED] CT HEAD W/O CONTRAST 1. No new acute intracranial process. 2. Chronic findings, as above. [MASKED] MRI 1. Interval evolution of subacute on chronic thromboembolic ischemic changes in the right cerebral hemisphere and right pons. 2. No new infarct or acute intracranial hemorrhage. No evidence for PRES. 3. Additional findings as described above. [MASKED] CHEST XR In comparison with the study of [MASKED], the there are lower lung volumes. Moderate enlargement of the cardiac silhouette is again seen with moderate pulmonary vascular congestion. Opacification at the right base silhouetting hemidiaphragm is consistent with pleural fluid and atelectatic changes at the base. Retrocardiac opacification suggests volume loss in the left lower lobe. No evidence of acute focal consolidation, though this would be difficult to unequivocally exclude in the appropriate clinical setting, especially in the absence of a lateral view. There is a spiculated opacification in the right upper quadrant of the abdomen, raising the possibility of a gallstone. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old woman with complex medical history notable for renal transplant in [MASKED] on immunosuppression, CAD s/p [MASKED] 4 (most recent [MASKED], HFrEF (EF 35-40% [MASKED], brittle T1DM, autonomic dysfunction with poorly controlled HTN and orthostatic hypotension, scleroderma/CREST, recent admission for acute on chronic HFrEF, course complicated by CVA and seizures, brought to the ED [MASKED] from rehab after an episode of hypoglycemia, admitted for altered mental status and weakness presumed secondary to UTI. ACUTE ISSUES: =================== # Toxic Metabolic Encephalopathy # Generalized Weakness / Fatigue Since her discharge on [MASKED] patient generally weak and reported periods of confusion where she did not know the date or know where she was. Sister/HCP reported she was somnolent since prior to discharge, sleeping all the time, not herself. Worsened after an episode of hypoglycemia, improved with treatment of UTI below. Suspected a multifactorial process, in part related to delirium from UTI, poor glycemic control, recent hospitalizations superimposed on numerous chronic medical problems and neurologic injury including seizure and strokes. Initially also concerned for post-ictal state vs seizure I/s/o hypoglycemia. Neurology was consulted, recommended EEG, which from [MASKED] was w/o any evidence of seizure. Valproate was initially low likely i/s/o missing a dose in the ED, s/p one load remained in normal range. Keppra level was 48, but per neurology, this was okay and patient should continue keppra 500mg BID. CT head and MRI w/o any new acute strokes. Mental status returned to baseline by discharge. #DM type 1 c/b episode of hypoglycemia Blood sugar 400 at rehab, was given 10u SC insulin, then decreased to 50 and had AMS. Endorsed poor appetite, so was likely receiving inappropriate amount of insulin for how much she was taking in. Per sister, she has very brittle diabetes for a long time. [MASKED] was consulted. BG were very labile, swings from low to high with minimal change to insulin regimen. Patient had continuous glucose monitor, sensor was lost in the hospital, replaced on [MASKED]. Discharged on lower amount of Levemir than previously (see below for full regimen). #E. coli UTI in transplanted kidney UA positive, w/ lower abdominal pain, leukocytosis to 20 (previously normal). Urine culture grew E. coli sensitive to ceftriaxone, resistant to cipro. Started IV ceftriaxone, transitioned to cefpodoxime [MASKED] to complete a 10 day course. #Hypertensive Urgency Per outpatient nephrologist, goal SBP<180. Increased isosorbide dinitrate to 60 mg tid, Hydralazine to 100mg q8h and increased metoprolol XL to 50mg. SBPs remained elevated as high as 180s but further increases in BP meds limited by orthostasis. Follow up arranged with Cardiology and Neurology. #Orthostatic hypotension #Acute on chronic systolic heart failure #Acute kidney injury Initially had orthostasis, held diuretics, then developed edema/pulmonary edema. Edema improved with diuretics but then renal function worsened. Now appears dry to euvolemic, allowing for autoregulation for now, decreased lasix to twice weekly on discharge. Per discussion with transplant nephrology, given that Cr has peaked, safe for discharge with close follow up. Discontinued cilastozol (increased mortality in HF). #Autonomic Dysfunction Labile BPs and volume status as above. Followed by Neurology as outpatient. Etiology thought to be due to diabetes. Prior workup for other etiologies negative. #CAD [MASKED] 4 (most recent [MASKED] #Chest Pain Having intermittent chest pain, sometimes intermittent in nature. Troponin have been stable. From [MASKED] cath, still have 70% lesion in D1, but EKG have been stable. Continued home statin, metop, asa, ranolazine. Of note, patient had DES placed [MASKED] but was directed to stop taking ticagrelor in [MASKED], which she had stopped for a procedure. Confirmed with outpatient cardiologist that ticagrelor is not necessary to continue. #Akathisia / Hyperactivity Patient noted to be moving her extremities continually after somnolence improved, had a hard time extinguishing the movement with volition. Likely medication effect (Phenergan most trimethobenzamide). Valproate level within normal limits. Symptoms improved since discontinuing phenergan and trimethobenzamide. Phenergan restarted on [MASKED] w/o any adverse effects. #Chronic nausea Has has difficult to control nausea of unclear etiology on phenergan and trimethobenzamide, followed by GI as outpatient. Nausea appeared to correlate with episodes of hyperglycemia. Nausea was controlled with initially PRN Zofran, but became ineffective. Phenergan restarted on [MASKED] w/o any adverse effects. Trimethobenzamide discontinued due to akithisia. #Blurry vision Has known cataract, diabetic retinopathy, followed by [MASKED]. Last seen by opthaomlogy on [MASKED]. Discussed with on-call opthalmology, no indication to be seen inpatient, but should have follow up with opthalmology in [MASKED] weeks. No evidence of new strokes on head imaging this admission. #Anemia Has chronic anemia and receives epogen as outpatient and occasional blood transfusion. Hgb downtrending inpatient, likely in setting of iatrogenic blood draw and not receiving epogen. No melena/hematochezia or symptom to suspect acute drop. Iron studies c/w ACD likely iso of CKD. Received 1u PRBC on [MASKED] for hgb of 6.6, with exaggerated response and hgb was stable. Epogen was restarted. Goal hgb >8 #BPPV Had vertigo on [MASKED] with exam consistent with BPPV as diagnosed with [MASKED]. Improved with epley maneuver and meclizine. No concern for posterior stroke. CHRONIC ISSUES: ============ #Seizure Disorder Recent nonconvulsive status diagnosed on last hospitalization. Started Divalproate and Keppra during that hospitalization. EEG w/o any seizures as above, continued home AEDs. s/p 1 valproate load. #ESRD [MASKED] T1DM and HTN s/p LURT ([MASKED]) Has known chronic allograft dysfunction. Renal US in ED w/ improved intrarenal arterial flow and patent vasculature. Renal transplant was consulted. Continued immunosuppression as below. # Immunosuppression Continued Cyclosporine (25 mg q12h), MMF 500 mg bid and prednisone 5 mg daily. # Bone mineral ds Per Renal, continued Vitamin D, no indication for phos binders # Anemia Previously receiving weekly EPO injections but did not have the week before admission due to concern of seizure as a side effect. No inpatient indication for ESA. # Recent CVA MRI showed two subacute infarcts in the right periventricular pericollosal artery territory and punctate infarct in pons. Given distribution, highest suspicion was for small vessel etiology. Given this and timing related to right heart cath, TTE with bubble was performed, which showed no e/o PFO. It was therefore felt that the infarcts are unlikely related to the right heart catheterization. Continued home Asa. #Scleroderma w/ CREST syndrome. On immunosuppression as above #Gastroparesis/GERD/Hiatal hernia. Continued Omeprazole. #Gout. Continued allopurinol. #IPMN. Seen on recent EUS, needs outpatient followup. TRANSITIONAL ISSUES: ===================== [] recheck BMP on [MASKED] or [MASKED] to ensure stability of Cr [] Lasix restarted at 20mg twice weekly. Has bibasilar crackles on discharge, but did not aggressively diurese given Cr and predisposition to orthostasis [] discharge weight: 130.4kg [] Pt with brittle diabetes. Would only make small changes at a time to insulin regimen. Discharge insulin regimen: 12u glargine qam, Humalog [MASKED] with meals [] please check orthostatics before making further changes to BP regimen, as has historically had significant orthostatic hypotension. [MASKED] not tolerate significantly more BP medication [] Needs close follow up with ophthalmology and [MASKED]. [] If having repeated episodes of vertigo, likely peripheral and would benefit from vestibular [MASKED] New medications: Meclizine PRN vertigo Changed medications: Hydralazine 75mg TID to [MASKED] TID Isosorbide Dinitrate 40mg TID to 60mg TID Metoprolol XL 25mg to 50mg Held medications: [MASKED] Stopped medications: Cilastozol #CODE: Full (presumed) #CONTACT: [MASKED] [MASKED]: SISTER Phone number: [MASKED] Cell phone: [MASKED] More than 30 minutes were spent preparing this discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Calcitriol 0.25 mcg PO DAILY 3. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 4. Ferrous Sulfate 325 mg PO DAILY 5. Levothyroxine Sodium 125 mcg PO DAILY 6. Lidocaine 5% Patch [MASKED] PTCH TD QAM 7. Mycophenolate Mofetil 500 mg PO BID 8. Pravastatin 30 mg PO QPM 9. PredniSONE 5 mg PO DAILY 10. Promethazine 25 mg PO Q6 HR-Q8HR 11. Ranolazine ER 500 mg PO BID 12. Vitamin D [MASKED] UNIT PO DAILY 13. Divalproex (DELayed Release) 750 mg PO BID 14. Metoprolol Succinate XL 25 mg PO DAILY 15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 16. pen needle, diabetic 32 gauge x [MASKED] miscellaneous Other 17. Sodium Bicarbonate 1300 mg PO BID 18. trimethobenzamide 300 mg oral Q6H:PRN 19. Allopurinol [MASKED] mg PO DAILY 20. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 21. Calcium Carbonate 500 mg PO DAILY 22. Cilostazol 50 mg PO BID 23. Esomeprazole Magnesium 40 mg oral BID 24. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL SC Prior to meals 25. melatonin 10 mg oral QHS 26. LevETIRAcetam 500 mg PO BID 27. HydrALAZINE 75 mg PO Q8H 28. Isosorbide Dinitrate 40 mg PO TID 29. Furosemide 20 mg PO DAILY Discharge Medications: 1. Meclizine 12.5 mg PO Q8H:PRN vertigo, nausea 2. Multivitamins W/minerals 1 TAB PO DAILY 3. Polyethylene Glycol 17 g PO DAILY 4. Senna 8.6 mg PO BID 5. Furosemide 20 mg PO 2X/WEEK (MO,TH) 6. HydrALAZINE 100 mg PO Q8H 7. Glargine 12 Units Breakfast Humalog 3 Units Breakfast Humalog 3 Units Lunch Humalog 5 Units Dinner Insulin SC Sliding Scale using HUM Insulin 8. Isosorbide Dinitrate 60 mg PO TID 9. Lidocaine 5% Patch 1 PTCH TD QAM 10. Metoprolol Succinate XL 50 mg PO DAILY 11. Promethazine 25 mg PO Q8H:PRN nausea 12. Allopurinol [MASKED] mg PO DAILY 13. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 14. Aspirin 81 mg PO DAILY 15. Calcitriol 0.25 mcg PO DAILY 16. Calcium Carbonate 500 mg PO DAILY 17. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 18. Divalproex (DELayed Release) 750 mg PO BID 19. Esomeprazole Magnesium 40 mg oral BID 20. Ferrous Sulfate 325 mg PO DAILY 21. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL SC Prior to meals 22. LevETIRAcetam 500 mg PO BID 23. Levothyroxine Sodium 125 mcg PO DAILY 24. melatonin 10 mg oral QHS 25. Mycophenolate Mofetil 500 mg PO BID 26. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 27. pen needle, diabetic 32 gauge x [MASKED] miscellaneous Other 28. Pravastatin 30 mg PO QPM 29. PredniSONE 5 mg PO DAILY 30. Ranolazine ER 500 mg PO BID 31. Sodium Bicarbonate 1300 mg PO BID 32. Vitamin D [MASKED] UNIT PO DAILY 33. HELD- trimethobenzamide 300 mg oral Q6H:PRN This medication was held. Do not restart trimethobenzamide until told by your doctor Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary: Complicated UTI Toxic Metabolic Encephalopathy Akathisia [MASKED] Phenergan Diabetes mellitus type 1 with hyperglycemia Autonomic dysfunction with supine hypertension and orthostatic hypotension Acute on chronic systolic heart failure Acute on chronic renal failure Renal transplant on chronic immunosuppression Secondary: Nausea Benign positional vertigo Seizure disorder Recent stroke Coronary artery disease status post percutaneous coronary interventions Chronic multifactorial anemia Chronic urinary retention Diabetic retinopathy and cataracts CREST syndrome GERD Hiatal hernia Gastroparesis History of gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You came to the hospital because your blood sugar was very low after receiving some insulin and you were hard to wake up. You received antibiotics for a urinary tract infection and became more alert. You had more imaging of your brain including CT scan and MRI that showed no new strokes. The diabetes doctors worked with [MASKED] to keep your blood sugar in a safe range. You received a new continuous glucose monitoring. You received a unit of blood, but became fluid overloaded and required Lasix. Your blood pressure medications were uptitrated. When you return to rehab, please: - we changed some of your medicines - see below - see below for your followup appontments It was a pleasure caring for you and we wish you the best, Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"N390",
"N179",
"Z794",
"I110",
"I2510",
"D649",
"K219"
] |
[
"N390: Urinary tract infection, site not specified",
"G92: Toxic encephalopathy",
"I5023: Acute on chronic systolic (congestive) heart failure",
"T8619: Other complication of kidney transplant",
"N179: Acute kidney failure, unspecified",
"R531: Weakness",
"R5383: Other fatigue",
"E10649: Type 1 diabetes mellitus with hypoglycemia without coma",
"Z794: Long term (current) use of insulin",
"B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere",
"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",
"I160: Hypertensive urgency",
"I110: Hypertensive heart disease with heart failure",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"G2571: Drug induced akathisia",
"R110: Nausea",
"H8110: Benign paroxysmal vertigo, unspecified ear",
"D649: Anemia, unspecified",
"G40909: Epilepsy, unspecified, not intractable, without status epilepticus",
"M349: Systemic sclerosis, unspecified",
"M341: CR(E)ST syndrome",
"K3184: Gastroparesis",
"K219: Gastro-esophageal reflux disease without esophagitis",
"K449: Diaphragmatic hernia without obstruction or gangrene",
"T426X5A: Adverse effect of other antiepileptic and sedative-hypnotic drugs, initial encounter",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema"
] |
10,030,753
| 22,869,628
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol
Attending: ___.
Chief Complaint:
orthopnea, chest pressure
Major Surgical or Invasive Procedure:
PCI with DESE to distal LAD
History of Present Illness:
___ w/ ___ (41% EF on most recent TTE in ___, HTN, T1DM,
CAD s/p multiple stents to LAD/Cx in ___, renal transplant on
chronic immunosuppression presents with dyspnea. Patient reports
last night having acute onset of dyspnea. She suddenly had a
difficult time getting comfortable and had to sit up in bed to
avoid being SOB. She also notes that her weight was up (129 lbs
at home from a dry weight of 125-126). Patient also reports some
sinus congestion over the last couple of days and a couple of
episodes of diarrhea yesterday. She had one episode of CP
(described as her typical angina w/ substernal chest pressure w/
radiation down her R arm) that resolved with one dose of nitro.
Reports PND, orthopnea, and ___ edema. She says she has been
taking her medications and does not report any changes in her
diet recently. Notably w/ recent travel to ___. History of
DVT/PE though no reported asymmetric ___ pain/swelling/erythema.
In the ED initial vitals were: 98.1 ___ 20 100%4LNC
FSBG
438
Exam: Afebrile. SBP 180s. HR low 100s. Satting mid ___ on 2L NC.
Pleasant F in NAD
JVP elevated above clavicle sitting upright
Slightly tachy. Systolic ejection murmur loudest at LUSB w/
radiation to carotids
Bilateral crackles in lower lung fields
Abdomen soft, NT/ND, BS+
Pitting edema mid-way up shins
EKG: Sinus tach. ST depressions in V5-V6 stable from prior.
Labs/studies notable for:
137/95/41
---------<421
4.2/___/2.2
10.9>9.7/29.6<288 with 83%N and MCV 93
troponin-T 0.28
proBNP pending
VBG 7.40/49/31
Lactate 1.4
CXR PA/LAT
1. Compared to ___, persistent mild cardiomegaly
with new mild pulmonary edema.
2. No focal consolidations
Patient was given:
___ 09:50 SC Insulin Regular 10 units
___ 10:21 IV Furosemide 20 mg
___ 11:36 PO/NG Atorvastatin 80 mg
___ 11:36 SC Insulin 10 Units
Vitals on transfer: 160/79 97 15 100% 2L NC FSBG 356
On the floor... she is feeling well and without chest pain, arm
pain (describes prior angina as R arm pain and dyspnea). She
describes several weeks of nocturnal awakening with angina. She
describes increasing orthopnea which seemed to acutely worsen
day
of admission, when she felt she could not lay down at all.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of chest pain,
ankle edema, palpitations, syncope, or presyncope.
On further review of systems, denies any prior history of
stroke,
TIA, deep venous thrombosis, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. Denies exertional buttock or calf pain. Denies recent
fevers, chills or rigors. All of the other review of systems
were
negative.
Past Medical History:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___
DES to LAD and Cx/OM ___
3. OTHER PAST MEDICAL HISTORY. End-stage renal disease ___
diabetes s/p L-sided living kidney transplant in ___
- Scleroderma w/ CREST syndrome
- Gastroparesis/GERD/Hiatal hernia
- Gout diagnosed ___ years ago
- OSA
Social History:
___
Family History:
Mother with angina in ___. Maternal grandfather with MI in ___
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=====================
VITALS: 98.2 PO 164 / 89 L Sitting ___ 2 L
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP to jawline
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. 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
=========================
24 HR Data (last updated ___ @ 1142)
Temp: 98.7 (Tm 98.9), BP: 160/74 (106-182/63-80), HR: 75
(65-79), RR: 16 (___), O2 sat: 97% (97-100), O2 delivery: Ra,
Wt: 130.29 lb/59.1 kg
Fluid Balance (last updated ___ @ 956)
Last 8 hours Total cumulative -410ml
IN: Total 240ml, PO Amt 240ml
OUT: Total 650ml, Urine Amt 650ml
Last 24 hours Total cumulative -730ml
IN: Total 520ml, PO Amt 520ml
OUT: Total 1250ml, Urine Amt 1250ml, Emesis 0ml
Weight: 59.1 kg
Dry weight: 125 lbs (56.8).
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. MMM
NECK: supple, JVD of ~6cm at 60 degrees
CARDIAC: RRR, normal S1, S2. ___ systolic murmur best heard over
LLSB
LUNGS: CTAB, no wheezing, rales, or ronchi
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e. Warm and well perfused.
Pertinent Results:
ADMISSION LABS
====================
___ 08:40AM BLOOD WBC-10.9* RBC-3.17* Hgb-9.7* Hct-29.6*
MCV-93 MCH-30.6 MCHC-32.8 RDW-12.7 RDWSD-43.8 Plt ___
___ 08:40AM BLOOD Neuts-82.7* Lymphs-7.5* Monos-7.6 Eos-1.2
Baso-0.4 Im ___ AbsNeut-9.02*# AbsLymp-0.82* AbsMono-0.83*
AbsEos-0.13 AbsBaso-0.04
___ 08:40AM BLOOD Plt ___
___ 08:40AM BLOOD Glucose-421* UreaN-41* Creat-2.2* Na-137
K-4.2 Cl-95* HCO3-26 AnGap-16
___ 09:55AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.0
___ 09:55AM BLOOD Cyclspr-35*
PERTINENT LABS
===================
___ 08:40AM BLOOD CK-MB-7 ___
___ 08:40AM BLOOD cTropnT-0.28*
___ 08:45AM BLOOD CK-MB-3 cTropnT-0.54*
___ 10:30AM BLOOD CK-MB-3 cTropnT-0.49*
MICROBIOLOGY
==================
___ 1:12 pm URINE **FINAL REPORT ___
URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
IMAGING
==================
___ Nuclear stress
IMPRESSION: 1. No perfusion defect is identified. 2. Globally
reduced wallmotion and reduced ejection fraction of 39%,
decreased compared to ___.
___ Cardiac stress
IMPRESSION : No anginal type symptoms or ST segment changes.
Nuclear
report sent separately
INTERPRETATION: This ___ year old IDDM woman with h/o CKD and CAD
s/p
multiple stents was referred to the lab for evaluation. She was
infused
with 0.4 mg of regadenoson over 20 seconds. No chest, arm, neck
or back
discomfort reported. No significant ST segment changes noticed
from
baseline EKG. Rhythm was sinus with no ectopy. Baseline mild
systolic
HTN with appropriate HR and BP response to the infusion.
Aminophylline
125 mg IV given to the patient 2 minutes post-infusion.
IMPRESSION : No anginal type symptoms or ST segment changes.
Nuclear
report sent separately.
___ Cardiac Cath
1. Successful PTCA and ___ 1 to distal LAD lesion
LM- normal, LAD- 40% proximal, minimal mid disease, 80% distal
lesion beyond previous stent. D1 small with 70% ostial and long
70% mid lesion
LCx- 20% proximal in-stent restenosis, There is a focal 80% mid
LCx lesion just beyond OM1 where the vessel is jailed by
previous DES. OM1 stent is widely patent. OM2 is a medium sized
vessel with 70%
tubular stenosis. OM3 is a small vessel with mild luminal
irregularities
RCA- small, dominant vessel with mild luminal irregularities;
R-PDA is medium sized with a 50% proximal lesion
___ (PA & LAT) IMPRESSION:
Compared to ___, persistent mild cardiomegaly with
new mild pulmonary edema. No focal consolidations.
DISCHARGE LABS
=======================
___ 09:00AM BLOOD WBC-8.8 RBC-2.77* Hgb-8.6* Hct-27.6*
MCV-100* MCH-31.0 MCHC-31.2* RDW-13.7 RDWSD-50.1* Plt ___
___ 09:00AM BLOOD Plt ___
___ 09:00AM BLOOD Glucose-228* UreaN-52* Creat-2.8* Na-140
K-4.3 Cl-99 HCO3-28 AnGap-13
___ 09:00AM BLOOD Calcium-10.5* Phos-3.9 Mg-2.1
___ 09:00AM BLOOD Cyclspr-___ w/ ___ (41% EF on most recent TTE in ___, HTN, T1DM,
CAD s/p multiple stents to LAD/Cx in ___ admitted for dyspnea
and orthopnea concerning for acute ___ exacerbation and found
to have NSTEMI, s/p cardiac cath and DES to distal LAD, course
complicated by ___, likely contrast induced. Originally planned
for second PCI this admission to ___, but given her significant
contrast nephropathy and resolution of symptoms, repeat
perfusion stress test was performed and was negative. Deferring
further PCI to the outpatient setting once her creatinine
improves.
ACUTE ISSUES
===============================
#NSTEMI
Patient presented with chest pressure with radiation down R arm
that resolved with nitro x1 at home. Unchanged EKG however
elevated troponin T to 0.28 on admission. Patient received
treatment with IV heparin. Cath on ___ showed normal LM,
40% proximal LAD, 80% distal lesion beyond previous stent. 80%
mid LCx lesion. Successful PTCA and DES x1 to distal LAD lesion.
Given CKD with elevated creatinine, staged cath was planned.
Ticagrelor 90 mg PO bid started to prevent stent thrombosis.
Patient was continued on home statin (reduced dose given renal
function) and aspirin. Metoprolol was started given ACS. Given
persisted elevation of her creatinine, a nuclear stress test
was performed ___ and showed no perfusion defects and
globally reduced wall motion and reduced ejection fraction of
39%, decreased compared to ___. Given the absence of any
significant ischemia on nuclear stress test, decision was made
to defer staged PCI to the outpatient setting once her renal
function improves.
___ on CKD
Patient with CKD and baseline creatitine of 2.2-2.4. Hospital
course complicated by ___, likely contrast induced. Patient's
kidney function fluctuated with peak creatinine of 3. Her
discharge cr. is 2.8.
___ exacerbation LVEF 41% (___).
Patient presented with dyspnea, orthopnea, PND, and evidence of
volume overload on admission. BNP>35000. Likely secondary to
NSTEMI. Patient was diuresed with IV lasix, with good symptom
improvement. Home hydralazine was continued for afterload
reduction, and metoprolol was titrated with good effect. Her
discharge weight is 59.1 kg (130.29 lb). On discharge, she will
take Lasix prn as she had been previously to achieve a dry
weight of 125 lb.
#HTN
Patient has history of orthostatic hypotension and had stopped
carvedilol and metoprolol in the past. Blood pressures labile
with SBP in the 120's-180's throughout admission. Patient did
not tolerate increased hydralazine (had orthostatic
hypotension), and her metoprolol dose was slowly titrated.
Amlodipine was started and titrated, with good effect and no
observed orthostatic hypotension.
CHRONIC ISSUES
===================
#DM1: Patient with blood glucose in 400's on admission with no
evidence of acidosis. Likely elevated in setting of NSTEMI.
Sugars remained labile while inpatient, managed during admission
with help from ___. Patient on home To___ and insulin
Humalog sliding scale. At discharge her home ___ dose is 36U
daily.
#ESRD s/p renal transplant. Patient was follwed by renal
transplant team during admission. Home immunosuppression was
continued (Cyclosporine 25mg QAM and 50mg QPM , MMF 500 mg bid,
and Prednisone 6 mg daily).
TRANSITIONAL ISSUES
=======================
[] Draw labs on ___ minutes before 1000 dose of
cyclosporin: CBC; Basic Metabolic Panel; ALT; Calcium; AST;
Total Bili; Phosphate; Albumin; Cyclosporin. Please fax results
to Dr. ___ ___
[] Please draw labwork on ___ for: Basic Metabolic Panel.
Please fax results to: Dr. ___ Dr. ___ at ___
[] Pt should avoid doses of ASA higher than 100mg and NSAIDS
while on ticagrelor.
[] Patient's weight at discharge is 59.1 kg (130.29 lb). Please
weigh patient every day in the morning. Call patient's doctor
Dr. ___ Dr. ___ at ___ if her weight goes
up by more than 3 lbs.
[] Please take daily vital signs and weights.
[] CODE: full
[] CONTACT: HCP: ___ (sister) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Calcitriol 0.25 mcg PO DAILY
7. Calcium Carbonate 500 mg PO BID
8. Cilostazol 100 mg PO QAM
9. Cilostazol 50 mg PO QPM
10. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM
11. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM
12. Ferrous Sulfate 325 mg PO DAILY
13. HydrALAZINE 50 mg PO QHS
14. Levothyroxine Sodium 125 mcg PO DAILY
15. Mycophenolate Mofetil 500 mg PO BID
16. PredniSONE 6 mg PO DAILY
17. Promethazine 25 mg PO DAILY PRN nausea
18. Ranolazine ER 500 mg PO BID
19. Vitamin D ___ UNIT PO DAILY
20. Esomeprazole 40 mg Other BID
21. Furosemide 20 mg PO DAILY
22. Lidocaine 5% Patch 1 PTCH TD QAM
23. naftifine 2 % topical BID To soles of feet and between toe
webs
24. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
25. melatonin 10 mg oral QHS
26. Toujeo SoloStar (insulin glargine) 36 U subcutaneous QAM
27. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
*** Note: Patient was verbally contacted regarding this
prescription and notified regarding the CORRECT dosage- BID not
daily. In addition an additional e script was submitted by Dr.
___ for additional ticagrelor to ensure enough supply
for this month.***
4. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
5. Toujeo SoloStar (insulin glargine) 36 Units subcutaneous Q
Breakfast
6. Allopurinol ___ mg PO DAILY
7. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
8. Ascorbic Acid ___ mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 20 mg PO QPM
11. Calcitriol 0.25 mcg PO DAILY
12. Calcium Carbonate 500 mg PO BID
13. Cilostazol 50 mg PO QPM
14. Cilostazol 100 mg PO QAM
15. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM
16. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM
17. Esomeprazole 40 mg Other BID
18. Ferrous Sulfate 325 mg PO DAILY
19. Furosemide 20 mg PO DAILY
20. HydrALAZINE 50 mg PO QHS
21. Levothyroxine Sodium 125 mcg PO DAILY
22. Lidocaine 5% Patch 1 PTCH TD QAM
23. melatonin 10 mg oral QHS
24. Mycophenolate Mofetil 500 mg PO BID
25. naftifine 2 % topical BID To soles of feet and between toe
webs
26. PredniSONE 6 mg PO DAILY
27. Promethazine 25 mg PO DAILY PRN nausea
28. Ranolazine ER 500 mg PO BID
29. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
30. Vitamin D ___ UNIT PO DAILY
31.Outpatient Lab Work
Draw on ___ minutes before 1000 dose of
cyclosporin: CBC; Basic Metabolic Panel; ALT; Calcium; AST;
Total Bili; Phosphate; Albumin; Cyclosporin
ICD Diagnosis Codes:
___.0 Kidney transplant status
Z79.899 Other long term (current) drug therapy
Please fax results to Dr. ___ ___
32.Outpatient Lab Work
Please draw labwork on ___ for:
Test(s): Basic Metabolic Panel
ICD-10 Diagnoses: I50.9 HEART FAILURE, UNSPECIFIED
Please fax results to: Dr. ___ ___ and Dr. ___
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
NSTEMI
Acute exacerbation of ___
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 admitted to the hospital?
-You were admitted because you had chest pain and tightness and
trouble breathing.
What happened while I was in the hospital?
-Your symptoms were most likely due to a heart attack, and you
received a procedure to have a stent placed to improve blood
flow to your heart ("PCI"). You also received a medication to
decrease extra fluid in your body ("FUROSEMIDE"). You also
received a test called a nuclear stress test, which showed that
your heart is weaker overall but it did not show any specific
areas of the heart that is lacking in blood flow after your
stent was placed.
What should I do after leaving the hospital?
- You need lab work drawn on ___ to evaluate your kidney
function and cyclosporine dose. This information should be faxed
to Dr. ___ Drs. ___.
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
-It is very important to take your aspirin once daily and
ticagrelor twice daily to protect your new stent.
-These two medications keep the stents in the vessels of the
heart open and help reduce your risk of having a future heart
attack.
-If you stop these medications or miss ___ dose, you risk causing
a blood clot forming in your heart stents, and you may die from
a massive heart attack.
-Please do not stop taking either medication without taking to
your heart doctor.
- While you're on ticagrelor, you should avoid doses of aspirin
higher than 100mg. You also need to avoid NSAIDS (Nonsteroidal
anti-inflammatory drugs) like ibuprofen or naproxen.
-Your weight at discharge is 59.1 kg (130.29 lb). Please weigh
yourself today at home.
-Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
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Allergies: Penicillins / Ativan / carvedilol Chief Complaint: orthopnea, chest pressure Major Surgical or Invasive Procedure: PCI with DESE to distal LAD History of Present Illness: [MASKED] w/ [MASKED] (41% EF on most recent TTE in [MASKED], HTN, T1DM, CAD s/p multiple stents to LAD/Cx in [MASKED], renal transplant on chronic immunosuppression presents with dyspnea. Patient reports last night having acute onset of dyspnea. She suddenly had a difficult time getting comfortable and had to sit up in bed to avoid being SOB. She also notes that her weight was up (129 lbs at home from a dry weight of 125-126). Patient also reports some sinus congestion over the last couple of days and a couple of episodes of diarrhea yesterday. She had one episode of CP (described as her typical angina w/ substernal chest pressure w/ radiation down her R arm) that resolved with one dose of nitro. Reports PND, orthopnea, and [MASKED] edema. She says she has been taking her medications and does not report any changes in her diet recently. Notably w/ recent travel to [MASKED]. History of DVT/PE though no reported asymmetric [MASKED] pain/swelling/erythema. In the ED initial vitals were: 98.1 [MASKED] 20 100%4LNC FSBG 438 Exam: Afebrile. SBP 180s. HR low 100s. Satting mid [MASKED] on 2L NC. Pleasant F in NAD JVP elevated above clavicle sitting upright Slightly tachy. Systolic ejection murmur loudest at LUSB w/ radiation to carotids Bilateral crackles in lower lung fields Abdomen soft, NT/ND, BS+ Pitting edema mid-way up shins EKG: Sinus tach. ST depressions in V5-V6 stable from prior. Labs/studies notable for: 137/95/41 ---------<421 4.2/[MASKED]/2.2 10.9>9.7/29.6<288 with 83%N and MCV 93 troponin-T 0.28 proBNP pending VBG 7.40/49/31 Lactate 1.4 CXR PA/LAT 1. Compared to [MASKED], persistent mild cardiomegaly with new mild pulmonary edema. 2. No focal consolidations Patient was given: [MASKED] 09:50 SC Insulin Regular 10 units [MASKED] 10:21 IV Furosemide 20 mg [MASKED] 11:36 PO/NG Atorvastatin 80 mg [MASKED] 11:36 SC Insulin 10 Units Vitals on transfer: 160/79 97 15 100% 2L NC FSBG 356 On the floor... she is feeling well and without chest pain, arm pain (describes prior angina as R arm pain and dyspnea). She describes several weeks of nocturnal awakening with angina. She describes increasing orthopnea which seemed to acutely worsen day of admission, when she felt she could not lay down at all. REVIEW OF SYSTEMS: Cardiac review of systems is notable for absence of chest pain, ankle edema, palpitations, syncope, or presyncope. On further review of systems, denies any prior history of stroke, TIA, deep venous thrombosis, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Denies exertional buttock or calf pain. Denies recent fevers, chills or rigors. All of the other review of systems were negative. Past Medical History: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED] 3. OTHER PAST MEDICAL HISTORY. End-stage renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] - Scleroderma w/ CREST syndrome - Gastroparesis/GERD/Hiatal hernia - Gout diagnosed [MASKED] years ago - OSA Social History: [MASKED] Family History: Mother with angina in [MASKED]. Maternal grandfather with MI in [MASKED] Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION PHYSICAL EXAMINATION: ===================== VITALS: 98.2 PO 164 / 89 L Sitting [MASKED] 2 L GENERAL: Well-developed, well-nourished. NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP to jawline CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. 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 ========================= 24 HR Data (last updated [MASKED] @ 1142) Temp: 98.7 (Tm 98.9), BP: 160/74 (106-182/63-80), HR: 75 (65-79), RR: 16 ([MASKED]), O2 sat: 97% (97-100), O2 delivery: Ra, Wt: 130.29 lb/59.1 kg Fluid Balance (last updated [MASKED] @ 956) Last 8 hours Total cumulative -410ml IN: Total 240ml, PO Amt 240ml OUT: Total 650ml, Urine Amt 650ml Last 24 hours Total cumulative -730ml IN: Total 520ml, PO Amt 520ml OUT: Total 1250ml, Urine Amt 1250ml, Emesis 0ml Weight: 59.1 kg Dry weight: 125 lbs (56.8). GENERAL: Well-developed, well-nourished. NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. MMM NECK: supple, JVD of ~6cm at 60 degrees CARDIAC: RRR, normal S1, S2. [MASKED] systolic murmur best heard over LLSB LUNGS: CTAB, no wheezing, rales, or ronchi ABDOMEN: Soft, NTND. EXTREMITIES: No c/c/e. Warm and well perfused. Pertinent Results: ADMISSION LABS ==================== [MASKED] 08:40AM BLOOD WBC-10.9* RBC-3.17* Hgb-9.7* Hct-29.6* MCV-93 MCH-30.6 MCHC-32.8 RDW-12.7 RDWSD-43.8 Plt [MASKED] [MASKED] 08:40AM BLOOD Neuts-82.7* Lymphs-7.5* Monos-7.6 Eos-1.2 Baso-0.4 Im [MASKED] AbsNeut-9.02*# AbsLymp-0.82* AbsMono-0.83* AbsEos-0.13 AbsBaso-0.04 [MASKED] 08:40AM BLOOD Plt [MASKED] [MASKED] 08:40AM BLOOD Glucose-421* UreaN-41* Creat-2.2* Na-137 K-4.2 Cl-95* HCO3-26 AnGap-16 [MASKED] 09:55AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.0 [MASKED] 09:55AM BLOOD Cyclspr-35* PERTINENT LABS =================== [MASKED] 08:40AM BLOOD CK-MB-7 [MASKED] [MASKED] 08:40AM BLOOD cTropnT-0.28* [MASKED] 08:45AM BLOOD CK-MB-3 cTropnT-0.54* [MASKED] 10:30AM BLOOD CK-MB-3 cTropnT-0.49* MICROBIOLOGY ================== [MASKED] 1:12 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING ================== [MASKED] Nuclear stress IMPRESSION: 1. No perfusion defect is identified. 2. Globally reduced wallmotion and reduced ejection fraction of 39%, decreased compared to [MASKED]. [MASKED] Cardiac stress IMPRESSION : No anginal type symptoms or ST segment changes. Nuclear report sent separately INTERPRETATION: This [MASKED] year old IDDM woman with h/o CKD and CAD s/p multiple stents was referred to the lab for evaluation. She was infused with 0.4 mg of regadenoson over 20 seconds. No chest, arm, neck or back discomfort reported. No significant ST segment changes noticed from baseline EKG. Rhythm was sinus with no ectopy. Baseline mild systolic HTN with appropriate HR and BP response to the infusion. Aminophylline 125 mg IV given to the patient 2 minutes post-infusion. IMPRESSION : No anginal type symptoms or ST segment changes. Nuclear report sent separately. [MASKED] Cardiac Cath 1. Successful PTCA and [MASKED] 1 to distal LAD lesion LM- normal, LAD- 40% proximal, minimal mid disease, 80% distal lesion beyond previous stent. D1 small with 70% ostial and long 70% mid lesion LCx- 20% proximal in-stent restenosis, There is a focal 80% mid LCx lesion just beyond OM1 where the vessel is jailed by previous DES. OM1 stent is widely patent. OM2 is a medium sized vessel with 70% tubular stenosis. OM3 is a small vessel with mild luminal irregularities RCA- small, dominant vessel with mild luminal irregularities; R-PDA is medium sized with a 50% proximal lesion [MASKED] (PA & LAT) IMPRESSION: Compared to [MASKED], persistent mild cardiomegaly with new mild pulmonary edema. No focal consolidations. DISCHARGE LABS ======================= [MASKED] 09:00AM BLOOD WBC-8.8 RBC-2.77* Hgb-8.6* Hct-27.6* MCV-100* MCH-31.0 MCHC-31.2* RDW-13.7 RDWSD-50.1* Plt [MASKED] [MASKED] 09:00AM BLOOD Plt [MASKED] [MASKED] 09:00AM BLOOD Glucose-228* UreaN-52* Creat-2.8* Na-140 K-4.3 Cl-99 HCO3-28 AnGap-13 [MASKED] 09:00AM BLOOD Calcium-10.5* Phos-3.9 Mg-2.1 [MASKED] 09:00AM BLOOD Cyclspr-[MASKED] w/ [MASKED] (41% EF on most recent TTE in [MASKED], HTN, T1DM, CAD s/p multiple stents to LAD/Cx in [MASKED] admitted for dyspnea and orthopnea concerning for acute [MASKED] exacerbation and found to have NSTEMI, s/p cardiac cath and DES to distal LAD, course complicated by [MASKED], likely contrast induced. Originally planned for second PCI this admission to [MASKED], but given her significant contrast nephropathy and resolution of symptoms, repeat perfusion stress test was performed and was negative. Deferring further PCI to the outpatient setting once her creatinine improves. ACUTE ISSUES =============================== #NSTEMI Patient presented with chest pressure with radiation down R arm that resolved with nitro x1 at home. Unchanged EKG however elevated troponin T to 0.28 on admission. Patient received treatment with IV heparin. Cath on [MASKED] showed normal LM, 40% proximal LAD, 80% distal lesion beyond previous stent. 80% mid LCx lesion. Successful PTCA and DES x1 to distal LAD lesion. Given CKD with elevated creatinine, staged cath was planned. Ticagrelor 90 mg PO bid started to prevent stent thrombosis. Patient was continued on home statin (reduced dose given renal function) and aspirin. Metoprolol was started given ACS. Given persisted elevation of her creatinine, a nuclear stress test was performed [MASKED] and showed no perfusion defects and globally reduced wall motion and reduced ejection fraction of 39%, decreased compared to [MASKED]. Given the absence of any significant ischemia on nuclear stress test, decision was made to defer staged PCI to the outpatient setting once her renal function improves. [MASKED] on CKD Patient with CKD and baseline creatitine of 2.2-2.4. Hospital course complicated by [MASKED], likely contrast induced. Patient's kidney function fluctuated with peak creatinine of 3. Her discharge cr. is 2.8. [MASKED] exacerbation LVEF 41% ([MASKED]). Patient presented with dyspnea, orthopnea, PND, and evidence of volume overload on admission. BNP>35000. Likely secondary to NSTEMI. Patient was diuresed with IV lasix, with good symptom improvement. Home hydralazine was continued for afterload reduction, and metoprolol was titrated with good effect. Her discharge weight is 59.1 kg (130.29 lb). On discharge, she will take Lasix prn as she had been previously to achieve a dry weight of 125 lb. #HTN Patient has history of orthostatic hypotension and had stopped carvedilol and metoprolol in the past. Blood pressures labile with SBP in the 120's-180's throughout admission. Patient did not tolerate increased hydralazine (had orthostatic hypotension), and her metoprolol dose was slowly titrated. Amlodipine was started and titrated, with good effect and no observed orthostatic hypotension. CHRONIC ISSUES =================== #DM1: Patient with blood glucose in 400's on admission with no evidence of acidosis. Likely elevated in setting of NSTEMI. Sugars remained labile while inpatient, managed during admission with help from [MASKED]. Patient on home To and insulin Humalog sliding scale. At discharge her home [MASKED] dose is 36U daily. #ESRD s/p renal transplant. Patient was follwed by renal transplant team during admission. Home immunosuppression was continued (Cyclosporine 25mg QAM and 50mg QPM , MMF 500 mg bid, and Prednisone 6 mg daily). TRANSITIONAL ISSUES ======================= [] Draw labs on [MASKED] minutes before 1000 dose of cyclosporin: CBC; Basic Metabolic Panel; ALT; Calcium; AST; Total Bili; Phosphate; Albumin; Cyclosporin. Please fax results to Dr. [MASKED] [MASKED] [] Please draw labwork on [MASKED] for: Basic Metabolic Panel. Please fax results to: Dr. [MASKED] Dr. [MASKED] at [MASKED] [] Pt should avoid doses of ASA higher than 100mg and NSAIDS while on ticagrelor. [] Patient's weight at discharge is 59.1 kg (130.29 lb). Please weigh patient every day in the morning. Call patient's doctor Dr. [MASKED] Dr. [MASKED] at [MASKED] if her weight goes up by more than 3 lbs. [] Please take daily vital signs and weights. [] CODE: full [] CONTACT: HCP: [MASKED] (sister) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 3. Ascorbic Acid [MASKED] mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Calcitriol 0.25 mcg PO DAILY 7. Calcium Carbonate 500 mg PO BID 8. Cilostazol 100 mg PO QAM 9. Cilostazol 50 mg PO QPM 10. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM 11. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM 12. Ferrous Sulfate 325 mg PO DAILY 13. HydrALAZINE 50 mg PO QHS 14. Levothyroxine Sodium 125 mcg PO DAILY 15. Mycophenolate Mofetil 500 mg PO BID 16. PredniSONE 6 mg PO DAILY 17. Promethazine 25 mg PO DAILY PRN nausea 18. Ranolazine ER 500 mg PO BID 19. Vitamin D [MASKED] UNIT PO DAILY 20. Esomeprazole 40 mg Other BID 21. Furosemide 20 mg PO DAILY 22. Lidocaine 5% Patch 1 PTCH TD QAM 23. naftifine 2 % topical BID To soles of feet and between toe webs 24. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 25. melatonin 10 mg oral QHS 26. Toujeo SoloStar (insulin glargine) 36 U subcutaneous QAM 27. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 *** Note: Patient was verbally contacted regarding this prescription and notified regarding the CORRECT dosage- BID not daily. In addition an additional e script was submitted by Dr. [MASKED] for additional ticagrelor to ensure enough supply for this month.*** 4. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin 5. Toujeo SoloStar (insulin glargine) 36 Units subcutaneous Q Breakfast 6. Allopurinol [MASKED] mg PO DAILY 7. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 8. Ascorbic Acid [MASKED] mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Atorvastatin 20 mg PO QPM 11. Calcitriol 0.25 mcg PO DAILY 12. Calcium Carbonate 500 mg PO BID 13. Cilostazol 50 mg PO QPM 14. Cilostazol 100 mg PO QAM 15. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM 16. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM 17. Esomeprazole 40 mg Other BID 18. Ferrous Sulfate 325 mg PO DAILY 19. Furosemide 20 mg PO DAILY 20. HydrALAZINE 50 mg PO QHS 21. Levothyroxine Sodium 125 mcg PO DAILY 22. Lidocaine 5% Patch 1 PTCH TD QAM 23. melatonin 10 mg oral QHS 24. Mycophenolate Mofetil 500 mg PO BID 25. naftifine 2 % topical BID To soles of feet and between toe webs 26. PredniSONE 6 mg PO DAILY 27. Promethazine 25 mg PO DAILY PRN nausea 28. Ranolazine ER 500 mg PO BID 29. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 30. Vitamin D [MASKED] UNIT PO DAILY 31.Outpatient Lab Work Draw on [MASKED] minutes before 1000 dose of cyclosporin: CBC; Basic Metabolic Panel; ALT; Calcium; AST; Total Bili; Phosphate; Albumin; Cyclosporin ICD Diagnosis Codes: [MASKED].0 Kidney transplant status Z79.899 Other long term (current) drug therapy Please fax results to Dr. [MASKED] [MASKED] 32.Outpatient Lab Work Please draw labwork on [MASKED] for: Test(s): Basic Metabolic Panel ICD-10 Diagnoses: I50.9 HEART FAILURE, UNSPECIFIED Please fax results to: Dr. [MASKED] [MASKED] and Dr. [MASKED] [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: NSTEMI Acute exacerbation of [MASKED] 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 admitted to the hospital? -You were admitted because you had chest pain and tightness and trouble breathing. What happened while I was in the hospital? -Your symptoms were most likely due to a heart attack, and you received a procedure to have a stent placed to improve blood flow to your heart ("PCI"). You also received a medication to decrease extra fluid in your body ("FUROSEMIDE"). You also received a test called a nuclear stress test, which showed that your heart is weaker overall but it did not show any specific areas of the heart that is lacking in blood flow after your stent was placed. What should I do after leaving the hospital? - You need lab work drawn on [MASKED] to evaluate your kidney function and cyclosporine dose. This information should be faxed to Dr. [MASKED] Drs. [MASKED]. - Please take your medications as listed in discharge summary and follow up at the listed appointments. -It is very important to take your aspirin once daily and ticagrelor twice daily to protect your new stent. -These two medications keep the stents in the vessels of the heart open and help reduce your risk of having a future heart attack. -If you stop these medications or miss [MASKED] dose, you risk causing a blood clot forming in your heart stents, and you may die from a massive heart attack. -Please do not stop taking either medication without taking to your heart doctor. - While you're on ticagrelor, you should avoid doses of aspirin higher than 100mg. You also need to avoid NSAIDS (Nonsteroidal anti-inflammatory drugs) like ibuprofen or naproxen. -Your weight at discharge is 59.1 kg (130.29 lb). Please weigh yourself today at home. -Please weigh yourself every day in the morning. Call your doctor if your weight goes up by more than 3 lbs. Thank you for allowing us to be involved in your care, we wish you all the best! Your [MASKED] Healthcare Team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"I130",
"K219",
"M109",
"G4733",
"Z955",
"Z87891",
"Z794",
"Z86718",
"Y92230",
"Y929"
] |
[
"I214: Non-ST elevation (NSTEMI) myocardial infarction",
"I5023: Acute on chronic systolic (congestive) heart failure",
"T8619: Other complication of kidney transplant",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"M341: CR(E)ST syndrome",
"N179: Acute kidney failure, unspecified",
"N184: Chronic kidney disease, stage 4 (severe)",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"K3184: Gastroparesis",
"T82855A: Stenosis of coronary artery stent, initial encounter",
"I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris",
"E10649: Type 1 diabetes mellitus with hypoglycemia without coma",
"N319: Neuromuscular dysfunction of bladder, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"E7800: Pure hypercholesterolemia, unspecified",
"M109: Gout, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"T508X5A: Adverse effect of diagnostic agents, initial encounter",
"N141: Nephropathy induced by other drugs, medicaments and biological substances",
"I951: Orthostatic hypotension",
"Z955: Presence of coronary angioplasty implant and graft",
"Z87891: Personal history of nicotine dependence",
"Z794: Long term (current) use of insulin",
"Z86718: Personal history of other venous thrombosis and embolism",
"Z86711: Personal history of pulmonary embolism",
"Y92230: Patient room 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",
"Y929: Unspecified place or not applicable"
] |
10,030,753
| 23,017,050
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___.
Chief Complaint:
Dyspnea, Pedal Edema, Transfer
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ y/o female with a history of ESRD (s/p LURT
___, anemia, CAD s/p ___ 4 (most recently ___, HFrEF (EF
~40%), IPMN (___), HTN, T1DM, and h/o multiple MDR UTIs
(Klebsiella, E.coli, Enterococcus), cryptogenic stroke,
scleroderma/CREST who presents with worsening lower extremity
edema, at the request of her primary cardiologist. The patient
was recently here in ___, where she was managed for
hypoglycemia. Baseline creatinine is ~3mg/dL; was biopsies in
___ which elucidated diabetic kidney disease, with Grade II
IFTA, and moderate arteriosclerosis.
In the setting of worsening lower extremity edema, the patient's
Lasix was up-titrated to daily from, twice weekly dosing on
___. The patient notes she has gained about 10 pounds
over the past month. She has remained volume overloaded, but
barring any lower extremity edema, the patient denies symptoms
suggestive of CHF such as SOB, cough, orthopnea, or PND.
Notably, labile blood pressures have been difficult to manage,
given diabetic dysautonomia; this has hindered diuresis in the
past per documentation. An implantable loop recorder was placed
given her history of cryptogenic stroke, with aim of detecting
possible occult atrial dysrhythmia. Last underwent cardiac cath
in ___, revealing elevated filling pressures, but as
aforementioned, more aggressive diuresis has been hindered by
labile BP's. Last echocardiogram revealed a depressed EF of
35-40, when prior TTE's had always suggested preserved systolic
function. Repeat catheterization has been deferred given
patient's advanced kidney disease. Various titrations of the
home
BP regimen have been undertaken in recent months.
Past Medical History:
-CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___ DES to LAD ___
PCI of Cx and OM with ___
-___ renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
-Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
-Hypertension
-Dyslipidemia
-Scleroderma w/ CREST syndrome
-Gastroparesis/GERD/Hiatal hernia
-Gout diagnosed ___ years ago
-OSA
-Pancreatic cyst
-Non convulsive status epilepticus
-stroke
-BPPV
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: reviewed in OMR
GENERAL: Caucasian female in NAD, alert and interactive. Appears
older than her stated age.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally with bibasilar crackles
noted. No wheezes. No increased work of breathing on RA.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: +BS, soft, slightly distended, but non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: 1+ edema bilaterally to mid-shins. No clubbing or
cyanosis. Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. No rash.
NEUROLOGIC: A&Ox3, no focal neurologic deficits. CN2-12 grossly
intact. ___ strength throughout.
DISCHARGE PHYSICAL EXAM:
GENERAL: Ill appearing woman laying in bed, NAD
HEENT: NCAT.
NECK: JVP of ~10cm
CARDIAC: Normal rate and rhythm. Loud S2. Grade ___ blowing
systolic murmur.
LUNGS: Crackles bilaterally at the bases. No wheezes or rhonchi.
ABDOMEN: Soft, non-tender to deep palpation in all four
quadrants. Distended.
EXTREMITIES: Warm and well perfused. 1+ pitting edema
bilaterally
to mid shin. No clubbing or cyanosis. Pulses DP/Radial 2+
bilaterally.
NEUROLOGIC: Alert. Oriented to self, place, and time. Sensation
to light touch intact throughout. Motor function symmetric
throughout.
Pertinent Results:
ADMISSION LABS:
=================
___ 07:44PM WBC-4.9 RBC-2.98* HGB-10.4* HCT-32.4*
MCV-109* MCH-34.9* MCHC-32.1 RDW-14.7 RDWSD-58.2*
___ 07:44PM PLT COUNT-180
___ 07:44PM NEUTS-76.7* LYMPHS-12.0* MONOS-8.7 EOS-1.6
BASOS-0.4 IM ___ AbsNeut-3.72 AbsLymp-0.58* AbsMono-0.42
AbsEos-0.08 AbsBaso-0.02
___ 07:44PM GLUCOSE-86 UREA N-57* CREAT-2.8* SODIUM-145
POTASSIUM-5.3 CHLORIDE-107 TOTAL CO2-28 ANION GAP-10
___ 07:44PM cTropnT-0.28*
___ 07:44PM CK-MB-7 proBNP->70000*
DISCHARGE LABS:
==================
___ 07:50AM BLOOD WBC-6.0 RBC-2.19* Hgb-7.6* Hct-24.4*
MCV-111* MCH-34.7* MCHC-31.1* RDW-12.8 RDWSD-51.3* Plt ___
___ 10:03AM BLOOD Neuts-82.9* Lymphs-8.1* Monos-8.1
Eos-0.3* Baso-0.3 Im ___ AbsNeut-5.75 AbsLymp-0.56*
AbsMono-0.56 AbsEos-0.02* AbsBaso-0.02
___ 07:50AM BLOOD Plt ___
___ 08:12AM BLOOD Glucose-137* UreaN-60* Creat-3.3* Na-145
K-4.6 Cl-107 HCO3-30 AnGap-8*
___ 08:12AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.1
MICROBIOLOGY:
================
__________________________________________________________
___ 12:56 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 10:05 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:25 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:30 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 11:50 am BLOOD CULTURE #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:44 pm BLOOD CULTURE #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
=========
CHEST (PA & LAT)Study Date of ___
IMPRESSION:
Mild basilar atelectasis without definite focal consolidation.
Difficult to
exclude trace pleural effusion, but no large pleural effusion is
seen. No
overt pulmonary edema.
RENAL TRANSPLANT U.S. RIGHTStudy Date of ___
IMPRESSION:
1. Unremarkable appearance of the transplant kidney in the left
lower quadrant
with no hydronephrosis.
2. Patent renal transplant vasculature. The RIs remain
elevated. The main
renal artery demonstrates mild parvus tardus waveform and absent
diastolic
flow.
3. Bladder wall thickening suggesting hypertrophy or neuropathic
bladder
changes.
Transthoracic Echocardiogram Report Date: ___
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
normal cavity size and mild to moderate global systolic
dysfunction. Increased PCWP. Mild mitral regurgitation. Mild
aortic regurgitation. Mild tricuspid regurgitation.
CT HEAD W/O CONTRASTStudy Date of ___
IMPRESSION:
1. No evidence for acute hemorrhage or acute major vascular
territorial
infarct.
2. Multiple chronic infarcts are again demonstrated.
3. Paranasal sinus disease.
CHEST (PORTABLE AP)Study Date of ___
IMPRESSION:
Compared to chest radiographs ___ through ___.
Moderate cardiomegaly is larger and pulmonary vasculature is
more engorged but
there is probably no pulmonary edema. Elevation right lung base
could be due
to subpulmonic pleural effusion or right basal atelectasis.
Skin fold should
not be mistaken for left pneumothorax.
MRA BRAIN W/O CONTRASTStudy Date of ___
IMPRESSION:
1. Multiple small acute or early subacute infarcts, in the right
thalamus,
right external capsule, right parietal cortex, and possibly in
the right
insular cortex.
2. 2 mm laterally projecting outpouching, right cavernous
intracranial ICA,
small infundibulum versus tiny aneurysm.
3. Areas of mild to severe luminal narrowing, bilateral
posterior cerebral
arteries, presumably due to underlying atheromatous disease,
most severely
affecting the left P4 PCA. There is nonetheless preserved
distal PCA runoff
bilaterally.
4. Otherwise, patent circle of ___ vasculature. No
additional stenosis,
aneurysm, or occlusion.
5. Multiple foci of supratentorial and infratentorial
encephalomalacia,
compatible sequelae of remote infarction.
6. Small chronic right periventricular white matter infarcts.
7. Multiple foci of chronic microhemorrhage; although there are
a few
supratentorial foci, these are most conspicuous in the
brainstem, raising the
possibility of hypertensive angiopathy.
Brief Hospital Course:
TO OUTSIDE PROVIDERS:
======================
___ woman with PMHx significant for ESRD s/p LURT in
___, CAD s/p ___ 4 (most recent ___, HFrEF (EF 35-40%
___, T1DM, poorly controlled HTN, scleroderma/CREST, who was
transferred from OSH for lower extremity edema with evidence of
HFrEF exacerbation, and UTI in setting of h/o MDR UTIs, hospital
course complicated by poorly controlled blood glucose, labile
blood pressure, and new CVA.
TRANSITIONAL ISSUES FOR PCP:
============================
[] MEDICATION CHANGES:
ADDITIONS:
-----------
clonidine 0.1 mg/24 hour
torsemide 20 mg QD
CHANGES (below is current regimen & stated reason for change):
allopurinol ___ mg Q48H (based on renal function)
cyclosporine 25 mg QAM + 50 mg QPM (per Renal based on levels
and renal function)
hydralazine 50 mg TID (for better BP control)
isosorbide mononitrate 120 mg QD (for better BP control)
levetiracetam 250 mg PO BID (based on renal function)
sodium bicarbonate 650 mg BID (based on HCO3- levels, per Renal)
HELD (all held to reduce pill burden, restart as necessary and
tolerated):
calcium carbonate 500 mg PO QD
esomeprazole magnesium 40 mg PO BID
ferrous sulfate 325 mg PO QD
furosemide 20 mg PO QD
meclizine 12.5 mg PO Q8H: PRN
ranolazine ER 500 mg PO BID
vitamin D ___ U PO QD
melatonin 10 mg PO QHS
[] Fluid status:
On discharge, we think she is still slightly volume overloaded.
We will start torsemide 20 mg daily, and we instructed her to
take daily weights. Please re-evaluate her edema and creatinine
and alter as necessary, eventually may need only Q48H dosing.
[] HTN:
Significant issue during hospitalization complicated by CVA.
Discharge regimen is:
clonidine 0.1 mg/24 hour
torsemide 20 mg QAM
hydralazine 50 mg TID
isosorbide mononitrate 120 mg QAM
metoprolol succinate 100 mg QHS
Please adjust as necessary, may need increase in clonidine patch
to 0.2 mg if continued hypertension. Consider ambulatory BP
monitor to assess control throughout the day.
ACUTE ISSUES:
=============
# Volume overload:
# ___ edema:
# c/f HFrEF Exacerbation (EF 35-40% on TTE in ___:
Patient with history of lower extremity edema but with labile
BPs that often prevent adequate diuresis. Presented to
cardiologist clinic with worsening ___ edema, found to have BNP
>70000 on
presentation to ___ ED. Also noted to be hypertensive as below
in the ED, but unclear if this was precipitating factor of HFrEF
exacerbation. Patient was diuresed with furosemide. Repeat TTE
generally unchanged, estimated elevated PCWP. Volume overload
also complicated by nephrotic syndrome.
#Acute and subacute thalamic and external capsule infarcts:
#Hypertensive angiopathy:
Patient received MRI/MRA head which revealed new infarcts in
deeper brain structures, concerning for hypertension as cause of
infarcts. Pt was seen by neurology who recommended daily
Aspirin and BP control for ongoing stroke prevention.
#Hypertensive urgency:
Patient presented with BP 201/110. Improved with
anti-hypertensives and diuresis in ED. Patient reports
compliance with medications and was normotensive at recent
outpatient appointment, so unclear what precipitated high BP in
ED. Pt has very labile BPs likely related to DM autonomic
neuropathy that was difficult to manage even while inpt.
Nephrotic syndrome may be contributing to HTN. Renal (time of
flight) MRI was performed to evaluate for RAS and there was not
evidence of arterial stenosis in vessels perfusing the
transplanted kidney. Medications were titrated to improve
pressures as listed in discharge medications.
#Acute complicated cystitis, treated:
Dysuria on admission, UA positive. UCx positive for
Enterococcus. Given PCN allergy, decision was made to treat with
vancomycin for 10 day course (given history of transplant) and
this course was completed.
___:
#ESRD ___ T1DM and HTN s/p LURT (___):
#Nephrotic syndrome:
Patient has chronic allograft dysfunction due to diabetic
nephropathy, partial rejection with baseline Cr reportedly 3.0
though slightly lower on chart review. Patient has long history
of nephrotic syndrome, biopsy proven ___ T1DM. Likely
contributing to her edema. Cr increased above baseline, likely
pre-renal ___ due to overdiuresis. Renal transplant was
consulted for management. She was continued on her home
immunosuppressants. SPEP/UPEP were negative. Renal assisted with
fluid management, Cr returned to near baseline at d/c.
#Type 1 DM:
Very labile blood sugar with episodes of hypo- and hyperglycemia
throughout hospitalization. ___ was consulted for assistance
with management of blood sugars. Regimen as noted on d/c
medications.
CHRONIC ISSUES:
===============
#Chronic nausea:
Continue home anti-emetics, standing promethazine PRN and
multiple medications held as they were contributing to pill
burden and daily vomiting.
#Scleroderma w/ CREST syndrome:
On immunosuppression as above.
#Gastroparesis/GERD/hiatal hernia:
Continued home esomeprazole.
#Seizure disorder:
Nonconvulsive status diagnosed during previous admission and
started on divalproate and levetiracetam at that time. Continued
home divalproex ___ BID, levetiracetam 250mg BID (dose-reduced
for renal function).
#Macrocytic anemia:
Chronic, secondary to ESRD, immunosuppression. Possibly a
dilutional component from fluids. Was initially maintained on
EPO, but was discontinued given new onset stroke.
#Gout:
-Continue home allopurinol.
#Hypothyroidism:
-Continue home levothyroxine.
#Hyperlipidemia:
-Continued home pravastatin.
#BPPV:
-Continued home meclizine PRN.
GOC: We held many discussions with patient and her sister
___ about her many medical issues contributing to her
declining quality of life with > 10 admissions during ___. Pt
endorsed poor tolerance of having to take so many pills and
waxing/waning confusion even at home. Pt often expressed
wanting to be DNAR/DNI and would NEVER want a feeding tube. She
was undecided about ever wanting dialysis. However, her sister
___ did not feel that these choices accurately represented the
patient's perspective as they had a different conversation weeks
before admission when they first filled out a MOLST.
Palliative care followed and will continue to see her as an
outpatient. I have reached out to her PCP to encourage ongoing
conversations about her goals as she is very likely to get
readmitted given her many medical problems that are difficult to
manage.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
6. Divalproex (DELayed Release) 750 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. LevETIRAcetam 500 mg PO BID
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Mycophenolate Mofetil 500 mg PO BID
11. Pravastatin 30 mg PO QPM
12. PredniSONE 5 mg PO DAILY
13. Ranolazine ER 500 mg PO BID
14. Sodium Bicarbonate 1300 mg PO BID
15. Senna 8.6 mg PO BID
16. melatonin 10 mg oral QHS
17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
18. Esomeprazole Magnesium 40 mg oral BID
19. Promethazine 25 mg PO Q8H:PRN nausea
20. Meclizine 12.5 mg PO Q8H:PRN vertigo, nausea
21. Lidocaine 5% Patch 1 PTCH TD QAM
22. Fluticasone Propionate NASAL 2 SPRY NU QHS
23. Furosemide 20 mg PO DAILY
24. HydrALAZINE 50 mg PO BID
25. Isosorbide Mononitrate (Extended Release) 60 mg PO QHS
26. Metoprolol Succinate XL 100 mg PO DAILY
27. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
28. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QSAT
RX *clonidine 0.1 ___ on skin. once a day Disp #*10
Patch Refills:*0
2. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
3. Allopurinol ___ mg PO EVERY OTHER DAY
4. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM
5. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM
6. HydrALAZINE 50 mg PO TID
7. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
8. LevETIRAcetam 250 mg PO BID
9. Metoprolol Succinate XL 100 mg PO QHS
10. Sodium Bicarbonate 650 mg PO BID
11. Aspirin 81 mg PO DAILY
12. Calcitriol 0.25 mcg PO DAILY
13. Divalproex (DELayed Release) 750 mg PO BID
14. Fluticasone Propionate NASAL 2 SPRY NU QHS
15. Levothyroxine Sodium 125 mcg PO DAILY
16. Lidocaine 5% Patch 1 PTCH TD QAM
17. Mycophenolate Mofetil 500 mg PO BID
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
19. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
20. Pravastatin 30 mg PO QPM
21. PredniSONE 5 mg PO DAILY
22. Promethazine 25 mg PO Q8H:PRN nausea
23. Senna 8.6 mg PO BID
24. HELD- Calcium Carbonate 500 mg PO DAILY This medication was
held. Do not restart Calcium Carbonate until told to restart by
a doctor.
25. HELD- Esomeprazole Magnesium 40 mg oral BID This medication
was held. Do not restart Esomeprazole Magnesium until told to
restart by a doctor.
26. HELD- Ferrous Sulfate 325 mg PO DAILY This medication was
held. Do not restart Ferrous Sulfate until told to restart by a
doctor.
27. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until told to restart by a doctor.
28. HELD- Meclizine 12.5 mg PO Q8H:PRN vertigo, nausea This
medication was held. Do not restart Meclizine until told to
restart by a doctor.
29. HELD- melatonin 10 mg oral QHS This medication was held. Do
not restart melatonin until told to restart by a doctor.
30. HELD- Ranolazine ER 500 mg PO BID This medication was held.
Do not restart Ranolazine ER until told to restart by a doctor.
31. HELD- Vitamin D ___ UNIT PO DAILY This medication was
held. Do not restart Vitamin D until told to restart by a
doctor.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
heart failure
stroke
hypertensive emergency
___
ESRD
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
WHY WERE YOU ADMITTED?
-You had lower extremity edema.
WHAT HAPPENED WHEN YOU WERE HERE?
-We thought you had fluid overload from heart failure so we
worked on getting fluid out of your body.
-Your blood pressure was very high we worked on controlling it.
-We noted that you had what looked like strokes on your head
imaging.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
-Continue to take all of your medications as described in your
discharge packet.
-Please followup with all of your doctors, especially your
primary care provider this week. Bring this handout.
-Your primary care doctor should help you with your diuretics
and blood pressure.
-Weight yourself daily and write the values down. If your
weight changes by a few pounds in 1 day, call your doctor for
assistance.
-Continue to check you blood pressure at home, making sure you
are seated for 5 minutes before checking it, resting your arm on
a table. Write down these values and bring them to your
doctor's appointments.
We wish you the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
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Allergies: Penicillins / Ativan / carvedilol / amlodipine Chief Complaint: Dyspnea, Pedal Edema, Transfer Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [MASKED] is a [MASKED] y/o female with a history of ESRD (s/p LURT [MASKED], anemia, CAD s/p [MASKED] 4 (most recently [MASKED], HFrEF (EF ~40%), IPMN ([MASKED]), HTN, T1DM, and h/o multiple MDR UTIs (Klebsiella, E.coli, Enterococcus), cryptogenic stroke, scleroderma/CREST who presents with worsening lower extremity edema, at the request of her primary cardiologist. The patient was recently here in [MASKED], where she was managed for hypoglycemia. Baseline creatinine is ~3mg/dL; was biopsies in [MASKED] which elucidated diabetic kidney disease, with Grade II IFTA, and moderate arteriosclerosis. In the setting of worsening lower extremity edema, the patient's Lasix was up-titrated to daily from, twice weekly dosing on [MASKED]. The patient notes she has gained about 10 pounds over the past month. She has remained volume overloaded, but barring any lower extremity edema, the patient denies symptoms suggestive of CHF such as SOB, cough, orthopnea, or PND. Notably, labile blood pressures have been difficult to manage, given diabetic dysautonomia; this has hindered diuresis in the past per documentation. An implantable loop recorder was placed given her history of cryptogenic stroke, with aim of detecting possible occult atrial dysrhythmia. Last underwent cardiac cath in [MASKED], revealing elevated filling pressures, but as aforementioned, more aggressive diuresis has been hindered by labile BP's. Last echocardiogram revealed a depressed EF of 35-40, when prior TTE's had always suggested preserved systolic function. Repeat catheterization has been deferred given patient's advanced kidney disease. Various titrations of the home BP regimen have been undertaken in recent months. Past Medical History: -CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED] DES to LAD [MASKED] PCI of Cx and OM with [MASKED] -[MASKED] renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] -Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) -Hypertension -Dyslipidemia -Scleroderma w/ CREST syndrome -Gastroparesis/GERD/Hiatal hernia -Gout diagnosed [MASKED] years ago -OSA -Pancreatic cyst -Non convulsive status epilepticus -stroke -BPPV Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: reviewed in OMR GENERAL: Caucasian female in NAD, alert and interactive. Appears older than her stated age. HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally with bibasilar crackles noted. No wheezes. No increased work of breathing on RA. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: +BS, soft, slightly distended, but non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: 1+ edema bilaterally to mid-shins. No clubbing or cyanosis. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. No rash. NEUROLOGIC: A&Ox3, no focal neurologic deficits. CN2-12 grossly intact. [MASKED] strength throughout. DISCHARGE PHYSICAL EXAM: GENERAL: Ill appearing woman laying in bed, NAD HEENT: NCAT. NECK: JVP of ~10cm CARDIAC: Normal rate and rhythm. Loud S2. Grade [MASKED] blowing systolic murmur. LUNGS: Crackles bilaterally at the bases. No wheezes or rhonchi. ABDOMEN: Soft, non-tender to deep palpation in all four quadrants. Distended. EXTREMITIES: Warm and well perfused. 1+ pitting edema bilaterally to mid shin. No clubbing or cyanosis. Pulses DP/Radial 2+ bilaterally. NEUROLOGIC: Alert. Oriented to self, place, and time. Sensation to light touch intact throughout. Motor function symmetric throughout. Pertinent Results: ADMISSION LABS: ================= [MASKED] 07:44PM WBC-4.9 RBC-2.98* HGB-10.4* HCT-32.4* MCV-109* MCH-34.9* MCHC-32.1 RDW-14.7 RDWSD-58.2* [MASKED] 07:44PM PLT COUNT-180 [MASKED] 07:44PM NEUTS-76.7* LYMPHS-12.0* MONOS-8.7 EOS-1.6 BASOS-0.4 IM [MASKED] AbsNeut-3.72 AbsLymp-0.58* AbsMono-0.42 AbsEos-0.08 AbsBaso-0.02 [MASKED] 07:44PM GLUCOSE-86 UREA N-57* CREAT-2.8* SODIUM-145 POTASSIUM-5.3 CHLORIDE-107 TOTAL CO2-28 ANION GAP-10 [MASKED] 07:44PM cTropnT-0.28* [MASKED] 07:44PM CK-MB-7 proBNP->70000* DISCHARGE LABS: ================== [MASKED] 07:50AM BLOOD WBC-6.0 RBC-2.19* Hgb-7.6* Hct-24.4* MCV-111* MCH-34.7* MCHC-31.1* RDW-12.8 RDWSD-51.3* Plt [MASKED] [MASKED] 10:03AM BLOOD Neuts-82.9* Lymphs-8.1* Monos-8.1 Eos-0.3* Baso-0.3 Im [MASKED] AbsNeut-5.75 AbsLymp-0.56* AbsMono-0.56 AbsEos-0.02* AbsBaso-0.02 [MASKED] 07:50AM BLOOD Plt [MASKED] [MASKED] 08:12AM BLOOD Glucose-137* UreaN-60* Creat-3.3* Na-145 K-4.6 Cl-107 HCO3-30 AnGap-8* [MASKED] 08:12AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.1 MICROBIOLOGY: ================ [MASKED] [MASKED] 12:56 pm URINE Source: Catheter. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 10:05 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 7:30 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 3:25 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 2:30 pm URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 11:50 am BLOOD CULTURE #2. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 7:44 pm BLOOD CULTURE #1. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. IMAGING: ========= CHEST (PA & LAT)Study Date of [MASKED] IMPRESSION: Mild basilar atelectasis without definite focal consolidation. Difficult to exclude trace pleural effusion, but no large pleural effusion is seen. No overt pulmonary edema. RENAL TRANSPLANT U.S. RIGHTStudy Date of [MASKED] IMPRESSION: 1. Unremarkable appearance of the transplant kidney in the left lower quadrant with no hydronephrosis. 2. Patent renal transplant vasculature. The RIs remain elevated. The main renal artery demonstrates mild parvus tardus waveform and absent diastolic flow. 3. Bladder wall thickening suggesting hypertrophy or neuropathic bladder changes. Transthoracic Echocardiogram Report Date: [MASKED] IMPRESSION: Moderate symmetric left ventricular hypertrophy with normal cavity size and mild to moderate global systolic dysfunction. Increased PCWP. Mild mitral regurgitation. Mild aortic regurgitation. Mild tricuspid regurgitation. CT HEAD W/O CONTRASTStudy Date of [MASKED] IMPRESSION: 1. No evidence for acute hemorrhage or acute major vascular territorial infarct. 2. Multiple chronic infarcts are again demonstrated. 3. Paranasal sinus disease. CHEST (PORTABLE AP)Study Date of [MASKED] IMPRESSION: Compared to chest radiographs [MASKED] through [MASKED]. Moderate cardiomegaly is larger and pulmonary vasculature is more engorged but there is probably no pulmonary edema. Elevation right lung base could be due to subpulmonic pleural effusion or right basal atelectasis. Skin fold should not be mistaken for left pneumothorax. MRA BRAIN W/O CONTRASTStudy Date of [MASKED] IMPRESSION: 1. Multiple small acute or early subacute infarcts, in the right thalamus, right external capsule, right parietal cortex, and possibly in the right insular cortex. 2. 2 mm laterally projecting outpouching, right cavernous intracranial ICA, small infundibulum versus tiny aneurysm. 3. Areas of mild to severe luminal narrowing, bilateral posterior cerebral arteries, presumably due to underlying atheromatous disease, most severely affecting the left P4 PCA. There is nonetheless preserved distal PCA runoff bilaterally. 4. Otherwise, patent circle of [MASKED] vasculature. No additional stenosis, aneurysm, or occlusion. 5. Multiple foci of supratentorial and infratentorial encephalomalacia, compatible sequelae of remote infarction. 6. Small chronic right periventricular white matter infarcts. 7. Multiple foci of chronic microhemorrhage; although there are a few supratentorial foci, these are most conspicuous in the brainstem, raising the possibility of hypertensive angiopathy. Brief Hospital Course: TO OUTSIDE PROVIDERS: ====================== [MASKED] woman with PMHx significant for ESRD s/p LURT in [MASKED], CAD s/p [MASKED] 4 (most recent [MASKED], HFrEF (EF 35-40% [MASKED], T1DM, poorly controlled HTN, scleroderma/CREST, who was transferred from OSH for lower extremity edema with evidence of HFrEF exacerbation, and UTI in setting of h/o MDR UTIs, hospital course complicated by poorly controlled blood glucose, labile blood pressure, and new CVA. TRANSITIONAL ISSUES FOR PCP: ============================ [] MEDICATION CHANGES: ADDITIONS: ----------- clonidine 0.1 mg/24 hour torsemide 20 mg QD CHANGES (below is current regimen & stated reason for change): allopurinol [MASKED] mg Q48H (based on renal function) cyclosporine 25 mg QAM + 50 mg QPM (per Renal based on levels and renal function) hydralazine 50 mg TID (for better BP control) isosorbide mononitrate 120 mg QD (for better BP control) levetiracetam 250 mg PO BID (based on renal function) sodium bicarbonate 650 mg BID (based on HCO3- levels, per Renal) HELD (all held to reduce pill burden, restart as necessary and tolerated): calcium carbonate 500 mg PO QD esomeprazole magnesium 40 mg PO BID ferrous sulfate 325 mg PO QD furosemide 20 mg PO QD meclizine 12.5 mg PO Q8H: PRN ranolazine ER 500 mg PO BID vitamin D [MASKED] U PO QD melatonin 10 mg PO QHS [] Fluid status: On discharge, we think she is still slightly volume overloaded. We will start torsemide 20 mg daily, and we instructed her to take daily weights. Please re-evaluate her edema and creatinine and alter as necessary, eventually may need only Q48H dosing. [] HTN: Significant issue during hospitalization complicated by CVA. Discharge regimen is: clonidine 0.1 mg/24 hour torsemide 20 mg QAM hydralazine 50 mg TID isosorbide mononitrate 120 mg QAM metoprolol succinate 100 mg QHS Please adjust as necessary, may need increase in clonidine patch to 0.2 mg if continued hypertension. Consider ambulatory BP monitor to assess control throughout the day. ACUTE ISSUES: ============= # Volume overload: # [MASKED] edema: # c/f HFrEF Exacerbation (EF 35-40% on TTE in [MASKED]: Patient with history of lower extremity edema but with labile BPs that often prevent adequate diuresis. Presented to cardiologist clinic with worsening [MASKED] edema, found to have BNP >70000 on presentation to [MASKED] ED. Also noted to be hypertensive as below in the ED, but unclear if this was precipitating factor of HFrEF exacerbation. Patient was diuresed with furosemide. Repeat TTE generally unchanged, estimated elevated PCWP. Volume overload also complicated by nephrotic syndrome. #Acute and subacute thalamic and external capsule infarcts: #Hypertensive angiopathy: Patient received MRI/MRA head which revealed new infarcts in deeper brain structures, concerning for hypertension as cause of infarcts. Pt was seen by neurology who recommended daily Aspirin and BP control for ongoing stroke prevention. #Hypertensive urgency: Patient presented with BP 201/110. Improved with anti-hypertensives and diuresis in ED. Patient reports compliance with medications and was normotensive at recent outpatient appointment, so unclear what precipitated high BP in ED. Pt has very labile BPs likely related to DM autonomic neuropathy that was difficult to manage even while inpt. Nephrotic syndrome may be contributing to HTN. Renal (time of flight) MRI was performed to evaluate for RAS and there was not evidence of arterial stenosis in vessels perfusing the transplanted kidney. Medications were titrated to improve pressures as listed in discharge medications. #Acute complicated cystitis, treated: Dysuria on admission, UA positive. UCx positive for Enterococcus. Given PCN allergy, decision was made to treat with vancomycin for 10 day course (given history of transplant) and this course was completed. [MASKED]: #ESRD [MASKED] T1DM and HTN s/p LURT ([MASKED]): #Nephrotic syndrome: Patient has chronic allograft dysfunction due to diabetic nephropathy, partial rejection with baseline Cr reportedly 3.0 though slightly lower on chart review. Patient has long history of nephrotic syndrome, biopsy proven [MASKED] T1DM. Likely contributing to her edema. Cr increased above baseline, likely pre-renal [MASKED] due to overdiuresis. Renal transplant was consulted for management. She was continued on her home immunosuppressants. SPEP/UPEP were negative. Renal assisted with fluid management, Cr returned to near baseline at d/c. #Type 1 DM: Very labile blood sugar with episodes of hypo- and hyperglycemia throughout hospitalization. [MASKED] was consulted for assistance with management of blood sugars. Regimen as noted on d/c medications. CHRONIC ISSUES: =============== #Chronic nausea: Continue home anti-emetics, standing promethazine PRN and multiple medications held as they were contributing to pill burden and daily vomiting. #Scleroderma w/ CREST syndrome: On immunosuppression as above. #Gastroparesis/GERD/hiatal hernia: Continued home esomeprazole. #Seizure disorder: Nonconvulsive status diagnosed during previous admission and started on divalproate and levetiracetam at that time. Continued home divalproex [MASKED] BID, levetiracetam 250mg BID (dose-reduced for renal function). #Macrocytic anemia: Chronic, secondary to ESRD, immunosuppression. Possibly a dilutional component from fluids. Was initially maintained on EPO, but was discontinued given new onset stroke. #Gout: -Continue home allopurinol. #Hypothyroidism: -Continue home levothyroxine. #Hyperlipidemia: -Continued home pravastatin. #BPPV: -Continued home meclizine PRN. GOC: We held many discussions with patient and her sister [MASKED] about her many medical issues contributing to her declining quality of life with > 10 admissions during [MASKED]. Pt endorsed poor tolerance of having to take so many pills and waxing/waning confusion even at home. Pt often expressed wanting to be DNAR/DNI and would NEVER want a feeding tube. She was undecided about ever wanting dialysis. However, her sister [MASKED] did not feel that these choices accurately represented the patient's perspective as they had a different conversation weeks before admission when they first filled out a MOLST. Palliative care followed and will continue to see her as an outpatient. I have reached out to her PCP to encourage ongoing conversations about her goals as she is very likely to get readmitted given her many medical problems that are difficult to manage. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Calcitriol 0.25 mcg PO DAILY 4. Calcium Carbonate 500 mg PO DAILY 5. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 6. Divalproex (DELayed Release) 750 mg PO BID 7. Ferrous Sulfate 325 mg PO DAILY 8. LevETIRAcetam 500 mg PO BID 9. Levothyroxine Sodium 125 mcg PO DAILY 10. Mycophenolate Mofetil 500 mg PO BID 11. Pravastatin 30 mg PO QPM 12. PredniSONE 5 mg PO DAILY 13. Ranolazine ER 500 mg PO BID 14. Sodium Bicarbonate 1300 mg PO BID 15. Senna 8.6 mg PO BID 16. melatonin 10 mg oral QHS 17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 18. Esomeprazole Magnesium 40 mg oral BID 19. Promethazine 25 mg PO Q8H:PRN nausea 20. Meclizine 12.5 mg PO Q8H:PRN vertigo, nausea 21. Lidocaine 5% Patch 1 PTCH TD QAM 22. Fluticasone Propionate NASAL 2 SPRY NU QHS 23. Furosemide 20 mg PO DAILY 24. HydrALAZINE 50 mg PO BID 25. Isosorbide Mononitrate (Extended Release) 60 mg PO QHS 26. Metoprolol Succinate XL 100 mg PO DAILY 27. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 28. Vitamin D [MASKED] UNIT PO DAILY Discharge Medications: 1. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QSAT RX *clonidine 0.1 [MASKED] on skin. once a day Disp #*10 Patch Refills:*0 2. Torsemide 20 mg PO DAILY RX *torsemide 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 3. Allopurinol [MASKED] mg PO EVERY OTHER DAY 4. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM 5. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM 6. HydrALAZINE 50 mg PO TID 7. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 8. LevETIRAcetam 250 mg PO BID 9. Metoprolol Succinate XL 100 mg PO QHS 10. Sodium Bicarbonate 650 mg PO BID 11. Aspirin 81 mg PO DAILY 12. Calcitriol 0.25 mcg PO DAILY 13. Divalproex (DELayed Release) 750 mg PO BID 14. Fluticasone Propionate NASAL 2 SPRY NU QHS 15. Levothyroxine Sodium 125 mcg PO DAILY 16. Lidocaine 5% Patch 1 PTCH TD QAM 17. Mycophenolate Mofetil 500 mg PO BID 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 19. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 20. Pravastatin 30 mg PO QPM 21. PredniSONE 5 mg PO DAILY 22. Promethazine 25 mg PO Q8H:PRN nausea 23. Senna 8.6 mg PO BID 24. HELD- Calcium Carbonate 500 mg PO DAILY This medication was held. Do not restart Calcium Carbonate until told to restart by a doctor. 25. HELD- Esomeprazole Magnesium 40 mg oral BID This medication was held. Do not restart Esomeprazole Magnesium until told to restart by a doctor. 26. HELD- Ferrous Sulfate 325 mg PO DAILY This medication was held. Do not restart Ferrous Sulfate until told to restart by a doctor. 27. HELD- Furosemide 20 mg PO DAILY This medication was held. Do not restart Furosemide until told to restart by a doctor. 28. HELD- Meclizine 12.5 mg PO Q8H:PRN vertigo, nausea This medication was held. Do not restart Meclizine until told to restart by a doctor. 29. HELD- melatonin 10 mg oral QHS This medication was held. Do not restart melatonin until told to restart by a doctor. 30. HELD- Ranolazine ER 500 mg PO BID This medication was held. Do not restart Ranolazine ER until told to restart by a doctor. 31. HELD- Vitamin D [MASKED] UNIT PO DAILY This medication was held. Do not restart Vitamin D until told to restart by a doctor. Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: heart failure stroke hypertensive emergency [MASKED] ESRD UTI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at [MASKED]. WHY WERE YOU ADMITTED? -You had lower extremity edema. WHAT HAPPENED WHEN YOU WERE HERE? -We thought you had fluid overload from heart failure so we worked on getting fluid out of your body. -Your blood pressure was very high we worked on controlling it. -We noted that you had what looked like strokes on your head imaging. WHAT SHOULD YOU DO WHEN YOU GO HOME? -Continue to take all of your medications as described in your discharge packet. -Please followup with all of your doctors, especially your primary care provider this week. Bring this handout. -Your primary care doctor should help you with your diuretics and blood pressure. -Weight yourself daily and write the values down. If your weight changes by a few pounds in 1 day, call your doctor for assistance. -Continue to check you blood pressure at home, making sure you are seated for 5 minutes before checking it, resting your arm on a table. Write down these values and bring them to your doctor's appointments. We wish you the best! Sincerely, Your [MASKED] Medicine Team Followup Instructions: [MASKED]
|
[] |
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[
"I160: Hypertensive urgency",
"I639: Cerebral infarction, unspecified",
"N186: End stage renal disease",
"I5023: Acute on chronic systolic (congestive) heart failure",
"N3000: Acute cystitis without hematuria",
"N179: Acute kidney failure, unspecified",
"T8619: Other complication of kidney transplant",
"I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease",
"H35033: Hypertensive retinopathy, bilateral",
"B952: Enterococcus as the cause of diseases classified elsewhere",
"G40909: Epilepsy, unspecified, not intractable, without status epilepticus",
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"K3184: Gastroparesis",
"E1065: Type 1 diabetes mellitus with hyperglycemia",
"E10649: Type 1 diabetes mellitus with hypoglycemia without coma",
"M341: CR(E)ST syndrome",
"R110: Nausea",
"M109: Gout, unspecified",
"D631: Anemia in chronic kidney disease",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"R531: Weakness",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z955: Presence of coronary angioplasty implant and graft",
"Z87440: Personal history of urinary (tract) infections",
"Z87891: Personal history of nicotine dependence",
"Z7952: Long term (current) use of systemic steroids",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"R29703: NIHSS score 3",
"G8324: Monoplegia of upper limb affecting left nondominant side"
] |
10,030,753
| 23,960,805
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan
Attending: ___
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a medically complex ___ with PMH significant
for poorly controlled T1DM c/b retinopathy, ESRD s/p living
kidney xplant in ___, neuropathy with neurogenic bladder and
gastroparesis, CAD s/p MI in ___ and with 3 DES placed in
___, hypothyroidism and h/o multiple MDR UTIs
(Klebsiella, E.coli, Enterococcus), sclerodermda/CREST and
antiphospholipid antibody syndrome with h/o PE in ___ who
presents to the ED with intractable N/V and mechanical fall with
head strike.
Patient was in her usual state of health until one week prior
to admission when she developed nausea and vomiting. This nausea
and vomiting seemed to occur after she took an oral antibiotic
while on vacation in ___ (unclear why this was
prescribed - clinic paperwork said for inguinal ___. She became
concerned that she was not able to tolerate PO intake and
specifically that she was not keeping down her anti-rejection
meds so she went to ___ urgent care. Vitals at urgent
care were: 97.3, 127/65, 122, 97%RA. She was given 500cc NS and
IV Zofran 4mg x1. Labs were checked which showed an INR of 4.9.
Urgent care recommended that she be seen at the ___ ED for
further evaluation. Patient decided to drive herself to ___
but unfortunately fell while exiting a restaurant (she felt
better after the Zofran and stopped for food on the way to
___. She fell down some stairs and struck her head but did
not lose conciousness. At this point in time, EMS was called and
brought her to ___.
Initial vitals in the ED were: 97.2, 135, 168/69, 18, 100% RA
Exam was notable for: laceration to right forehead and right
wrist swelling.
Labs were notable for: H/H 8.4/25.1 (recent baseline 9.5/28.8
but decline is recent in last 4 months), INR 4.8, plts 292, BNP
1547, Cr 1.4 (baseline 1.2-1.4), lactate 1.4, UA grossly
positive. Blood and urine cultures were sent.
Imaging showed: No acute fractures or intracranial pathology
but with right supraorbital soft tissue hematoma. C-spine
intact. No fracture of the right wrist.
Patient was given: IV ciprofloxacin 400mg x1
Consults: transplant nephrology who recommended medicine
admission.
Vitals prior to transfer were: 98.9, 115, 153/60, 18, 95% RA
On the floor, patient reports that she feels better and only
complains of right wrist pain. She denies nausea since she
received Zofran at the urgent care clinic.
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:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catherization) - most recent HgbA1c 12.4 in ___
- End-stage renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
- Scleroderma w/ CREST syndrome
- Antiphospholipid antibody syndrome and remote PE history on
Coumadin ___
- CAD s/p MI in ___ c/ LAD PTCA; s/p PTCA ___: one vessel
disease with LAD 60% apical lesion and 90% ___ diagonal lesion.
___ diagonal branch was treated with ballon angioplasty w/o
stenting. Final angiography demonstrated ___ residual
stenosis and improved flow down the diagonal branch.
- LVH
- Gastroparesis/GERD/Hiatal hernia
- Hypothyroidism
- Gout diagnosed ___ years ago
- Herniated disk
- OSA
- Carpal tunnel s/p release
- H/o multiple UTIs (Enterococcus vanc & amp sensitive,
Klebsiella, E. Coli)
- Hx of TIA?
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Physical Exam:
ADMISSION EXAM
VS: 98.3, 152/67, 117, 19, 97% RA wt 76.2kg.
General: well appearing Caucasian female in NAD
HEENT: NC, sclerae anicteric. Significant bruising and soft
tissue swelling of the right periorbital area. PERRL, EOMI. OP
clear without lesion or exudate.
Neck: Supple, no ___, no thyromegaly
CV: Tachycardic but regular. Normal s1/s2, no m/r/g
Lungs: CTAB posteriorly, no w/r/r
Abdomen: Distended but soft and nontender. Normal bowel sounds,
no rebound or guarding. Unable to appreciate organomegaly.
GU: no foley
Ext: WWP, DP pulses 1+ bilaterally. No cyanosis, clubbing or
edema
Neuro: CN ___ grossly intact, moving all 4 extremities with
purpose. Gait deferred.
Skin: Ecchymoses around right eye, right wrist, above right
breast and scattered throughout lower extremities.
DISCHARGE EXAM
Vitals 98.3 ___ 18 100RA
General: obese, NAD
HEENT: swollen erythematous R eye that has overall improved but
has some crusting; now L eye has some ecchymoses
Heart: borderline tachycardic, normal rhythm, no murmurs
Lungs: CTAB
Abdomen: Obese, NT, NABS, several well-healed scars
Extremities: 1+ pitting edema bilaterally
Skin: bruising on stomach, R breast, R eye
Pertinent Results:
ADMISSION LABS
___ 04:10PM BLOOD WBC-10.0 RBC-2.70* Hgb-8.4* Hct-25.1*
MCV-93 MCH-31.1 MCHC-33.5 RDW-13.8 RDWSD-45.7 Plt ___
___ 04:10PM BLOOD ___ PTT-60.1* ___
___ 04:10PM BLOOD Glucose-114* UreaN-21* Creat-1.4* Na-136
K-3.7 Cl-101 HCO3-24 AnGap-15
___ 04:10PM BLOOD ALT-16 AST-14 CK(CPK)-99 AlkPhos-85
TotBili-0.2
___ 06:41AM BLOOD Calcium-9.6 Phos-2.5* Mg-1.6
___ 06:41AM BLOOD tacroFK-7.4
DISCHARGE LABS
___ 04:42AM BLOOD WBC-5.5 RBC-2.72* Hgb-8.1* Hct-26.1*
MCV-96 MCH-29.8 MCHC-31.0* RDW-15.3 RDWSD-53.1* Plt ___
___ 04:42AM BLOOD ___ PTT-35.9 ___
___ 04:42AM BLOOD Glucose-304* UreaN-24* Creat-1.5* Na-140
K-4.0 Cl-105 HCO3-27 AnGap-12
___ 04:42AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.8
___ 04:42AM BLOOD tacroFK-5.6
MICRO
___ 4:57 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 ORGANISMS/ML..
___ 8:02 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:37 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
WRIST XRAY ___
Dorsal soft tissue swelling along the wrist without underlying
fracture.
Extensive vascular calcification.
CT HEAD ___. No acute intracranial hemorrhage.
2. Right frontal supraorbital superficial soft tissue hematoma.
No underlying fracture seen.
CT C-SPINE ___
No fracture or malalignment in the C-spine.
RENAL TRANSPLANT US ___
Mildly elevated intrarenal resistive indices which are slightly
higher than ___.
CT ABD/PELVIS ___. No intra or retroperitoneal or intramuscular hematoma noted
in the abdomen or pelvis.
2. Transplant kidney in the left lower quadrant demonstrates no
hydronephrosis.
3. Moderate amount of stool throughout the colon without bowel
obstruction.
CT HEAD ___. No acute intracranial hemorrhage.
2. Small, residual, supraorbital, right frontal scalp hematoma.
CXR ___
IN COMPARISON WITH THE STUDY OF ___, THERE IS LITTLE
CHANGE AND NO
ACUTE CARDIOPULMONARY DISEASE. THE CARDIAC SILHOUETTE IS
ENLARGED AND THERE IS NO EVIDENCE OF VASCULAR CONGESTION,
PLEURAL EFFUSION, OR ACUTE FOCAL PNEUMONIA.
CT HEAD ___. No evidence of fracture, infarction or intracranial
hemorrhage.
2. Minimal residual right frontal/supraorbital scalp swelling.
Brief Hospital Course:
___ yo F with history of T1DM and ESRD s/p living kidney
transplant ___ on MMF, tacro, prednisone, also with history of
CAD s/p multiple MI's and recent ___ 3 ___, and h/o
multiple UTI's (mostly enterococcus, Klebsiella, coag neg staph)
who presents for elevated INR and a mechanical fall down some
stairs at ___. Suffered trauma but no head bleed.
Nausea/vomiting resolved on admission. Experienced labile blood
pressures and orthostatic hypotension a/w anemia, improved after
transfusion of 1 unit of blood. INR drifted to <2 with improved
nutrition and warfarin resumed prior to d/c.
Investigations/Interventions
1. Elevated INR: patient is on coumadin for history of PE, and
she presented with INR 4.8 in setting of 1 week of nausea and
vomiting. Elevated INR likely due to poor nutrition. INR was
trended and coumadin restarted ___ when INR was 1.8. INR 1.5 on
day of discharge.
2. Fall: patient fell down some stairs at restaurant and had no
preceding symptoms. EKG on admission was at baseline. We felt
fall to be mechanical in nature due to poor vision related to
diabetic nephropathy.
3. Hypotension: patient initially presented with hypertension
sbp in 190s, then became hypotensive when working with ___ sbp in
___. She was orthostatic. Home anti-hypertensives discontinued.
In setting of fall with elevated INR there was concern for
internal bleeding so CT abd/pelvis, CT head, and CXR (PA &
lateral) were obtained which were negative for evidence of
bleeding. She refused IVF so we encouraged po intake which
resulted in stabilization of blood pressures. Discharging home
on blood pressure medication regimen of metoprolol succinate
12.5 mg daily and losartan 50 mg daily. Amlodipine discontinued
in favor of increasing losartan.
4. Anemia: pt has baseline anemia but Hgb downtrended to 6's in
house. As this was associated with hypotension, bleeding was
ruled out with imaging described above. She was transfused 1
unit PRBC's with return of her hgb to baseline. No evidence of
GI bleeding during hospitalization.
5. Vitreous, retinal hemorrhage: patient reported blurry vision
during hospitalization. Ophthalmology consulted who diagnosed
vitreous and retinal hemorrhage. Recommended to keep HOB
elevated, avoid bending over or straining. Instructed to follow
up with ___ clinic.
6. Diabetes mellitus: patient followed at ___. Home regimen
continued in house initially but patient experienced
hypoglycemia into the 70's in the morning. ___ consulted and
patient agreed to change pm Lantus from 20 units to 16 units.
She will also change her correction factor to 14.
7. History of UTI's: patient has history of many UTI's. UA on
admission c/w UTI so patient placed on ciprofloxacin. UCx grew
yeast which we did not treat. Due to her history of infection we
decided to discharge her on ciprofloxacin for 14 days, last day
being ___.
8. CKD, ESRD s/p kidney transplant: patient is s/p living donor
kidney transplant in ___. Maintained on tacro, MMF, prednisone
as outpt. Her graft has CKD, likely related to diabetic
nephropathy. Serial tacro levels were within goal range and she
was maintained on her home regimen of 1mg q12h. Home prednisone
dose changed from 6mg qd to 5mg qd. Patient also is on Bactrim
DS tab qd which was changed to SS tab qd for PCP ___.
9. CAD: patient with recent ___ 3 placed. Continued on Asa,
Plavix, statin in house.
Transitional Issues:
[]Medication changes: Prednisone to 5mg qd, Bactrim to SS tab
qd, losartan to 50 mg daily, qhs Glargine to 16 units daily.
Amlodipine discontinued.
[]Patient should take ciprofloxacin through ___
[]Patient instructed by ___ attending to change her
carbohydrate correction factor to 14
[]Patient is on several drugs which may not be needed, please
consider decreasing number of medications on an outpatient basis
[]Patient instructed to keep HOB elevated, avoid bending over or
straining due to retinal hemorrhage
[]Please follow up pending BCx
[]Patient has follow up with PCP ___ patient also
instructed to call Dr. ___ for nephrology and
diabetes appointments
#CODE: Full
#CONTACT: Patient, HCP sister ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 2.5 mg PO DAILY
3. Aspirin EC 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Calcitriol 0.25 mcg PO DAILY
6. Cilostazol 50 mg PO TID
7. DULoxetine 60 mg PO DAILY
8. Gabapentin 100 mg PO QHS
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Losartan Potassium 25 mg PO DAILY
11. Metoprolol Succinate XL 12.5 mg PO DAILY
12. Mycophenolate Mofetil 500 mg PO BID
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Pramipexole 0.5 mg PO QHS
15. PredniSONE 6 mg PO DAILY
16. Promethazine 25 mg PO Q6H:PRN nausea or vomiting
17. Ranitidine 300 mg PO QHS
18. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
19. Tacrolimus 1 mg PO Q12H
20. TraZODone 50 mg PO QHS
21. Vitamin D 400 UNIT PO DAILY
22. Warfarin 3 mg PO DAILY16
23. Clopidogrel 75 mg PO DAILY
24. alpha lipoic acid ___ mg oral DAILY
25. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN
26. Esomeprazole Magnesium 40 mg ORAL BID
27. Lidocaine 5% Patch 1 PTCH TD QPM
28. Promethazine 25 mg PR Q6H:PRN nausea or vomiting
29. HYDROcodone-acetaminophen ___ mg ORAL Q4H:PRN pain
30. Glargine 36 Units Breakfast
Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
31. melatonin 5 mg po Q24H
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Calcitriol 0.25 mcg PO DAILY
5. Cilostazol 50 mg PO TID
6. Clopidogrel 75 mg PO DAILY
7. DULoxetine 60 mg PO DAILY
8. Gabapentin 100 mg PO QHS
9. HYDROcodone-acetaminophen ___ mg ORAL Q4H:PRN pain
10. Levothyroxine Sodium 125 mcg PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD QPM
12. Mycophenolate Mofetil 500 mg PO BID
13. Pramipexole 0.5 mg PO QHS
14. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
15. Promethazine 25 mg PO Q6H:PRN nausea or vomiting
16. Promethazine 25 mg PR Q6H:PRN nausea or vomiting
17. Ranitidine 300 mg PO QHS
18. Tacrolimus 1 mg PO Q12H
19. TraZODone 50 mg PO QHS
20. Vitamin D 400 UNIT PO DAILY
21. Warfarin 3 mg PO DAILY16
22. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*0
23. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
24. Esomeprazole Magnesium 40 mg ORAL BID
25. melatonin 5 mg po Q24H
26. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN
27. alpha lipoic acid ___ mg oral DAILY
28. Ciprofloxacin HCl 500 mg PO Q12H Duration: 19 Doses
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*19 Tablet Refills:*0
29. Glargine 26 Units Breakfast
Glargine 16 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
30. Losartan Potassium 50 mg PO DAILY
RX *losartan 25 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
31. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Elevated INR
Mechanical fall
Anemia
Secondary:
CAD
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were hospitalized after a fall. You experienced extensive
bruising since you are on blood thinners. You required 1 unit
of blood to be transfused since your blood levels were low,
likely related to all of the bruising. We obtained extensive
imaging of your body to ensure no internal bleeding, and this
was all negative.
You also developed some right eye floaters and blurry vision.
You were evaluated by Ophthalmology who felt that you had a mild
vitreous hemorrhage. You should make sure to sleep with the
head of the bed elevated and to avoid any activities requiring
bending over or straining.
We continued your immunosuppressive drugs and insulin. Please
make sure to follow up with your PCP and kidney doctor, ___.
___. in addition, the diabetes doctors talked with ___ and
we changed your nightly insulin to 16 units of Glargine instead
of 20. You should also change your correction factor to 14.
It was a pleasure taking care of you!
Your ___ team
Followup Instructions:
___
|
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] |
Allergies: Penicillins / Ativan Chief Complaint: fall Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a medically complex [MASKED] with PMH significant for poorly controlled T1DM c/b retinopathy, ESRD s/p living kidney xplant in [MASKED], neuropathy with neurogenic bladder and gastroparesis, CAD s/p MI in [MASKED] and with 3 DES placed in [MASKED], hypothyroidism and h/o multiple MDR UTIs (Klebsiella, E.coli, Enterococcus), sclerodermda/CREST and antiphospholipid antibody syndrome with h/o PE in [MASKED] who presents to the ED with intractable N/V and mechanical fall with head strike. Patient was in her usual state of health until one week prior to admission when she developed nausea and vomiting. This nausea and vomiting seemed to occur after she took an oral antibiotic while on vacation in [MASKED] (unclear why this was prescribed - clinic paperwork said for inguinal [MASKED]. She became concerned that she was not able to tolerate PO intake and specifically that she was not keeping down her anti-rejection meds so she went to [MASKED] urgent care. Vitals at urgent care were: 97.3, 127/65, 122, 97%RA. She was given 500cc NS and IV Zofran 4mg x1. Labs were checked which showed an INR of 4.9. Urgent care recommended that she be seen at the [MASKED] ED for further evaluation. Patient decided to drive herself to [MASKED] but unfortunately fell while exiting a restaurant (she felt better after the Zofran and stopped for food on the way to [MASKED]. She fell down some stairs and struck her head but did not lose conciousness. At this point in time, EMS was called and brought her to [MASKED]. Initial vitals in the ED were: 97.2, 135, 168/69, 18, 100% RA Exam was notable for: laceration to right forehead and right wrist swelling. Labs were notable for: H/H 8.4/25.1 (recent baseline 9.5/28.8 but decline is recent in last 4 months), INR 4.8, plts 292, BNP 1547, Cr 1.4 (baseline 1.2-1.4), lactate 1.4, UA grossly positive. Blood and urine cultures were sent. Imaging showed: No acute fractures or intracranial pathology but with right supraorbital soft tissue hematoma. C-spine intact. No fracture of the right wrist. Patient was given: IV ciprofloxacin 400mg x1 Consults: transplant nephrology who recommended medicine admission. Vitals prior to transfer were: 98.9, 115, 153/60, 18, 95% RA On the floor, patient reports that she feels better and only complains of right wrist pain. She denies nausea since she received Zofran at the urgent care clinic. 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: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catherization) - most recent HgbA1c 12.4 in [MASKED] - End-stage renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] - Scleroderma w/ CREST syndrome - Antiphospholipid antibody syndrome and remote PE history on Coumadin [MASKED] - CAD s/p MI in [MASKED] c/ LAD PTCA; s/p PTCA [MASKED]: one vessel disease with LAD 60% apical lesion and 90% [MASKED] diagonal lesion. [MASKED] diagonal branch was treated with ballon angioplasty w/o stenting. Final angiography demonstrated [MASKED] residual stenosis and improved flow down the diagonal branch. - LVH - Gastroparesis/GERD/Hiatal hernia - Hypothyroidism - Gout diagnosed [MASKED] years ago - Herniated disk - OSA - Carpal tunnel s/p release - H/o multiple UTIs (Enterococcus vanc & amp sensitive, Klebsiella, E. Coli) - Hx of TIA? Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Physical Exam: ADMISSION EXAM VS: 98.3, 152/67, 117, 19, 97% RA wt 76.2kg. General: well appearing Caucasian female in NAD HEENT: NC, sclerae anicteric. Significant bruising and soft tissue swelling of the right periorbital area. PERRL, EOMI. OP clear without lesion or exudate. Neck: Supple, no [MASKED], no thyromegaly CV: Tachycardic but regular. Normal s1/s2, no m/r/g Lungs: CTAB posteriorly, no w/r/r Abdomen: Distended but soft and nontender. Normal bowel sounds, no rebound or guarding. Unable to appreciate organomegaly. GU: no foley Ext: WWP, DP pulses 1+ bilaterally. No cyanosis, clubbing or edema Neuro: CN [MASKED] grossly intact, moving all 4 extremities with purpose. Gait deferred. Skin: Ecchymoses around right eye, right wrist, above right breast and scattered throughout lower extremities. DISCHARGE EXAM Vitals 98.3 [MASKED] 18 100RA General: obese, NAD HEENT: swollen erythematous R eye that has overall improved but has some crusting; now L eye has some ecchymoses Heart: borderline tachycardic, normal rhythm, no murmurs Lungs: CTAB Abdomen: Obese, NT, NABS, several well-healed scars Extremities: 1+ pitting edema bilaterally Skin: bruising on stomach, R breast, R eye Pertinent Results: ADMISSION LABS [MASKED] 04:10PM BLOOD WBC-10.0 RBC-2.70* Hgb-8.4* Hct-25.1* MCV-93 MCH-31.1 MCHC-33.5 RDW-13.8 RDWSD-45.7 Plt [MASKED] [MASKED] 04:10PM BLOOD [MASKED] PTT-60.1* [MASKED] [MASKED] 04:10PM BLOOD Glucose-114* UreaN-21* Creat-1.4* Na-136 K-3.7 Cl-101 HCO3-24 AnGap-15 [MASKED] 04:10PM BLOOD ALT-16 AST-14 CK(CPK)-99 AlkPhos-85 TotBili-0.2 [MASKED] 06:41AM BLOOD Calcium-9.6 Phos-2.5* Mg-1.6 [MASKED] 06:41AM BLOOD tacroFK-7.4 DISCHARGE LABS [MASKED] 04:42AM BLOOD WBC-5.5 RBC-2.72* Hgb-8.1* Hct-26.1* MCV-96 MCH-29.8 MCHC-31.0* RDW-15.3 RDWSD-53.1* Plt [MASKED] [MASKED] 04:42AM BLOOD [MASKED] PTT-35.9 [MASKED] [MASKED] 04:42AM BLOOD Glucose-304* UreaN-24* Creat-1.5* Na-140 K-4.0 Cl-105 HCO3-27 AnGap-12 [MASKED] 04:42AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.8 [MASKED] 04:42AM BLOOD tacroFK-5.6 MICRO [MASKED] 4:57 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: YEAST. >100,000 ORGANISMS/ML.. [MASKED] 8:02 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 7:37 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. IMAGING WRIST XRAY [MASKED] Dorsal soft tissue swelling along the wrist without underlying fracture. Extensive vascular calcification. CT HEAD [MASKED]. No acute intracranial hemorrhage. 2. Right frontal supraorbital superficial soft tissue hematoma. No underlying fracture seen. CT C-SPINE [MASKED] No fracture or malalignment in the C-spine. RENAL TRANSPLANT US [MASKED] Mildly elevated intrarenal resistive indices which are slightly higher than [MASKED]. CT ABD/PELVIS [MASKED]. No intra or retroperitoneal or intramuscular hematoma noted in the abdomen or pelvis. 2. Transplant kidney in the left lower quadrant demonstrates no hydronephrosis. 3. Moderate amount of stool throughout the colon without bowel obstruction. CT HEAD [MASKED]. No acute intracranial hemorrhage. 2. Small, residual, supraorbital, right frontal scalp hematoma. CXR [MASKED] IN COMPARISON WITH THE STUDY OF [MASKED], THERE IS LITTLE CHANGE AND NO ACUTE CARDIOPULMONARY DISEASE. THE CARDIAC SILHOUETTE IS ENLARGED AND THERE IS NO EVIDENCE OF VASCULAR CONGESTION, PLEURAL EFFUSION, OR ACUTE FOCAL PNEUMONIA. CT HEAD [MASKED]. No evidence of fracture, infarction or intracranial hemorrhage. 2. Minimal residual right frontal/supraorbital scalp swelling. Brief Hospital Course: [MASKED] yo F with history of T1DM and ESRD s/p living kidney transplant [MASKED] on MMF, tacro, prednisone, also with history of CAD s/p multiple MI's and recent [MASKED] 3 [MASKED], and h/o multiple UTI's (mostly enterococcus, Klebsiella, coag neg staph) who presents for elevated INR and a mechanical fall down some stairs at [MASKED]. Suffered trauma but no head bleed. Nausea/vomiting resolved on admission. Experienced labile blood pressures and orthostatic hypotension a/w anemia, improved after transfusion of 1 unit of blood. INR drifted to <2 with improved nutrition and warfarin resumed prior to d/c. Investigations/Interventions 1. Elevated INR: patient is on coumadin for history of PE, and she presented with INR 4.8 in setting of 1 week of nausea and vomiting. Elevated INR likely due to poor nutrition. INR was trended and coumadin restarted [MASKED] when INR was 1.8. INR 1.5 on day of discharge. 2. Fall: patient fell down some stairs at restaurant and had no preceding symptoms. EKG on admission was at baseline. We felt fall to be mechanical in nature due to poor vision related to diabetic nephropathy. 3. Hypotension: patient initially presented with hypertension sbp in 190s, then became hypotensive when working with [MASKED] sbp in [MASKED]. She was orthostatic. Home anti-hypertensives discontinued. In setting of fall with elevated INR there was concern for internal bleeding so CT abd/pelvis, CT head, and CXR (PA & lateral) were obtained which were negative for evidence of bleeding. She refused IVF so we encouraged po intake which resulted in stabilization of blood pressures. Discharging home on blood pressure medication regimen of metoprolol succinate 12.5 mg daily and losartan 50 mg daily. Amlodipine discontinued in favor of increasing losartan. 4. Anemia: pt has baseline anemia but Hgb downtrended to 6's in house. As this was associated with hypotension, bleeding was ruled out with imaging described above. She was transfused 1 unit PRBC's with return of her hgb to baseline. No evidence of GI bleeding during hospitalization. 5. Vitreous, retinal hemorrhage: patient reported blurry vision during hospitalization. Ophthalmology consulted who diagnosed vitreous and retinal hemorrhage. Recommended to keep HOB elevated, avoid bending over or straining. Instructed to follow up with [MASKED] clinic. 6. Diabetes mellitus: patient followed at [MASKED]. Home regimen continued in house initially but patient experienced hypoglycemia into the 70's in the morning. [MASKED] consulted and patient agreed to change pm Lantus from 20 units to 16 units. She will also change her correction factor to 14. 7. History of UTI's: patient has history of many UTI's. UA on admission c/w UTI so patient placed on ciprofloxacin. UCx grew yeast which we did not treat. Due to her history of infection we decided to discharge her on ciprofloxacin for 14 days, last day being [MASKED]. 8. CKD, ESRD s/p kidney transplant: patient is s/p living donor kidney transplant in [MASKED]. Maintained on tacro, MMF, prednisone as outpt. Her graft has CKD, likely related to diabetic nephropathy. Serial tacro levels were within goal range and she was maintained on her home regimen of 1mg q12h. Home prednisone dose changed from 6mg qd to 5mg qd. Patient also is on Bactrim DS tab qd which was changed to SS tab qd for PCP [MASKED]. 9. CAD: patient with recent [MASKED] 3 placed. Continued on Asa, Plavix, statin in house. Transitional Issues: []Medication changes: Prednisone to 5mg qd, Bactrim to SS tab qd, losartan to 50 mg daily, qhs Glargine to 16 units daily. Amlodipine discontinued. []Patient should take ciprofloxacin through [MASKED] []Patient instructed by [MASKED] attending to change her carbohydrate correction factor to 14 []Patient is on several drugs which may not be needed, please consider decreasing number of medications on an outpatient basis []Patient instructed to keep HOB elevated, avoid bending over or straining due to retinal hemorrhage []Please follow up pending BCx []Patient has follow up with PCP [MASKED] patient also instructed to call Dr. [MASKED] for nephrology and diabetes appointments #CODE: Full #CONTACT: Patient, HCP sister [MASKED] [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Amlodipine 2.5 mg PO DAILY 3. Aspirin EC 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Calcitriol 0.25 mcg PO DAILY 6. Cilostazol 50 mg PO TID 7. DULoxetine 60 mg PO DAILY 8. Gabapentin 100 mg PO QHS 9. Levothyroxine Sodium 125 mcg PO DAILY 10. Losartan Potassium 25 mg PO DAILY 11. Metoprolol Succinate XL 12.5 mg PO DAILY 12. Mycophenolate Mofetil 500 mg PO BID 13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 14. Pramipexole 0.5 mg PO QHS 15. PredniSONE 6 mg PO DAILY 16. Promethazine 25 mg PO Q6H:PRN nausea or vomiting 17. Ranitidine 300 mg PO QHS 18. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 19. Tacrolimus 1 mg PO Q12H 20. TraZODone 50 mg PO QHS 21. Vitamin D 400 UNIT PO DAILY 22. Warfarin 3 mg PO DAILY16 23. Clopidogrel 75 mg PO DAILY 24. alpha lipoic acid [MASKED] mg oral DAILY 25. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN 26. Esomeprazole Magnesium 40 mg ORAL BID 27. Lidocaine 5% Patch 1 PTCH TD QPM 28. Promethazine 25 mg PR Q6H:PRN nausea or vomiting 29. HYDROcodone-acetaminophen [MASKED] mg ORAL Q4H:PRN pain 30. Glargine 36 Units Breakfast Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 31. melatonin 5 mg po Q24H Discharge Medications: 1. Allopurinol [MASKED] mg PO DAILY 2. Aspirin EC 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Calcitriol 0.25 mcg PO DAILY 5. Cilostazol 50 mg PO TID 6. Clopidogrel 75 mg PO DAILY 7. DULoxetine 60 mg PO DAILY 8. Gabapentin 100 mg PO QHS 9. HYDROcodone-acetaminophen [MASKED] mg ORAL Q4H:PRN pain 10. Levothyroxine Sodium 125 mcg PO DAILY 11. Lidocaine 5% Patch 1 PTCH TD QPM 12. Mycophenolate Mofetil 500 mg PO BID 13. Pramipexole 0.5 mg PO QHS 14. PredniSONE 5 mg PO DAILY RX *prednisone 5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 15. Promethazine 25 mg PO Q6H:PRN nausea or vomiting 16. Promethazine 25 mg PR Q6H:PRN nausea or vomiting 17. Ranitidine 300 mg PO QHS 18. Tacrolimus 1 mg PO Q12H 19. TraZODone 50 mg PO QHS 20. Vitamin D 400 UNIT PO DAILY 21. Warfarin 3 mg PO DAILY16 22. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 23. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 24. Esomeprazole Magnesium 40 mg ORAL BID 25. melatonin 5 mg po Q24H 26. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN 27. alpha lipoic acid [MASKED] mg oral DAILY 28. Ciprofloxacin HCl 500 mg PO Q12H Duration: 19 Doses RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*19 Tablet Refills:*0 29. Glargine 26 Units Breakfast Glargine 16 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 30. Losartan Potassium 50 mg PO DAILY RX *losartan 25 mg 2 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 31. Metoprolol Succinate XL 12.5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Elevated INR Mechanical fall Anemia Secondary: CAD Diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [MASKED], You were hospitalized after a fall. You experienced extensive bruising since you are on blood thinners. You required 1 unit of blood to be transfused since your blood levels were low, likely related to all of the bruising. We obtained extensive imaging of your body to ensure no internal bleeding, and this was all negative. You also developed some right eye floaters and blurry vision. You were evaluated by Ophthalmology who felt that you had a mild vitreous hemorrhage. You should make sure to sleep with the head of the bed elevated and to avoid any activities requiring bending over or straining. We continued your immunosuppressive drugs and insulin. Please make sure to follow up with your PCP and kidney doctor, [MASKED]. [MASKED]. in addition, the diabetes doctors talked with [MASKED] and we changed your nightly insulin to 16 units of Glargine instead of 20. You should also change your correction factor to 14. It was a pleasure taking care of you! Your [MASKED] team Followup Instructions: [MASKED]
|
[] |
[
"N390",
"D62",
"I2510",
"N189",
"I252",
"Z955",
"E039",
"K219",
"G4733",
"M109",
"Z87891",
"Z7901",
"Z7902",
"Y929",
"E669"
] |
[
"N390: Urinary tract infection, site not specified",
"D6861: Antiphospholipid syndrome",
"E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"K3184: Gastroparesis",
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"Z940: Kidney transplant status",
"D62: Acute posthemorrhagic anemia",
"S8011XA: Contusion of right lower leg, initial encounter",
"S2001XA: Contusion of right breast, initial encounter",
"R791: Abnormal coagulation profile",
"S0011XA: Contusion of right eyelid and periocular area, initial encounter",
"H3560: Retinal hemorrhage, unspecified eye",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"N189: Chronic kidney disease, unspecified",
"W109XXA: Fall (on) (from) unspecified stairs and steps, initial encounter",
"I252: Old myocardial infarction",
"Z955: Presence of coronary angioplasty implant and graft",
"E039: Hypothyroidism, unspecified",
"N319: Neuromuscular dysfunction of bladder, unspecified",
"Z86711: Personal history of pulmonary embolism",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"S8012XA: Contusion of left lower leg, initial encounter",
"K219: Gastro-esophageal reflux disease without esophagitis",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"I951: Orthostatic hypotension",
"M109: Gout, unspecified",
"E10649: Type 1 diabetes mellitus with hypoglycemia without coma",
"Z87891: Personal history of nicotine dependence",
"Z87440: Personal history of urinary (tract) infections",
"H4311: Vitreous hemorrhage, right eye",
"S60211A: Contusion of right wrist, initial encounter",
"T45515A: Adverse effect of anticoagulants, initial encounter",
"Z7901: Long term (current) use of anticoagulants",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"R112: Nausea with vomiting, unspecified",
"Y929: Unspecified place or not applicable",
"E669: Obesity, unspecified",
"Z6830: Body mass index [BMI]30.0-30.9, adult"
] |
10,030,753
| 24,506,973
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan
Attending: ___.
Chief Complaint:
Right facial swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a history of ESRD s/p living renal transplant in ___
on immunosuppression, DM1, scleroderma/CREST, and CAD s/p MI
presenting with pre-septal cellulitis, course complicated by DKA
requiring MICU transfer, now with resolved DKA.
The patient notes that when she woke on ___, her eye felt
swollen and had significant redness on skin around her eyelid.
She notes that it worsened since that time, and was associated
with clear, teary discharge and crusting. She does note
antecedent rhinorrhea without sore, throat, cough or shortness
of breath. She developed a fever at home up to 101.9 which
prompted her to come in on ___. She states that her vision
may be slightly more blurry, but does not feel significantly
difference from her baseline blurry vision, given her diabetic
retinopathy and prior laser surgeries.
In the ED, her initial vitals were temp 99.4, HR 114, BP
127-64, RR 18, 98% on room air. Her labs were notable for WBC
1.8, Hg 10.3, platelets 227. Chem-7 Na 131, Cl 93, bicarb 18,
BUN 36, Cr 2.2, and Lactate 1.7. She had a chest x ray notable
for no acute cardiopulmonary process. She was given IV Cefepime,
IV Vancomycin. She was seen by renal transplant who recommended
isotonic bicarbonate 500cc/hour for two hours, given her slight
elevation in Creatinine, as well as:
-agree with optho consult
-CXR, blood cx, urine cx, CMV VL
-would cover broadly with IV vanc/ceftazidime
-hold MMF tonight and in the AM, continue cyclosporine 50mg BID
Optho consulted:
Concern for pre-septal cellulitis. Low suspicion of orbital
involvement given no pain with eye movements or proptosis.
-Dilated fundus examination shows extensive PRP scarring with
vitreous hemorrhage in the right eye that appears unchanged from
her last examination.
-recommended CT of the orbit
-antibiotics
- artificial tears as needed
- No heavy lifting, bending, straining or activities with rapid
head movement.
- Follow-up with ___ Ophthalmology as scheduled
- Vitals prior to transfer:
Temp. 98.7, HR 102, BP 134/68, RR 16, 100% RA
ROS negative for SOB, chest pain, nausea, or diarrhea. Patient
denies headache. She does endorse chronic nausea and vomiting on
multiple PRN's for this. Notes this is stable.
Past Medical History:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___
DES to LAD and Cx/OM ___
3. OTHER PAST MEDICAL HISTORY
End-stage renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
- Scleroderma w/ CREST syndrome
- Gastroparesis/GERD/Hiatal hernia
- Gout diagnosed ___ years ago
- OSA
-NOT ACCURATE: - Antiphospholipid antibody syndrome and remote
PE
history on Coumadin ___ - this diagnosis viewed unlikely per
___ hematology/oncology note; warfarin discontinued ___
Social History:
___
Family History:
Per OMR:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
VS: 99.6 PO 114 / 61 102 16 98 Ra
GENERAL: Right eye erythematous with swelling.
HEENT: EOMI, pain with eye movement
CARDIAC: RRR
PULMONARY: clear bilaterally, no wheezes or rubs
ABDOMEN: soft, non-tender to palpation
GENITOURINARY: no foley
EXTREMITIES: no edema
SKIN: no rash
NEUROLOGIC: CN grossly intact
========================
DISCHARGE PHYSICAL EXAM
========================
Vitals: T 98.0, BP 180/77 (lying), HR 89, RR 18, ___ 94 on room
air
General: Pleasant, well-appearing, lying in bed.
HEENT: Atraumatic with improving erythema around right eyelid,
now limited to ~1.5cm around upper/lower lids. Oropharynx clear.
Neck: Supple with no lymphadenopathy or jugular venous
distention
Lungs: Clear to auscultation bilaterally
CV: Regular rate/rhythm, with systolic ejection murmur heard
best at lower sternal border. No rubs or gallops.
Abdomen: Soft, nontender, nondistended
Ext: Warm, well-perfused with 1+ pitting edema bilaterally.
Neuro: Alert, oriented to self, place, time. Moving all
extremities spontaneously and purposefully.
Pertinent Results:
===============
ADMISSION LABS
===============
___ 11:38PM ___ PO2-135* PCO2-29* PH-7.29* TOTAL
CO2-15* BASE XS--10 COMMENTS-GREEN TOP
___ 11:13PM GLUCOSE-601* UREA N-49* CREAT-2.5*
SODIUM-125* POTASSIUM-5.2* CHLORIDE-88* TOTAL CO2-12* ANION
GAP-30*
___ 11:13PM CALCIUM-8.2* PHOSPHATE-5.2* MAGNESIUM-1.7
___ 04:31PM LACTATE-1.7
___ 04:30PM GLUCOSE-365* UREA N-36* CREAT-2.2*
SODIUM-131* POTASSIUM-4.7 CHLORIDE-93* TOTAL CO2-18* ANION
GAP-25*
___ 04:30PM estGFR-Using this
___ 04:30PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-1.7
___ 04:30PM WBC-1.8*# RBC-3.36* HGB-10.3* HCT-31.6*
MCV-94 MCH-30.7 MCHC-32.6 RDW-13.0 RDWSD-44.5
___ 04:30PM NEUTS-3* BANDS-0 ___ MONOS-65* EOS-0
BASOS-0 ___ METAS-1* MYELOS-0 AbsNeut-0.05* AbsLymp-0.56*
AbsMono-1.17* AbsEos-0.00* AbsBaso-0.00*
___ 04:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
___ 04:30PM PLT SMR-NORMAL PLT COUNT-227
===============
DISCHARGE LABS
===============
___ 06:09AM BLOOD WBC-3.8* RBC-3.36* Hgb-10.1* Hct-30.1*
MCV-90 MCH-30.1 MCHC-33.6 RDW-13.9 RDWSD-45.4 Plt ___
___ 06:09AM BLOOD Neuts-64 Bands-0 Lymphs-18* Monos-16*
Eos-1 Baso-0 ___ Myelos-1* NRBC-2* AbsNeut-2.43
AbsLymp-0.68* AbsMono-0.61 AbsEos-0.04 AbsBaso-0.00*
___ 06:09AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 06:09AM BLOOD Plt Smr-NORMAL Plt ___
___ 06:09AM BLOOD Glucose-149* UreaN-46* Creat-2.3* Na-138
K-4.5 Cl-101 HCO3-28 AnGap-14
___ 06:09AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.8
___ 06:09AM BLOOD Cyclspr-PND
=============
MICROBIOLOGY
==============
___ 5:08 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
=========
IMAGING
=========
___ CHEST (PA & LAT)
FINDINGS:
There is minor right middle lobe atelectasis. No focal
consolidation is seen. No pleural effusion or pneumothorax is
seen. The cardiac and mediastinal silhouettes are stable. Right
upper quadrant surgical clips are seen, presumed prior
cholecystectomy.
IMPRESSION: No acute cardiopulmonary process.
___ CT ORBIT, SELLA & IAC W
IMPRESSION:
1. Pre-septal and periorbital soft tissue cellulitis without
drainable fluid collection or post-septal cellulitis.
___ CHEST (PORTABLE AP)
FINDINGS:
Compared to prior, there is a new right pleural effusion. There
is also
increased vascular congestion with mild pulmonary edema. There
is no
pneumothorax. Heart size is mildly enlarged.
IMPRESSION:
Mild pulmonary edema with a small right pleural effusion.
Brief Hospital Course:
___ with a history of ESRD s/p living renal transplant in ___
on immunosuppression, DM1, scleroderma/CREST, and CAD s/p MI
presenting with pre-septal cellulitis, course complicated by DKA
requiring MICU transfer, now with resolved DKA.
# DKA
The patient has a history of poorly controlled type 1 diabetes
with prior admissions for DKA. While on treatment for preseptal
cellulitis, she was found to have elevated blood sugars that
were non-responsive to subcutaneous insulin. She was transferred
to the MICU. Chem7 at 2300 on ___ showed glucose of 600, K of
5.2, HCO3 of 12, Gap of 25. She received an insulin bolus and
was started on a drip. She was also given bicarbonate. Her
glucose and gap improved on her insulin drip, so it was
discontinued. She was subsequently found to be hyperglycemic
again, so she was started on an insulin drip again, before
ultimately being transferred to subcutaneous insulin before her
transfer to the floor. Glucose was 103 and gap was 13 on
transfer to floor (___). She was followed by ___ while
inpatient, with adjustments made to her insulin regimen. Given
an episode of hypoglycemia one day prior to discharge, the
patient's insulin regimen was adjusted. She will follow up with
___ at her scheduled appointment within one week of
discharge.
# Pre-septal Cellulitis
Patient presented with right periorbital erythema without vision
changes from baseline and without pain on lateral gaze. She had
a CT scan which showed no orbital cellulitis. Ophthalmology was
consulted, who agreed that her presentation was consistent with
preseptal cellulitis. She was started on vancomycin and cefepime
on ___, given penicillin allergy. She did not have a reaction to
cefepime. She was later transitioned to
vancomycin/ceftriaxone/flagyl on ___, with improving
periorbital erythema and edema. MRSA screen was negative on
___, and vancomycin discontinued. On ___ she was transitioned
to cefpodoxime/flagyl in preparation for discharge with plan to
continue until her ID follow up appointment on ___.
# Leukopenia
On initial presentation, she was found to be leukopenic, in the
setting of a pre-septal cellulitis and immunosuppression. She
was treated with antibiotics as above, and her leukopenia
resolved. Her immunosuppressive medications were adjusted per
renal transplant recommendations. Her CBC with diff was trended.
Her leukopenia resolved prior to discharge. She will need her
CBC with diff checked within 1 week after discharge.
# ESRD s/p renal transplant w/metabolic acidosis (baseline Cr
1.8-2)
___ on CKD.
Patient presented with Cr of 2.2, which peaked at 2.9 in the
setting of DKA and infection. Her home mycophenylate was
stopped per renal transplant consult, and she was given IV
fluids and her DKA was treated as above. Her mycophenylate was
restarted at 250mg (half home dose) upon improvement of her DKA.
Her home cyclosporinge and prednisone were adjusted. Her home
calcitriol, bicarbonate, and calcium carbonate were continued.
CR lowered and stabilized at 2.3 on the floor. Her home dose of
MMF and prednisone were eventually resumed prior to discharge.
She was discharged on a lower dose of cyclosporine compared to
her home dose that she had previously been taking. She will need
her cyclosporine level to be checked within 1 week following
discharge with adjustments as indicated.
# Supine Hypertension with orthostasis
# Dysautonomia
The patient reported that this has been occurring for months,
likely secondary to her dysautonomia and potentially worsening
cardiac function. She was continued on home metoprolol. She was
started on QHS metoprolol tartrate to help with her supine
hypertension. She was also given support stockings as she wears
at home.
# Coronary Artery Disease s/p MI X2 and DES ___
She was continued on her home metoprolol, aspirin, atorvastatin,
cilostazol, ranolazine.
# Hyperlipidemia
She was continued on home atorvastatin.
# CREST
She was continued on home esomeprazole, metroclopramide, and
prochlorperazine
# Hypthyroidism
She was continued on home levothyroxine.
# History of Pulmonary Embolism
Patient had a history of provoked PE in 1990s, and was on
warfarin until last admission ___ at ___. Warfarin was
stopped given history of GI bleed on warfarin and negative
anti-cardiolipin AB on repeat check.
TRANSITIONAL ISSUES:
-treated preseptal cellulitis, discharged on cefpodoxime 200mg
q12h, flagyl 500mg q8h, with plan to continue PO abx until
scheduled ID follow-up on ___ at 10AM
-admitted to MICU for treatment of DKA in the setting of her
pre-septal cellulitis
-the patient's insulin regimen was adjusted per ___ recs. She
was discharged on a lower lantus dose compared to her home dose,
20U QAM with 8U at bedtime. Please adjust standing insulin
accordingly at ___ follow up appointment
-patient will need follow up labs drawn by ___ next week,
including CBC with diff, Chem 10, and cyclosporine level.
-the patient's cyclosporine dose was adjusted during her
hospitalization. She was discharged on 25mg q12h with plan to
recheck cyclosporine level on repeat labs next week. Please
follow up cyclosporine level and adjust accordingly.
-she was started on additional metoprolol QHS to help with her
supine hypertension. Please trend BP checks at outpatient follow
up visits
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 20 mg PO QPM
2. Calcitriol 0.25 mcg PO DAILY
3. CycloSPORINE (Sandimmune) 50 mg PO Q12H
4. Esomeprazole 40 mg Other BID
5. Furosemide 20 mg PO DAILY PRN WEIGHT GAIN weight gain
6. Glargine 22 Units Breakfast
Glargine 11 Units Bedtime
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Metoclopramide 10 mg PO QIDACHS
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Mycophenolate Mofetil 500 mg PO BID
11. PredniSONE 5 mg PO DAILY
12. Promethazine 25 mg PO DAILY PRN nausea
13. Ranolazine ER 500 mg PO BID
14. Ascorbic Acid ___ mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. Calcium Carbonate 500 mg PO BID
17. Ferrous Sulfate 325 mg PO DAILY
18. Vitamin D ___ UNIT PO DAILY
19. Cilostazol 100 mg PO QAM
20. Cilostazol 50 mg PO QPM
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
RX *dextran 70-hypromellose (PF) [Tears Naturale Free (PF)] 0.1
%-0.3 % ___ drops to eyes prn Disp #*1 Bottle Refills:*2
2. Cefpodoxime Proxetil 200 mg PO Q12H
please continue until follow up appointment with ID on ___
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*20 Tablet Refills:*0
3. Metoprolol Tartrate 12.5 mg PO QHS
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
at bedtime Disp #*30 Tablet Refills:*0
4. MetroNIDAZOLE 500 mg PO Q8H
please take until follow up appointment with ID on ___
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
5. Ondansetron 4 mg PO Q8H
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
6. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
please call your transplant doctor for medication adjustment
RX *cyclosporine modified 25 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*60 Capsule Refills:*0
7. Glargine 20 Units Breakfast
Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR
20 Units before BKFT; 8 Units before BED; Disp #*30 Syringe
Refills:*0
8. Ascorbic Acid ___ mg PO DAILY
RX *ascorbic acid (vitamin C) 500 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
9. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*0
11. Calcitriol 0.25 mcg PO DAILY
RX *calcitriol 0.25 mcg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
12. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth twice a day Disp #*60 Tablet Refills:*0
13. Cilostazol 100 mg PO QAM
RX *cilostazol 100 mg 1 tablet(s) by mouth QAM Disp #*30 Tablet
Refills:*0
14. Cilostazol 50 mg PO QPM
RX *cilostazol 50 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
15. Esomeprazole 40 mg Other BID
RX *esomeprazole magnesium 40 mg 1 capsule(s) by mouth twice a
day Disp #*60 Capsule Refills:*0
16. 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
17. Furosemide 20 mg PO DAILY PRN WEIGHT GAIN weight gain
RX *furosemide 20 mg 1 tablet(s) by mouth daily prn Disp #*30
Tablet Refills:*0
18. Levothyroxine Sodium 125 mcg PO DAILY
RX *levothyroxine 125 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
19. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
20. Mycophenolate Mofetil 500 mg PO BID
RX *mycophenolate mofetil 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
21. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
22. Promethazine 25 mg PO DAILY PRN nausea
RX *promethazine 25 mg 1 tablet by mouth daily prn Disp #*30
Tablet Refills:*0
23. Ranolazine ER 500 mg PO BID
RX *ranolazine [Ranexa] 500 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
24. Vitamin D ___ UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
25.Outpatient Lab Work
ICD 10: Z94.0 : Kidney transplant status
Chem 10, CBC with differential, Cyclosporine level
Date: please draw with ___ visit on ___ or ___
Please fax results to ___ at ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Preseptal Cellulitis
Diabetic Ketoacidosis (resolved)
End-stage renal disease with left-sided living kidney transplant
Diabetes Mellitus Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder
Hypertension
Autonomic Dysfunction/Dysautonomia
Secondary Diagnoses:
Dyslipidemia
Coronary Artery Disease
Scleroderma w/ CREST syndrome
Gastroparesis/GERD/Hiatal hernia
Gout
Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you. You were admitted because
of an infection in the skin around your eye, a condition called
pre-septal cellulitis. You were given antibiotics for this and
developed DKA during your treatment. You went to the MICU for
treatment of your DKA. You were given insulin and fluids and
your DKA eventually resolved. The swelling and redness around
your eye improved with IV antibiotic treatment. You were
discharged home with oral antibiotics to clear the infection.
Please continue to take all medications as prescribed, including
the oral antibiotics until your outpatient appointment with
Infectious Disease on ___. Please weigh yourself every morning,
call your doctor if weight goes up more than 3 lbs.
Please be sure to get your labs checked within one week of
hospital discharge. A prescription has been written for ___ to
draw your labs next week, with instructions to fax results to
Dr. ___.
We wish you the best in your health.
Sincerely,
Your ___ Team
Followup Instructions:
___
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Allergies: Penicillins / Ativan Chief Complaint: Right facial swelling Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] with a history of ESRD s/p living renal transplant in [MASKED] on immunosuppression, DM1, scleroderma/CREST, and CAD s/p MI presenting with pre-septal cellulitis, course complicated by DKA requiring MICU transfer, now with resolved DKA. The patient notes that when she woke on [MASKED], her eye felt swollen and had significant redness on skin around her eyelid. She notes that it worsened since that time, and was associated with clear, teary discharge and crusting. She does note antecedent rhinorrhea without sore, throat, cough or shortness of breath. She developed a fever at home up to 101.9 which prompted her to come in on [MASKED]. She states that her vision may be slightly more blurry, but does not feel significantly difference from her baseline blurry vision, given her diabetic retinopathy and prior laser surgeries. In the ED, her initial vitals were temp 99.4, HR 114, BP 127-64, RR 18, 98% on room air. Her labs were notable for WBC 1.8, Hg 10.3, platelets 227. Chem-7 Na 131, Cl 93, bicarb 18, BUN 36, Cr 2.2, and Lactate 1.7. She had a chest x ray notable for no acute cardiopulmonary process. She was given IV Cefepime, IV Vancomycin. She was seen by renal transplant who recommended isotonic bicarbonate 500cc/hour for two hours, given her slight elevation in Creatinine, as well as: -agree with optho consult -CXR, blood cx, urine cx, CMV VL -would cover broadly with IV vanc/ceftazidime -hold MMF tonight and in the AM, continue cyclosporine 50mg BID Optho consulted: Concern for pre-septal cellulitis. Low suspicion of orbital involvement given no pain with eye movements or proptosis. -Dilated fundus examination shows extensive PRP scarring with vitreous hemorrhage in the right eye that appears unchanged from her last examination. -recommended CT of the orbit -antibiotics - artificial tears as needed - No heavy lifting, bending, straining or activities with rapid head movement. - Follow-up with [MASKED] Ophthalmology as scheduled - Vitals prior to transfer: Temp. 98.7, HR 102, BP 134/68, RR 16, 100% RA ROS negative for SOB, chest pain, nausea, or diarrhea. Patient denies headache. She does endorse chronic nausea and vomiting on multiple PRN's for this. Notes this is stable. Past Medical History: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED] 3. OTHER PAST MEDICAL HISTORY End-stage renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] - Scleroderma w/ CREST syndrome - Gastroparesis/GERD/Hiatal hernia - Gout diagnosed [MASKED] years ago - OSA -NOT ACCURATE: - Antiphospholipid antibody syndrome and remote PE history on Coumadin [MASKED] - this diagnosis viewed unlikely per [MASKED] hematology/oncology note; warfarin discontinued [MASKED] Social History: [MASKED] Family History: Per OMR: Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: ======================== ADMISSION PHYSICAL EXAM ======================== VS: 99.6 PO 114 / 61 102 16 98 Ra GENERAL: Right eye erythematous with swelling. HEENT: EOMI, pain with eye movement CARDIAC: RRR PULMONARY: clear bilaterally, no wheezes or rubs ABDOMEN: soft, non-tender to palpation GENITOURINARY: no foley EXTREMITIES: no edema SKIN: no rash NEUROLOGIC: CN grossly intact ======================== DISCHARGE PHYSICAL EXAM ======================== Vitals: T 98.0, BP 180/77 (lying), HR 89, RR 18, [MASKED] 94 on room air General: Pleasant, well-appearing, lying in bed. HEENT: Atraumatic with improving erythema around right eyelid, now limited to ~1.5cm around upper/lower lids. Oropharynx clear. Neck: Supple with no lymphadenopathy or jugular venous distention Lungs: Clear to auscultation bilaterally CV: Regular rate/rhythm, with systolic ejection murmur heard best at lower sternal border. No rubs or gallops. Abdomen: Soft, nontender, nondistended Ext: Warm, well-perfused with 1+ pitting edema bilaterally. Neuro: Alert, oriented to self, place, time. Moving all extremities spontaneously and purposefully. Pertinent Results: =============== ADMISSION LABS =============== [MASKED] 11:38PM [MASKED] PO2-135* PCO2-29* PH-7.29* TOTAL CO2-15* BASE XS--10 COMMENTS-GREEN TOP [MASKED] 11:13PM GLUCOSE-601* UREA N-49* CREAT-2.5* SODIUM-125* POTASSIUM-5.2* CHLORIDE-88* TOTAL CO2-12* ANION GAP-30* [MASKED] 11:13PM CALCIUM-8.2* PHOSPHATE-5.2* MAGNESIUM-1.7 [MASKED] 04:31PM LACTATE-1.7 [MASKED] 04:30PM GLUCOSE-365* UREA N-36* CREAT-2.2* SODIUM-131* POTASSIUM-4.7 CHLORIDE-93* TOTAL CO2-18* ANION GAP-25* [MASKED] 04:30PM estGFR-Using this [MASKED] 04:30PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-1.7 [MASKED] 04:30PM WBC-1.8*# RBC-3.36* HGB-10.3* HCT-31.6* MCV-94 MCH-30.7 MCHC-32.6 RDW-13.0 RDWSD-44.5 [MASKED] 04:30PM NEUTS-3* BANDS-0 [MASKED] MONOS-65* EOS-0 BASOS-0 [MASKED] METAS-1* MYELOS-0 AbsNeut-0.05* AbsLymp-0.56* AbsMono-1.17* AbsEos-0.00* AbsBaso-0.00* [MASKED] 04:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL [MASKED] 04:30PM PLT SMR-NORMAL PLT COUNT-227 =============== DISCHARGE LABS =============== [MASKED] 06:09AM BLOOD WBC-3.8* RBC-3.36* Hgb-10.1* Hct-30.1* MCV-90 MCH-30.1 MCHC-33.6 RDW-13.9 RDWSD-45.4 Plt [MASKED] [MASKED] 06:09AM BLOOD Neuts-64 Bands-0 Lymphs-18* Monos-16* Eos-1 Baso-0 [MASKED] Myelos-1* NRBC-2* AbsNeut-2.43 AbsLymp-0.68* AbsMono-0.61 AbsEos-0.04 AbsBaso-0.00* [MASKED] 06:09AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [MASKED] 06:09AM BLOOD Plt Smr-NORMAL Plt [MASKED] [MASKED] 06:09AM BLOOD Glucose-149* UreaN-46* Creat-2.3* Na-138 K-4.5 Cl-101 HCO3-28 AnGap-14 [MASKED] 06:09AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.8 [MASKED] 06:09AM BLOOD Cyclspr-PND ============= MICROBIOLOGY ============== [MASKED] 5:08 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [MASKED] MRSA SCREEN (Final [MASKED]: No MRSA isolated. ========= IMAGING ========= [MASKED] CHEST (PA & LAT) FINDINGS: There is minor right middle lobe atelectasis. No focal consolidation is seen. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. Right upper quadrant surgical clips are seen, presumed prior cholecystectomy. IMPRESSION: No acute cardiopulmonary process. [MASKED] CT ORBIT, SELLA & IAC W IMPRESSION: 1. Pre-septal and periorbital soft tissue cellulitis without drainable fluid collection or post-septal cellulitis. [MASKED] CHEST (PORTABLE AP) FINDINGS: Compared to prior, there is a new right pleural effusion. There is also increased vascular congestion with mild pulmonary edema. There is no pneumothorax. Heart size is mildly enlarged. IMPRESSION: Mild pulmonary edema with a small right pleural effusion. Brief Hospital Course: [MASKED] with a history of ESRD s/p living renal transplant in [MASKED] on immunosuppression, DM1, scleroderma/CREST, and CAD s/p MI presenting with pre-septal cellulitis, course complicated by DKA requiring MICU transfer, now with resolved DKA. # DKA The patient has a history of poorly controlled type 1 diabetes with prior admissions for DKA. While on treatment for preseptal cellulitis, she was found to have elevated blood sugars that were non-responsive to subcutaneous insulin. She was transferred to the MICU. Chem7 at 2300 on [MASKED] showed glucose of 600, K of 5.2, HCO3 of 12, Gap of 25. She received an insulin bolus and was started on a drip. She was also given bicarbonate. Her glucose and gap improved on her insulin drip, so it was discontinued. She was subsequently found to be hyperglycemic again, so she was started on an insulin drip again, before ultimately being transferred to subcutaneous insulin before her transfer to the floor. Glucose was 103 and gap was 13 on transfer to floor ([MASKED]). She was followed by [MASKED] while inpatient, with adjustments made to her insulin regimen. Given an episode of hypoglycemia one day prior to discharge, the patient's insulin regimen was adjusted. She will follow up with [MASKED] at her scheduled appointment within one week of discharge. # Pre-septal Cellulitis Patient presented with right periorbital erythema without vision changes from baseline and without pain on lateral gaze. She had a CT scan which showed no orbital cellulitis. Ophthalmology was consulted, who agreed that her presentation was consistent with preseptal cellulitis. She was started on vancomycin and cefepime on [MASKED], given penicillin allergy. She did not have a reaction to cefepime. She was later transitioned to vancomycin/ceftriaxone/flagyl on [MASKED], with improving periorbital erythema and edema. MRSA screen was negative on [MASKED], and vancomycin discontinued. On [MASKED] she was transitioned to cefpodoxime/flagyl in preparation for discharge with plan to continue until her ID follow up appointment on [MASKED]. # Leukopenia On initial presentation, she was found to be leukopenic, in the setting of a pre-septal cellulitis and immunosuppression. She was treated with antibiotics as above, and her leukopenia resolved. Her immunosuppressive medications were adjusted per renal transplant recommendations. Her CBC with diff was trended. Her leukopenia resolved prior to discharge. She will need her CBC with diff checked within 1 week after discharge. # ESRD s/p renal transplant w/metabolic acidosis (baseline Cr 1.8-2) [MASKED] on CKD. Patient presented with Cr of 2.2, which peaked at 2.9 in the setting of DKA and infection. Her home mycophenylate was stopped per renal transplant consult, and she was given IV fluids and her DKA was treated as above. Her mycophenylate was restarted at 250mg (half home dose) upon improvement of her DKA. Her home cyclosporinge and prednisone were adjusted. Her home calcitriol, bicarbonate, and calcium carbonate were continued. CR lowered and stabilized at 2.3 on the floor. Her home dose of MMF and prednisone were eventually resumed prior to discharge. She was discharged on a lower dose of cyclosporine compared to her home dose that she had previously been taking. She will need her cyclosporine level to be checked within 1 week following discharge with adjustments as indicated. # Supine Hypertension with orthostasis # Dysautonomia The patient reported that this has been occurring for months, likely secondary to her dysautonomia and potentially worsening cardiac function. She was continued on home metoprolol. She was started on QHS metoprolol tartrate to help with her supine hypertension. She was also given support stockings as she wears at home. # Coronary Artery Disease s/p MI X2 and DES [MASKED] She was continued on her home metoprolol, aspirin, atorvastatin, cilostazol, ranolazine. # Hyperlipidemia She was continued on home atorvastatin. # CREST She was continued on home esomeprazole, metroclopramide, and prochlorperazine # Hypthyroidism She was continued on home levothyroxine. # History of Pulmonary Embolism Patient had a history of provoked PE in 1990s, and was on warfarin until last admission [MASKED] at [MASKED]. Warfarin was stopped given history of GI bleed on warfarin and negative anti-cardiolipin AB on repeat check. TRANSITIONAL ISSUES: -treated preseptal cellulitis, discharged on cefpodoxime 200mg q12h, flagyl 500mg q8h, with plan to continue PO abx until scheduled ID follow-up on [MASKED] at 10AM -admitted to MICU for treatment of DKA in the setting of her pre-septal cellulitis -the patient's insulin regimen was adjusted per [MASKED] recs. She was discharged on a lower lantus dose compared to her home dose, 20U QAM with 8U at bedtime. Please adjust standing insulin accordingly at [MASKED] follow up appointment -patient will need follow up labs drawn by [MASKED] next week, including CBC with diff, Chem 10, and cyclosporine level. -the patient's cyclosporine dose was adjusted during her hospitalization. She was discharged on 25mg q12h with plan to recheck cyclosporine level on repeat labs next week. Please follow up cyclosporine level and adjust accordingly. -she was started on additional metoprolol QHS to help with her supine hypertension. Please trend BP checks at outpatient follow up visits Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atorvastatin 20 mg PO QPM 2. Calcitriol 0.25 mcg PO DAILY 3. CycloSPORINE (Sandimmune) 50 mg PO Q12H 4. Esomeprazole 40 mg Other BID 5. Furosemide 20 mg PO DAILY PRN WEIGHT GAIN weight gain 6. Glargine 22 Units Breakfast Glargine 11 Units Bedtime 7. Levothyroxine Sodium 125 mcg PO DAILY 8. Metoclopramide 10 mg PO QIDACHS 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Mycophenolate Mofetil 500 mg PO BID 11. PredniSONE 5 mg PO DAILY 12. Promethazine 25 mg PO DAILY PRN nausea 13. Ranolazine ER 500 mg PO BID 14. Ascorbic Acid [MASKED] mg PO DAILY 15. Aspirin 81 mg PO DAILY 16. Calcium Carbonate 500 mg PO BID 17. Ferrous Sulfate 325 mg PO DAILY 18. Vitamin D [MASKED] UNIT PO DAILY 19. Cilostazol 100 mg PO QAM 20. Cilostazol 50 mg PO QPM Discharge Medications: 1. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes RX *dextran 70-hypromellose (PF) [Tears Naturale Free (PF)] 0.1 %-0.3 % [MASKED] drops to eyes prn Disp #*1 Bottle Refills:*2 2. Cefpodoxime Proxetil 200 mg PO Q12H please continue until follow up appointment with ID on [MASKED] RX *cefpodoxime 200 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*20 Tablet Refills:*0 3. Metoprolol Tartrate 12.5 mg PO QHS RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 4. MetroNIDAZOLE 500 mg PO Q8H please take until follow up appointment with ID on [MASKED] RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 5. Ondansetron 4 mg PO Q8H RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 6. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H please call your transplant doctor for medication adjustment RX *cyclosporine modified 25 mg 1 capsule(s) by mouth every twelve (12) hours Disp #*60 Capsule Refills:*0 7. Glargine 20 Units Breakfast Glargine 8 Units Bedtime Insulin SC Sliding Scale using HUM Insulin RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR 20 Units before BKFT; 8 Units before BED; Disp #*30 Syringe Refills:*0 8. Ascorbic Acid [MASKED] mg PO DAILY RX *ascorbic acid (vitamin C) 500 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Atorvastatin 20 mg PO QPM RX *atorvastatin 20 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet Refills:*0 11. Calcitriol 0.25 mcg PO DAILY RX *calcitriol 0.25 mcg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 12. Calcium Carbonate 500 mg PO BID RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 13. Cilostazol 100 mg PO QAM RX *cilostazol 100 mg 1 tablet(s) by mouth QAM Disp #*30 Tablet Refills:*0 14. Cilostazol 50 mg PO QPM RX *cilostazol 50 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet Refills:*0 15. Esomeprazole 40 mg Other BID RX *esomeprazole magnesium 40 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 16. 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 17. Furosemide 20 mg PO DAILY PRN WEIGHT GAIN weight gain RX *furosemide 20 mg 1 tablet(s) by mouth daily prn Disp #*30 Tablet Refills:*0 18. Levothyroxine Sodium 125 mcg PO DAILY RX *levothyroxine 125 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 19. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 20. Mycophenolate Mofetil 500 mg PO BID RX *mycophenolate mofetil 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 21. PredniSONE 5 mg PO DAILY RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 22. Promethazine 25 mg PO DAILY PRN nausea RX *promethazine 25 mg 1 tablet by mouth daily prn Disp #*30 Tablet Refills:*0 23. Ranolazine ER 500 mg PO BID RX *ranolazine [Ranexa] 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 24. Vitamin D [MASKED] UNIT PO DAILY RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 25.Outpatient Lab Work ICD 10: Z94.0 : Kidney transplant status Chem 10, CBC with differential, Cyclosporine level Date: please draw with [MASKED] visit on [MASKED] or [MASKED] Please fax results to [MASKED] at [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary Diagnoses: Preseptal Cellulitis Diabetic Ketoacidosis (resolved) End-stage renal disease with left-sided living kidney transplant Diabetes Mellitus Type 1 complicated by neuropathy, retinopathy, neurogenic bladder Hypertension Autonomic Dysfunction/Dysautonomia Secondary Diagnoses: Dyslipidemia Coronary Artery Disease Scleroderma w/ CREST syndrome Gastroparesis/GERD/Hiatal hernia Gout Obstructive Sleep Apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], [MASKED] was a pleasure taking care of you. You were admitted because of an infection in the skin around your eye, a condition called pre-septal cellulitis. You were given antibiotics for this and developed DKA during your treatment. You went to the MICU for treatment of your DKA. You were given insulin and fluids and your DKA eventually resolved. The swelling and redness around your eye improved with IV antibiotic treatment. You were discharged home with oral antibiotics to clear the infection. Please continue to take all medications as prescribed, including the oral antibiotics until your outpatient appointment with Infectious Disease on [MASKED]. Please weigh yourself every morning, call your doctor if weight goes up more than 3 lbs. Please be sure to get your labs checked within one week of hospital discharge. A prescription has been written for [MASKED] to draw your labs next week, with instructions to fax results to Dr. [MASKED]. We wish you the best in your health. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"I130",
"I129",
"N189",
"Z87891",
"Z794",
"J45909",
"F329",
"K219",
"E039",
"I2510",
"G4733",
"Z955"
] |
[
"L03213: Periorbital cellulitis",
"E1010: Type 1 diabetes mellitus with ketoacidosis without coma",
"T8619: Other complication of kidney transplant",
"N179: Acute kidney failure, unspecified",
"D702: Other drug-induced agranulocytosis",
"I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"I509: Heart failure, unspecified",
"N183: Chronic kidney disease, stage 3 (moderate)",
"M341: CR(E)ST syndrome",
"Z940: Kidney transplant status",
"N2581: Secondary hyperparathyroidism of renal origin",
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"K3184: Gastroparesis",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"E103593: Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral",
"E10610: Type 1 diabetes mellitus with diabetic neuropathic arthropathy",
"N189: Chronic kidney disease, unspecified",
"Z87891: Personal history of nicotine dependence",
"Z794: Long term (current) use of insulin",
"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",
"Y92239: Unspecified place in hospital as the place of occurrence of the external cause",
"D703: Neutropenia due to infection",
"E1065: Type 1 diabetes mellitus with hyperglycemia",
"H25013: Cortical age-related cataract, bilateral",
"J45909: Unspecified asthma, uncomplicated",
"I951: Orthostatic hypotension",
"E7800: Pure hypercholesterolemia, unspecified",
"H4311: Vitreous hemorrhage, right eye",
"N318: Other neuromuscular dysfunction of bladder",
"F329: Major depressive disorder, single episode, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"E039: Hypothyroidism, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"G3184: Mild cognitive impairment, so stated",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"Z955: Presence of coronary angioplasty implant and graft",
"Z86711: Personal history of pulmonary embolism",
"T361X5A: Adverse effect of cephalosporins and other beta-lactam antibiotics, initial encounter"
] |
10,030,753
| 25,110,668
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH significant for antiphospholipid syndrome, history of PE
on warfarin, and poorly-controlled T1DM complicated by
retinopathy, neuropathy with gastroparesis and neurogenic
bladder and ESRD status post living kidney transplant in ___ on
MMF, tacrolimus, prednisone, several artery CAD s/p MI in ___
and ___ and 3 drug-eluting stents placed in ___ who
presents with recurrent episodes of chest pain for three days.
Patient described episode of right-sided chest pain on ___
(___) night while at rest lying in bed. Pain did not radiate
anywhere and was resolved with 1 dose of NTG. She reported
suffering similar episode subsequently on ___ and ___
night as well, each time resolving with one dose of NTG. She
called her cardiologist who recommended she come to ED for
evaluation. She also endorsed SOB during these episodes of chest
pain. Denied any other symptoms of chest pain with exertion
during this time. In general, patient endorsed nocturnal dyspnea
and orthopnea and sleeps on many pillows at night. She denied
any additional swelling in her legs.
Of note, she had recently been admitted to transplant nephrology
service from ___ to ___ after a traumatic fall resulting in
vitreous and retinal hemorrhage in left eye. Since then she has
complained of persistent "floaters" in her eyes.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___,
DES to LAD and Cx/OM ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization) - End-stage renal disease ___ diabetes s/p
L-sided living kidney transplant in ___
- Scleroderma w/ CREST syndrome
- Antiphospholipid antibody syndrome and remote PE history on
Coumadin ___
- Gastroparesis/GERD/Hiatal hernia
- Gout diagnosed ___ years ago
- OSA
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Physical Exam:
ACCEPT PHYSICAL EXAM
VS: Tc 98.4, BP 144/64, HR 106, RR 18, SaO2 98%RA
GENERAL: woman sitting in bed with bruises on face
HEENT: EOMI; fundoscopy: red reflex bilaterally; hemorrhage
noted on R side, blurring visualization of disc, blurred disc
margins on L; OP clear; bruising along face
LUNGS: CTAB
CARDIAC: RRR, harsh systolic murmur ___ heard at apex; no
carotid bruits; no r/g
ABDOMEN: BS+, soft, nontender, slightly distended, scar left of
umbilicus well-healed; renal transplant placed in LLQ
EXTREMITIES: no sensation past knee bilaterally; distal pulses
not easily palpable, extremities warm
DISCHARGE PHYSICAL EXAM
VS: Tc 98, BP 181/80, HR 95, RR 18, SaO2 98%RA
GENERAL: woman sitting in bed with bruises on face
HEENT: OP clear; bruising along face
LUNGS: CTAB
CARDIAC: RRR, harsh systolic murmur ___ heard at apex; no
carotid bruits; no r/g
ABDOMEN: BS+, soft, nontender, slightly distended, scar left of
umbilicus well-healed; renal transplant placed in LLQ
EXTREMITIES: no sensation past knee bilaterally; distal pulses
not easily palpable, extremities warm. 1+ edema
Pertinent Results:
ADMISSION LABS:
___ 07:00PM BLOOD WBC-5.7 RBC-3.13* Hgb-9.2* Hct-28.8*
MCV-92 MCH-29.4 MCHC-31.9* RDW-14.7 RDWSD-49.2* Plt ___
___ 07:00PM BLOOD Neuts-83.8* Lymphs-5.4* Monos-8.0 Eos-2.4
Baso-0.2 Im ___ AbsNeut-4.80 AbsLymp-0.31* AbsMono-0.46
AbsEos-0.14 AbsBaso-0.01
___ 07:00PM BLOOD ___ PTT-45.6* ___
___ 07:00PM BLOOD Glucose-238* UreaN-17 Creat-1.5* Na-140
K-3.9 Cl-106 HCO3-26 AnGap-12
___ 07:00PM BLOOD CK(CPK)-145
___ 07:00PM BLOOD CK-MB-5 proBNP-1731*
___ 07:00PM BLOOD cTropnT-0.10*'
DISCHARGE LABS:
___ 06:00AM BLOOD Albumin-3.6 Calcium-9.4 Phos-3.3 Mg-1.5*
___ 04:01PM BLOOD Lactate-2.0
___ 06:10AM BLOOD WBC-6.6 RBC-2.98* Hgb-8.8* Hct-28.6*
MCV-96 MCH-29.5 MCHC-30.8* RDW-14.6 RDWSD-51.6* Plt ___
___ 06:10AM BLOOD ___ PTT-41.1* ___
___ 06:10AM BLOOD Glucose-265* UreaN-22* Creat-1.5* Na-142
K-4.2 Cl-110* HCO3-22 AnGap-14
___ 03:01PM BLOOD cTropnT-0.09*
___ 06:10AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.0
___ 06:10AM BLOOD tacroFK-3.9*
IMAGING:
CT HEAD
___
No acute intracranial abnormality
EKG:
___
Rate 104, rhythm sinus, normal axis, QTc 471, nearly biphasic T
wave in V2, Q wave in III
MICRO:
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
___ with CAD s/p multiple PCIs most recently in ___,
poorly-controlled DM1, ESRD s/p LRRT on immunosuppression and
APLS presenting with recurrent chest pain relieved by
nitroglycerin. Found to have asymptomatic bacteriuria.
- CORONARIES: LMCA clean. LAD with DES. Cx/OM with DES. Diagonal
50-60% stenosis. LPL branch with mid/distal 60% stenosis.
- PUMP: normal EF
- RHYTHM: sinus
# Angina: patient with chest pain occurring at rest, multiple
times, relieved by nitroglycerin, concerning for unstable angina
(ACS). No chest pain in over 24 hours at this time. She did have
evidence of troponin leak with troponin 0.10, which is above
baseline for similar renal function. Her troponins downtrended
and stabilized. She recently had PCI to LAD and Cx/OM with DES,
on warfarin, aspirin and Plavix. Cardiac catheterization at the
time showed evidence of multi-vessel CAD, but patient preferred
multiple PCIs over CABG. DDx: microvascular disease vs.
restenosis of stent vs. progressive stenosis due to CAD. Given
recent onset of symptoms following stent placement and results
of recent catheterization, most likely diagnosis is angina from
microvascular disease, likely secondary to T1DM. Catheterization
was initially deferred given unlikely active ACS based on recent
cath images. An attempt was made to start her on isosorbide
dinitrate for angina but patient did not tolerate secondary to
hypotension and confusion (see below). Her anginal symptoms were
treated with Ranolazine instead. She was continued on aspirin
and Plavix, warfarin (one dose held given initial possible
cath), statin, and metoprolol. Patient having some trouble not
vomiting up pills at home, but was counseled on importance of
focusing on ASA/Plavix and anti-rejection meds.
#UTI, Bacteriuria: Noted to have bactiuria in urinalysis on ___
but asymptomatic. However, because patient has renal transplant,
must be treated even for asymptomatic bacteriuria. She also had
recent UTI but likely did not receive full tx course given
vomiting pills at home. Started on ceftriaxone instead of cipro
given concern for long qt on EKG on ___ (QTc 471). Recently
treated for UTI with cipro, but couldn't complete treatment
course because of nausea/vomiting likely secondary to
gastroparesis. She received 1 dose fosfomycin prior to
discharge. Urine culture is pending.
# Hypertension: SBP in 180s noted but was not symptomatic. Plan
is to medically manage blood pressure in a way that does not
cause hypotensive symptoms. Goal for renal transplant is BP <
140/80 unless there is significant proteinuria, in which case
goal is 130/80. Urinalysis on ___ shows some proteinuria, so
___ consider protein:Cr ratio in outpatient setting. She was
continued on amlodipine 2.5mg PO daily, losartan 50mg PO daily,
and home metoprolol (see below).
# ESRD s/p LRRT complicated by CKD, likely secondary to diabetic
nephropathy: baseline Cr is approximately 1.3-1.5, no signs of
current problem with her graft. She was continued on tacrolimus
1mg PO q12hrs, prednisone 5mg PO daily, MMF 500mg PO BID,
Bactrim ppx and calcitriol
# Hypotension, lethargy, confusion: afternoon of ___, after
receiving isosorbide dinitrate, patient had relative
hypotension, lethargy, and confusion while eating lunch. FSG
initially 133 but continued to decrease to 58. Lay down and
received 1L IVF and started to feel better but then had
recurrence 30 minutes later and was found to have low BS and
stable BP ~105. Subsequently had BP to high ___. Suspected
reaction to long-acting nitrate and insulin. Non-contrast head
CT on ___ normal. Isosorbide dinitrate was discontinued and
decreased Metop back to home dose (had attempted to increase to
25 BID). She was given 2.5L IV fluids. Decreased insulin to
___ recs from previous admissions; her insulin should be
titrated as an outpatient.
# DM1: Hgb A1C 9.3% (___). patient was managed on glargine
and Humalog sliding scale. Her home sliding scale is
(BG-130)/17. Initially started on Glargine 36U QAM and 16U QPM,
which was decreased to 26qAM & 10qHS after hypoglycemic episode.
She was continued on promethazine for nausea as well as
duloxetine, gabapentin and lidocaine patches for diabetic
neuropathy. She should have outpatient titration of insulin
# Gastroparesis: Pt with vomiting with solid foods x 10 days.
Has no trouble with PO liquids. She was noted to have long QT
(471 on ___ that later improved, but Zofran was avoided.
# History of PE, APLAS: continue warfarin, goal INR ___.
Restarted warfarin (had been held in anticipation of Cath)
# PAD: continued home cilostazol.
# Anemia: At recent baseline, but previously 13 >6mo ago
# GERD: continued ranitidine. Replace esomeprzole with
omeprazole while inpatient.
# Hypothyroidism: continued levothyroxine.
# Floaters: Has recent vitreous/retinal hemorrhage from truama.
Patient was complaining of worsening floaters transiently while
BP was low. Patient should have outpatient follow-up with
ophthalmology
# Gout: continued allopurinol, dose reduced for renal function.
# CODE: Full
# CONTACT: Patient, HCP sister ___ ___
TRANSITIONAL ISSUES:
=============================
- Patient should have ophtho follow up for vitreous/retinal
hemorrhage
- Pt had hypoglycemic episode to 58 and recent A1C of >9%.
Recommend follow up with endocrinology for insulin titration.
- Concern that patient ___ not be getting all meds ___
gastroparesis. Further outpatient nausea management recommended.
Note that patient had QTc to 470s inpatient, although improved
on discharge.
- Patient had confusion and hypotension when given isosorbide
dinitrate. ___ have been situational given dehydration, but this
medication should be used with caution if needed
- Urine and blood cultures pending on discharge
- Started on Ranolazine for angina
- Patient should be checking blood pressures at home daily or as
symptomatic
- tacro dose increased to 1.5mg BID given low levels in
hospital; to have labs at transplant level on ___ to have
level checked
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Calcitriol 0.25 mcg PO DAILY
5. Cilostazol 100 mg PO QAM
6. Clopidogrel 75 mg PO DAILY
7. DULoxetine 60 mg PO DAILY
8. Gabapentin 100 mg PO QHS
9. HYDROcodone-acetaminophen ___ mg ORAL Q4H:PRN pain
10. Levothyroxine Sodium 125 mcg PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD QPM
12. Mycophenolate Mofetil 500 mg PO BID
13. Pramipexole 0.25 mg PO QHS
14. PredniSONE 5 mg PO DAILY
15. Promethazine 25 mg PO BID nausea or vomiting
16. Promethazine 25 mg PR Q6H:PRN nausea or vomiting
17. Ranitidine 300 mg PO QHS
18. Tacrolimus 1 mg PO Q12H
19. TraZODone 50 mg PO QHS
20. Vitamin D 400 UNIT PO DAILY
21. Warfarin 2.5 mg PO DAILY16
22. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
23. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
24. Esomeprazole Magnesium 40 mg ORAL BID
25. melatonin 5 mg po Q24H
26. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN
27. alpha lipoic acid ___ mg oral DAILY
28. Losartan Potassium 50 mg PO DAILY
29. Metoprolol Succinate XL 25 mg PO DAILY
30. Lidocaine 5% Patch 1 PTCH TD QPM
31. Promethazine 25 mg PO Q6H:PRN nausea, vomiting
32. Cilostazol 50 mg PO QPM
33. Glargine 26 Units Breakfast
Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
34. amLODIPine 2.5 mg PO DAILY
Discharge Medications:
1. Ranolazine ER 500 mg PO BID
RX *ranolazine [Ranexa] 500 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Allopurinol ___ mg PO DAILY
3. amLODIPine 2.5 mg PO DAILY
4. Aspirin EC 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Calcitriol 0.25 mcg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Warfarin 2.5 mg PO DAILY16
9. TraZODone 50 mg PO QHS
10. Ranitidine 300 mg PO QHS
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
12. DULoxetine 60 mg PO DAILY
13. Gabapentin 100 mg PO QHS
14. HYDROcodone-acetaminophen ___ mg ORAL Q4H:PRN pain
15. Levothyroxine Sodium 125 mcg PO DAILY
16. Lidocaine 5% Patch 1 PTCH TD QPM
17. Lidocaine 5% Patch 1 PTCH TD QPM
18. Losartan Potassium 50 mg PO DAILY
19. Mycophenolate Mofetil 500 mg PO BID
20. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
21. Pramipexole 0.25 mg PO QHS
22. PredniSONE 5 mg PO DAILY
23. Promethazine 25 mg PO BID nausea or vomiting
24. Cilostazol 100 mg PO QAM
25. Cilostazol 50 mg PO QPM
26. Metoprolol Succinate XL 25 mg PO DAILY
27. Esomeprazole Magnesium 40 mg ORAL BID
28. alpha lipoic acid ___ mg oral DAILY
29. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN
30. melatonin 5 mg po Q24H
31. Promethazine 25 mg PR Q6H:PRN nausea or vomiting
32. Promethazine 25 mg PO Q6H:PRN nausea, vomiting
33. Vitamin D 400 UNIT PO DAILY
34. Glargine 26 Units Breakfast
Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
35. Tacrolimus 1.5 mg PO BID
RX *tacrolimus 0.5 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Angina
UTI
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ for your chest pain. In reviewing your
imaging from your images from your angiography last month, it is
unlikely that you are having coronary disease that would require
re-catheterization. We started you on a long-acting nitrate
(isosorbide dinitrate) to help with your symptoms, however this
caused an unsafe drop in your blood pressure. Although this
blood pressure drop was likely exacerbated by your recent
dehydration from vomiting, you should let future providers know
about this episode if you are prescribed it again.
We also recommend that you monitor your blood pressure at home.
Because you were unable to tolerate the isosorbide, we started
you on a different medication, ranolazine, to help with your
chest pain. It is really important that you continue to take
your aspirin and Plavix as well as your immunosuppressants.
Please call your primary care doctor if you feel that you are
unable to keep these medications down.
We have also set up follow up with endocrinology, ophthalmology,
and your cardiologist in the next couple of weeks. Your primary
care physician should call you with an appointment as well.
Please take your medications as prescribed and follow up at your
outpatient appointments.
We wish you the best in your health,
Your ___ team
Followup Instructions:
___
|
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] |
Allergies: Penicillins / Ativan Chief Complaint: chest pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] PMH significant for antiphospholipid syndrome, history of PE on warfarin, and poorly-controlled T1DM complicated by retinopathy, neuropathy with gastroparesis and neurogenic bladder and ESRD status post living kidney transplant in [MASKED] on MMF, tacrolimus, prednisone, several artery CAD s/p MI in [MASKED] and [MASKED] and 3 drug-eluting stents placed in [MASKED] who presents with recurrent episodes of chest pain for three days. Patient described episode of right-sided chest pain on [MASKED] ([MASKED]) night while at rest lying in bed. Pain did not radiate anywhere and was resolved with 1 dose of NTG. She reported suffering similar episode subsequently on [MASKED] and [MASKED] night as well, each time resolving with one dose of NTG. She called her cardiologist who recommended she come to ED for evaluation. She also endorsed SOB during these episodes of chest pain. Denied any other symptoms of chest pain with exertion during this time. In general, patient endorsed nocturnal dyspnea and orthopnea and sleeps on many pillows at night. She denied any additional swelling in her legs. Of note, she had recently been admitted to transplant nephrology service from [MASKED] to [MASKED] after a traumatic fall resulting in vitreous and retinal hemorrhage in left eye. Since then she has complained of persistent "floaters" in her eyes. Past Medical History: 1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA [MASKED], DES to LAD and Cx/OM [MASKED] - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) - End-stage renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] - Scleroderma w/ CREST syndrome - Antiphospholipid antibody syndrome and remote PE history on Coumadin [MASKED] - Gastroparesis/GERD/Hiatal hernia - Gout diagnosed [MASKED] years ago - OSA Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Physical Exam: ACCEPT PHYSICAL EXAM VS: Tc 98.4, BP 144/64, HR 106, RR 18, SaO2 98%RA GENERAL: woman sitting in bed with bruises on face HEENT: EOMI; fundoscopy: red reflex bilaterally; hemorrhage noted on R side, blurring visualization of disc, blurred disc margins on L; OP clear; bruising along face LUNGS: CTAB CARDIAC: RRR, harsh systolic murmur [MASKED] heard at apex; no carotid bruits; no r/g ABDOMEN: BS+, soft, nontender, slightly distended, scar left of umbilicus well-healed; renal transplant placed in LLQ EXTREMITIES: no sensation past knee bilaterally; distal pulses not easily palpable, extremities warm DISCHARGE PHYSICAL EXAM VS: Tc 98, BP 181/80, HR 95, RR 18, SaO2 98%RA GENERAL: woman sitting in bed with bruises on face HEENT: OP clear; bruising along face LUNGS: CTAB CARDIAC: RRR, harsh systolic murmur [MASKED] heard at apex; no carotid bruits; no r/g ABDOMEN: BS+, soft, nontender, slightly distended, scar left of umbilicus well-healed; renal transplant placed in LLQ EXTREMITIES: no sensation past knee bilaterally; distal pulses not easily palpable, extremities warm. 1+ edema Pertinent Results: ADMISSION LABS: [MASKED] 07:00PM BLOOD WBC-5.7 RBC-3.13* Hgb-9.2* Hct-28.8* MCV-92 MCH-29.4 MCHC-31.9* RDW-14.7 RDWSD-49.2* Plt [MASKED] [MASKED] 07:00PM BLOOD Neuts-83.8* Lymphs-5.4* Monos-8.0 Eos-2.4 Baso-0.2 Im [MASKED] AbsNeut-4.80 AbsLymp-0.31* AbsMono-0.46 AbsEos-0.14 AbsBaso-0.01 [MASKED] 07:00PM BLOOD [MASKED] PTT-45.6* [MASKED] [MASKED] 07:00PM BLOOD Glucose-238* UreaN-17 Creat-1.5* Na-140 K-3.9 Cl-106 HCO3-26 AnGap-12 [MASKED] 07:00PM BLOOD CK(CPK)-145 [MASKED] 07:00PM BLOOD CK-MB-5 proBNP-1731* [MASKED] 07:00PM BLOOD cTropnT-0.10*' DISCHARGE LABS: [MASKED] 06:00AM BLOOD Albumin-3.6 Calcium-9.4 Phos-3.3 Mg-1.5* [MASKED] 04:01PM BLOOD Lactate-2.0 [MASKED] 06:10AM BLOOD WBC-6.6 RBC-2.98* Hgb-8.8* Hct-28.6* MCV-96 MCH-29.5 MCHC-30.8* RDW-14.6 RDWSD-51.6* Plt [MASKED] [MASKED] 06:10AM BLOOD [MASKED] PTT-41.1* [MASKED] [MASKED] 06:10AM BLOOD Glucose-265* UreaN-22* Creat-1.5* Na-142 K-4.2 Cl-110* HCO3-22 AnGap-14 [MASKED] 03:01PM BLOOD cTropnT-0.09* [MASKED] 06:10AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.0 [MASKED] 06:10AM BLOOD tacroFK-3.9* IMAGING: CT HEAD [MASKED] No acute intracranial abnormality EKG: [MASKED] Rate 104, rhythm sinus, normal axis, QTc 471, nearly biphasic T wave in V2, Q wave in III MICRO: **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Brief Hospital Course: [MASKED] with CAD s/p multiple PCIs most recently in [MASKED], poorly-controlled DM1, ESRD s/p LRRT on immunosuppression and APLS presenting with recurrent chest pain relieved by nitroglycerin. Found to have asymptomatic bacteriuria. - CORONARIES: LMCA clean. LAD with DES. Cx/OM with DES. Diagonal 50-60% stenosis. LPL branch with mid/distal 60% stenosis. - PUMP: normal EF - RHYTHM: sinus # Angina: patient with chest pain occurring at rest, multiple times, relieved by nitroglycerin, concerning for unstable angina (ACS). No chest pain in over 24 hours at this time. She did have evidence of troponin leak with troponin 0.10, which is above baseline for similar renal function. Her troponins downtrended and stabilized. She recently had PCI to LAD and Cx/OM with DES, on warfarin, aspirin and Plavix. Cardiac catheterization at the time showed evidence of multi-vessel CAD, but patient preferred multiple PCIs over CABG. DDx: microvascular disease vs. restenosis of stent vs. progressive stenosis due to CAD. Given recent onset of symptoms following stent placement and results of recent catheterization, most likely diagnosis is angina from microvascular disease, likely secondary to T1DM. Catheterization was initially deferred given unlikely active ACS based on recent cath images. An attempt was made to start her on isosorbide dinitrate for angina but patient did not tolerate secondary to hypotension and confusion (see below). Her anginal symptoms were treated with Ranolazine instead. She was continued on aspirin and Plavix, warfarin (one dose held given initial possible cath), statin, and metoprolol. Patient having some trouble not vomiting up pills at home, but was counseled on importance of focusing on ASA/Plavix and anti-rejection meds. #UTI, Bacteriuria: Noted to have bactiuria in urinalysis on [MASKED] but asymptomatic. However, because patient has renal transplant, must be treated even for asymptomatic bacteriuria. She also had recent UTI but likely did not receive full tx course given vomiting pills at home. Started on ceftriaxone instead of cipro given concern for long qt on EKG on [MASKED] (QTc 471). Recently treated for UTI with cipro, but couldn't complete treatment course because of nausea/vomiting likely secondary to gastroparesis. She received 1 dose fosfomycin prior to discharge. Urine culture is pending. # Hypertension: SBP in 180s noted but was not symptomatic. Plan is to medically manage blood pressure in a way that does not cause hypotensive symptoms. Goal for renal transplant is BP < 140/80 unless there is significant proteinuria, in which case goal is 130/80. Urinalysis on [MASKED] shows some proteinuria, so [MASKED] consider protein:Cr ratio in outpatient setting. She was continued on amlodipine 2.5mg PO daily, losartan 50mg PO daily, and home metoprolol (see below). # ESRD s/p LRRT complicated by CKD, likely secondary to diabetic nephropathy: baseline Cr is approximately 1.3-1.5, no signs of current problem with her graft. She was continued on tacrolimus 1mg PO q12hrs, prednisone 5mg PO daily, MMF 500mg PO BID, Bactrim ppx and calcitriol # Hypotension, lethargy, confusion: afternoon of [MASKED], after receiving isosorbide dinitrate, patient had relative hypotension, lethargy, and confusion while eating lunch. FSG initially 133 but continued to decrease to 58. Lay down and received 1L IVF and started to feel better but then had recurrence 30 minutes later and was found to have low BS and stable BP ~105. Subsequently had BP to high [MASKED]. Suspected reaction to long-acting nitrate and insulin. Non-contrast head CT on [MASKED] normal. Isosorbide dinitrate was discontinued and decreased Metop back to home dose (had attempted to increase to 25 BID). She was given 2.5L IV fluids. Decreased insulin to [MASKED] recs from previous admissions; her insulin should be titrated as an outpatient. # DM1: Hgb A1C 9.3% ([MASKED]). patient was managed on glargine and Humalog sliding scale. Her home sliding scale is (BG-130)/17. Initially started on Glargine 36U QAM and 16U QPM, which was decreased to 26qAM & 10qHS after hypoglycemic episode. She was continued on promethazine for nausea as well as duloxetine, gabapentin and lidocaine patches for diabetic neuropathy. She should have outpatient titration of insulin # Gastroparesis: Pt with vomiting with solid foods x 10 days. Has no trouble with PO liquids. She was noted to have long QT (471 on [MASKED] that later improved, but Zofran was avoided. # History of PE, APLAS: continue warfarin, goal INR [MASKED]. Restarted warfarin (had been held in anticipation of Cath) # PAD: continued home cilostazol. # Anemia: At recent baseline, but previously 13 >6mo ago # GERD: continued ranitidine. Replace esomeprzole with omeprazole while inpatient. # Hypothyroidism: continued levothyroxine. # Floaters: Has recent vitreous/retinal hemorrhage from truama. Patient was complaining of worsening floaters transiently while BP was low. Patient should have outpatient follow-up with ophthalmology # Gout: continued allopurinol, dose reduced for renal function. # CODE: Full # CONTACT: Patient, HCP sister [MASKED] [MASKED] TRANSITIONAL ISSUES: ============================= - Patient should have ophtho follow up for vitreous/retinal hemorrhage - Pt had hypoglycemic episode to 58 and recent A1C of >9%. Recommend follow up with endocrinology for insulin titration. - Concern that patient [MASKED] not be getting all meds [MASKED] gastroparesis. Further outpatient nausea management recommended. Note that patient had QTc to 470s inpatient, although improved on discharge. - Patient had confusion and hypotension when given isosorbide dinitrate. [MASKED] have been situational given dehydration, but this medication should be used with caution if needed - Urine and blood cultures pending on discharge - Started on Ranolazine for angina - Patient should be checking blood pressures at home daily or as symptomatic - tacro dose increased to 1.5mg BID given low levels in hospital; to have labs at transplant level on [MASKED] to have level checked Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Aspirin EC 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Calcitriol 0.25 mcg PO DAILY 5. Cilostazol 100 mg PO QAM 6. Clopidogrel 75 mg PO DAILY 7. DULoxetine 60 mg PO DAILY 8. Gabapentin 100 mg PO QHS 9. HYDROcodone-acetaminophen [MASKED] mg ORAL Q4H:PRN pain 10. Levothyroxine Sodium 125 mcg PO DAILY 11. Lidocaine 5% Patch 1 PTCH TD QPM 12. Mycophenolate Mofetil 500 mg PO BID 13. Pramipexole 0.25 mg PO QHS 14. PredniSONE 5 mg PO DAILY 15. Promethazine 25 mg PO BID nausea or vomiting 16. Promethazine 25 mg PR Q6H:PRN nausea or vomiting 17. Ranitidine 300 mg PO QHS 18. Tacrolimus 1 mg PO Q12H 19. TraZODone 50 mg PO QHS 20. Vitamin D 400 UNIT PO DAILY 21. Warfarin 2.5 mg PO DAILY16 22. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 23. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 24. Esomeprazole Magnesium 40 mg ORAL BID 25. melatonin 5 mg po Q24H 26. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN 27. alpha lipoic acid [MASKED] mg oral DAILY 28. Losartan Potassium 50 mg PO DAILY 29. Metoprolol Succinate XL 25 mg PO DAILY 30. Lidocaine 5% Patch 1 PTCH TD QPM 31. Promethazine 25 mg PO Q6H:PRN nausea, vomiting 32. Cilostazol 50 mg PO QPM 33. Glargine 26 Units Breakfast Glargine 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 34. amLODIPine 2.5 mg PO DAILY Discharge Medications: 1. Ranolazine ER 500 mg PO BID RX *ranolazine [Ranexa] 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Allopurinol [MASKED] mg PO DAILY 3. amLODIPine 2.5 mg PO DAILY 4. Aspirin EC 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Calcitriol 0.25 mcg PO DAILY 7. Clopidogrel 75 mg PO DAILY 8. Warfarin 2.5 mg PO DAILY16 9. TraZODone 50 mg PO QHS 10. Ranitidine 300 mg PO QHS 11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 12. DULoxetine 60 mg PO DAILY 13. Gabapentin 100 mg PO QHS 14. HYDROcodone-acetaminophen [MASKED] mg ORAL Q4H:PRN pain 15. Levothyroxine Sodium 125 mcg PO DAILY 16. Lidocaine 5% Patch 1 PTCH TD QPM 17. Lidocaine 5% Patch 1 PTCH TD QPM 18. Losartan Potassium 50 mg PO DAILY 19. Mycophenolate Mofetil 500 mg PO BID 20. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 21. Pramipexole 0.25 mg PO QHS 22. PredniSONE 5 mg PO DAILY 23. Promethazine 25 mg PO BID nausea or vomiting 24. Cilostazol 100 mg PO QAM 25. Cilostazol 50 mg PO QPM 26. Metoprolol Succinate XL 25 mg PO DAILY 27. Esomeprazole Magnesium 40 mg ORAL BID 28. alpha lipoic acid [MASKED] mg oral DAILY 29. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN 30. melatonin 5 mg po Q24H 31. Promethazine 25 mg PR Q6H:PRN nausea or vomiting 32. Promethazine 25 mg PO Q6H:PRN nausea, vomiting 33. Vitamin D 400 UNIT PO DAILY 34. Glargine 26 Units Breakfast Glargine 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 35. Tacrolimus 1.5 mg PO BID RX *tacrolimus 0.5 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Angina UTI Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were seen at [MASKED] for your chest pain. In reviewing your imaging from your images from your angiography last month, it is unlikely that you are having coronary disease that would require re-catheterization. We started you on a long-acting nitrate (isosorbide dinitrate) to help with your symptoms, however this caused an unsafe drop in your blood pressure. Although this blood pressure drop was likely exacerbated by your recent dehydration from vomiting, you should let future providers know about this episode if you are prescribed it again. We also recommend that you monitor your blood pressure at home. Because you were unable to tolerate the isosorbide, we started you on a different medication, ranolazine, to help with your chest pain. It is really important that you continue to take your aspirin and Plavix as well as your immunosuppressants. Please call your primary care doctor if you feel that you are unable to keep these medications down. We have also set up follow up with endocrinology, ophthalmology, and your cardiologist in the next couple of weeks. Your primary care physician should call you with an appointment as well. Please take your medications as prescribed and follow up at your outpatient appointments. We wish you the best in your health, Your [MASKED] team Followup Instructions: [MASKED]
|
[] |
[
"N390",
"I252",
"Z955",
"Z7901",
"I10",
"E785",
"K219",
"G4733",
"M109",
"Z87891",
"Z7902",
"E039",
"D649"
] |
[
"E1069: Type 1 diabetes mellitus with other specified complication",
"D6861: Antiphospholipid syndrome",
"K3184: Gastroparesis",
"E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified",
"N390: Urinary tract infection, site not specified",
"Z940: Kidney transplant status",
"I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris",
"I952: Hypotension due to drugs",
"I252: Old myocardial infarction",
"Z955: Presence of coronary angioplasty implant and graft",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"Z86711: Personal history of pulmonary embolism",
"Z7901: Long term (current) use of anticoagulants",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"I739: Peripheral vascular disease, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"M109: Gout, unspecified",
"H43399: Other vitreous opacities, unspecified eye",
"E860: Dehydration",
"E10649: Type 1 diabetes mellitus with hypoglycemia without coma",
"T463X5A: Adverse effect of coronary vasodilators, initial encounter",
"Z87891: Personal history of nicotine dependence",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"E039: Hypothyroidism, unspecified",
"D649: Anemia, unspecified",
"Y92239: Unspecified place in hospital as the place of occurrence of the external cause"
] |
10,030,753
| 25,629,024
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan
Attending: ___
Chief Complaint:
Dizziness and Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMhx of ___ s/p living kidney transplant ___ on
cyclosporine, cellcept, prednisone, CREST, PE previously on
warfarin, CAD (s/p ___ and OM ___ who presents for
hypotension and prescyncope in the setting of recent
up-titration of her home blood pressure medications.
Of note, she was recently discharged from the ET service for an
admission related to a new ___ for which she underwent renal bx.
Initial concern was for possible acute rejection of her
transplant, but bx was reassuring in this regard, showing
advanced changes associated with diabetic nephropathy.
Additionally during her stay, she was noted to have volume
overload in the setting of her ___, and she was started on a
number of different medications for hypertension management,
volume control and diuretics, as well as an aggressive insulin
regimen recommended by the ___.
Since her discharge, she has felt overall well until in the
middle of the night she awoke and felt dizzy. She notes this was
prior to taking her AM medications. She went back to bed
following this incident, and when she awoke she was notably
lightheaded and dizzy. She went to her PCP office for routine
follow-up, and was noted to have blood pressures ranging from
60-80 systolic, and thus was sent to the ED for further
evaluation. She denies any fevers, chills, CP, SOB, cough,
diarrhea, abd pain, or dysuria.
In the ED, initial vitals were:
97.1 71 110/56 19 93% RA
- Labs notable for: SCr 2.0, stable from recent admission
- Imaging was notable for:
Absent diastolic flow in transplanted kidney
The patient was given 1L NS and her home nifedipine and Lasix
were held. SBPs improved to 150s overnight and patient is
hypertensive to 180s this morning.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___,
DES to LAD and Cx/OM ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
- End-stage renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
- Scleroderma w/ CREST syndrome
- Gastroparesis/GERD/Hiatal hernia
- Gout diagnosed ___ years ago
- OSA
NOT ACCURATE: - Antiphospholipid antibody syndrome and remote PE
history on Coumadin ___ - this diagnosis viewed unlikely per
___ hematology/oncology note
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITAL SIGNS: Afeb, 120-180/60, 80-90, ___, 94% RA
GENERAL: Comfortable, NAD
HEENT: PERRL, OP clear without lesions or thrush
NECK: supple, no JVD
CARDIAC: RRR, no MRG
LUNGS: CTAB without wheezing or rhonchi
ABDOMEN: soft, nt, nd
EXTREMITIES: wwp, no peripheral edema or cyanosis
SKIN: no suspicious rashes or lesions
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.1, 158/71, 80, 18, 99% RA
GENERAL: Comfortable, NAD
HEENT: PERRL, OP clear without lesions or thrush
NECK: supple, no JVD
CARDIAC: RRR, no MRG
LUNGS: CTAB without wheezing or rhonchi
ABDOMEN: soft, nt, nd
EXTREMITIES: wwp, no peripheral edema or cyanosis
SKIN: no suspicious rashes or lesions
Pertinent Results:
ADMISSION LABS:
===============
___ 06:10AM PLT COUNT-323
___ 06:10AM WBC-7.3 RBC-2.76* HGB-8.3* HCT-25.9* MCV-94
MCH-30.1 MCHC-32.0 RDW-13.5 RDWSD-46.5*
___ 06:10AM CYCLSPRN-168
___ 06:10AM CALCIUM-9.0 PHOSPHATE-4.3 MAGNESIUM-1.9
___ 06:10AM GLUCOSE-85 UREA N-49* CREAT-2.0* SODIUM-138
POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-31 ANION GAP-17
___ 05:45PM PLT COUNT-272
___ 05:45PM NEUTS-92.0* LYMPHS-3.0* MONOS-4.2* EOS-0.2*
BASOS-0.1 IM ___ AbsNeut-7.47* AbsLymp-0.24* AbsMono-0.34
AbsEos-0.02* AbsBaso-0.01
___ 05:45PM WBC-8.1 RBC-2.74* HGB-8.2* HCT-26.1* MCV-95
MCH-29.9 MCHC-31.4* RDW-13.8 RDWSD-48.3*
___ 05:45PM ALBUMIN-3.2* CALCIUM-8.9 PHOSPHATE-3.9
MAGNESIUM-2.0
___ 05:45PM ALT(SGPT)-22 AST(SGOT)-20 ALK PHOS-81 TOT
BILI-0.3
___ 05:45PM GLUCOSE-231* UREA N-48* CREAT-2.0* SODIUM-134
POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-26 ANION GAP-18
___ 05:52PM LACTATE-1.3
DISCHARGE LABS:
===============
___ 05:24AM BLOOD WBC-6.1 RBC-2.43* Hgb-7.5* Hct-23.2*
MCV-96 MCH-30.9 MCHC-32.3 RDW-13.4 RDWSD-46.5* Plt ___
___ 05:24AM BLOOD Glucose-166* UreaN-42* Creat-1.8* Na-140
K-4.2 Cl-104 HCO3-26 AnGap-14
___ 07:44AM BLOOD ALT-17 AST-12 LD(LDH)-257* AlkPhos-75
TotBili-0.2
___ 05:24AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9
___ 05:24AM BLOOD Cyclspr-204
MICROBIOLOGY:
=============
None
IMAGING:
========
___ (PA & LAT)
Stable mild cardiomegaly, decreased right pleural effusion, now
tiny.
___ TRANSPLANT U.S.
The left lower quadrant transplant renal morphology is normal
measuring 13.2 cm in length. Specifically, the cortex is of
normal thickness and echogenicity, pyramids are normal, there is
no urothelial thickening, and
renal sinus fat is normal. There is no hydronephrosis and no
perinephric fluid collection.
Doppler: There is absent diastolic flow main renal artery as
well as the intralobar branches, which is more convincing on
todays exam compared with prior. The main renal vein is patent.
Brief Hospital Course:
Ms. ___ is a ___ with PMhx of ___ s/p living kidney
transplant ___ on cyclosporine, cellcept, prednisone, CREST,
PE previously on warfarin, CAD (s/p ___ and OM ___ who
presents for hypotension and prescyncope in the setting of
up-titrating her anti-hypertensives. On admission, the patient
was given 1L NS and her nifedipine and Lasix were held. Her
symptoms resolved. She remained significantly orthostatic,
likely ___ longstanding diabetes and autonomic dysfunction.
Patient was discharged home on Carvedilol 12.5mg PO QAM, 25mg PO
QPM and Lasix 20mg PO daily with plans to continue to adjust her
blood pressure medications as an out-patient and possible
outpatient ABPM.
#Presyncope/hypotension:
Patient presented with hypotension i/s/o starting multiple
antihypertensives and a new diuretic regimen. Held
antihypertensives and diuretics for ___ and gave IVF with
improvement of blood pressure. Likely d/t medication effect, as
no evidence of infection. See "Hypertension" for discharge
regimen.
#Hypertension/Orthostasis:
Essential hypertension in the setting of tacrolimus therapy with
very poorly controlled blood pressures and difficult medication
titration given orthostasis and hypotension. Patient initially
hypotensive on admission but quickly became hypertensive to SBPs
of 200s with IVF and holding antihypertensives. However patient
was very orthostatic with drop to SBPS of 120s from 200s with
standing, despite being asymptomatic. Concern for diabetes
induced dysautonomia. Patient was maintained on carvedilol
12.5mg qAM, 25mg qPM and lasix 20mg PO daily on discharge with
SBPs in the 160s-170s. Plan is forcontinued titration of BP meds
and monitoring of orthostatics as an out-patient with ABPM.
# CKD
# S/p living unrelated donor kidney transplant ___:
Recent admission with renal bx showing diabetic changes without
signs of rejection. Her immunosuppressive regimen was increased
and she was discharged with a more aggressive antidiabetic
regimen and antihypertensive regimen.
- Decreased cyclosporine to 50mg BID given levels
- Continued home prednisone 5mg PO daily
- Continued home MMF 500mg BID
- Continued home diabetes regimen as below
# DM1, hyperglycemia: A1C 7.5% (___), had issues with
hypoglycemia d/t poor intake.
- Continued prior discharge regimen:
* Lantus 22 units qAM and 17 units qhs
* Humalog 8 units TID with meals
* Humalog sliding scale TID with meals
* ___ c/s
CHRONIC ISSUES
===============
# Hypothyroidism: recent TSH 0.69
- Continued home levothyroxine 125 mcg QD
# PE. Hx of provoked PE in 1990s, on warfarin until last
admission ___ at ___. Warfarin was stopped given hx of
GIB on warfarin and negative anti-cardiolipin AB on repeat
check.
# CAD. S/p ___ and OM ___. Completed 6 months on Plavix
- Continued home ASA 81 mg QD
- Continued home Ranexa ER 500 mg BID
# Nausea
- Continued home Zofran 8 mg QD:PRN, reglan 10 mg TID
# Gout
- Continued home allopurinol ___ mg QD
# HLD
- Continued home atorvastatin 20 mg QD
# CREST:
- Held home esomeprazole 40 mg capsule BID
- Pantoprazole 40 mg BID while inpatient
# PVD
- Continued home cilostazol 100 mg QAM, 50 mg QPM
TRANSITIONAL ISSUES:
====================
NEW MEDICATIONS:
- None
ADJUSTED MEDICATIONS:
- Cyclosporin 50mg PO Q12H
- Lasix 20mg daily
- Carvedilol 12.5mg PO QAM, 25mg PO QPM
STOPPED MEDICATIONS:
- Nifedipine CR 30mg daily
TO-DOs:
[ ] Monitor blood pressure and adjust anti-hypertensives
accordingly
[ ] Monitor weight and adjust Lasix accordingly - Dry weight
61.5 Kg
[ ] Set-up patient for ABPM within ___ weeks of discharge with
Dr. ___ appointment above)
[ ] Recheck CMP and CsA levels on ___
[ ] Recheck CMP and CsA levels on ___
# CODE: Full
# Contact: ___ (sister/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Calcitriol 0.25 mcg PO DAILY
5. Cilostazol 100 mg PO QAM
6. Cilostazol 50 mg PO QHS
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Mycophenolate Mofetil 500 mg PO BID
9. PredniSONE 5 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. Carvedilol 25 mg PO BID
12. NIFEdipine CR 30 mg PO DAILY
13. Ascorbic Acid ___ mg PO DAILY
14. Calcium Carbonate 500 mg PO BID
15. Esomeprazole Magnesium 40 mg oral BID
16. Ferrous Sulfate 325 mg PO DAILY
17. Ranolazine ER 500 mg PO BID
18. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
19. Furosemide 20 mg PO BID
20. Glargine 22 Units Breakfast
Glargine 15 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Carvedilol 25 mg PO QHS
RX *carvedilol 25 mg 1 tablet(s) by mouth Daily at bedtime Disp
#*30 Tablet Refills:*0
2. Carvedilol 12.5 mg PO QAM
RX *carvedilol 12.5 mg 1 tablet(s) by mouth Daily in the morning
Disp #*30 Tablet Refills:*0
3. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
RX *cyclosporine modified 25 mg 2 capsule(s) by mouth twice a
day Disp #*120 Capsule Refills:*0
4. Furosemide 20 mg PO DAILY
RX *furosemide 40 mg 0.5 (One half) tablet(s) by mouth Daily
Disp #*15 Tablet Refills:*0
5. Glargine 22 Units Breakfast
Glargine 17 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Allopurinol ___ mg PO DAILY
7. Ascorbic Acid ___ mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 20 mg PO QPM
10. Calcitriol 0.25 mcg PO DAILY
11. Calcium Carbonate 500 mg PO BID
12. Cilostazol 100 mg PO QAM
13. Cilostazol 50 mg PO QHS
14. Esomeprazole Magnesium 40 mg oral BID
15. Ferrous Sulfate 325 mg PO DAILY
16. Levothyroxine Sodium 125 mcg PO DAILY
17. Mycophenolate Mofetil 500 mg PO BID
18. PredniSONE 5 mg PO DAILY
19. Ranolazine ER 500 mg PO BID
20. Vitamin D ___ UNIT PO DAILY
21.Outpatient Lab Work
Z94.0
___: CHEM10, Cyclosporin level
Please fax to Dr. ___ at ___.
22.Outpatient Lab Work
Z94.0
___: CHEM10, Cyclosporin level
Please fax to Dr. ___ at ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
========
Hypotension
Supine hypertension
Orthostatic hypotension
Secondary:
==========
Status-post kidney transplant, uncontrolled DMI, 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 taking care of you during your stay at ___
___. You were admitted for lightheadedness and
low pressure. This was likely due to your new blood pressure
medications and the water pills. Some of these symptoms are also
related to the longstanding diabetes that causes nerve damage
that prevents you blood vessels from maintaining a stable blood
pressure. You were give intravenous fluid and your blood
pressure improved. We have stopped your nifedipine and decreased
the dose of the carvedilol you were on. We restarted you on a
small dose of the water pills to keep you from accumulating
fluid. You should follow-up with your primary care physician
___ 2 days of discharge. This appointment has been scheduled
for you.
We wish you all the best!
Your ___ Team
Followup Instructions:
___
|
[
"E1043",
"G903",
"E1022",
"M341",
"E1051",
"Z940",
"K3184",
"I952",
"E1065",
"I129",
"N189",
"I2510",
"K219",
"I252",
"M109",
"G4733",
"E861",
"N312",
"E785",
"E103593",
"T447X5A",
"Z955",
"Z86711",
"Z794",
"Y929",
"T501X5A"
] |
Allergies: Penicillins / Ativan Chief Complaint: Dizziness and Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with PMhx of [MASKED] s/p living kidney transplant [MASKED] on cyclosporine, cellcept, prednisone, CREST, PE previously on warfarin, CAD (s/p [MASKED] and OM [MASKED] who presents for hypotension and prescyncope in the setting of recent up-titration of her home blood pressure medications. Of note, she was recently discharged from the ET service for an admission related to a new [MASKED] for which she underwent renal bx. Initial concern was for possible acute rejection of her transplant, but bx was reassuring in this regard, showing advanced changes associated with diabetic nephropathy. Additionally during her stay, she was noted to have volume overload in the setting of her [MASKED], and she was started on a number of different medications for hypertension management, volume control and diuretics, as well as an aggressive insulin regimen recommended by the [MASKED]. Since her discharge, she has felt overall well until in the middle of the night she awoke and felt dizzy. She notes this was prior to taking her AM medications. She went back to bed following this incident, and when she awoke she was notably lightheaded and dizzy. She went to her PCP office for routine follow-up, and was noted to have blood pressures ranging from 60-80 systolic, and thus was sent to the ED for further evaluation. She denies any fevers, chills, CP, SOB, cough, diarrhea, abd pain, or dysuria. In the ED, initial vitals were: 97.1 71 110/56 19 93% RA - Labs notable for: SCr 2.0, stable from recent admission - Imaging was notable for: Absent diastolic flow in transplanted kidney The patient was given 1L NS and her home nifedipine and Lasix were held. SBPs improved to 150s overnight and patient is hypertensive to 180s this morning. Past Medical History: 1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA [MASKED], DES to LAD and Cx/OM [MASKED] - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) - End-stage renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] - Scleroderma w/ CREST syndrome - Gastroparesis/GERD/Hiatal hernia - Gout diagnosed [MASKED] years ago - OSA NOT ACCURATE: - Antiphospholipid antibody syndrome and remote PE history on Coumadin [MASKED] - this diagnosis viewed unlikely per [MASKED] hematology/oncology note Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITAL SIGNS: Afeb, 120-180/60, 80-90, [MASKED], 94% RA GENERAL: Comfortable, NAD HEENT: PERRL, OP clear without lesions or thrush NECK: supple, no JVD CARDIAC: RRR, no MRG LUNGS: CTAB without wheezing or rhonchi ABDOMEN: soft, nt, nd EXTREMITIES: wwp, no peripheral edema or cyanosis SKIN: no suspicious rashes or lesions DISCHARGE PHYSICAL EXAM: ======================== VS: 98.1, 158/71, 80, 18, 99% RA GENERAL: Comfortable, NAD HEENT: PERRL, OP clear without lesions or thrush NECK: supple, no JVD CARDIAC: RRR, no MRG LUNGS: CTAB without wheezing or rhonchi ABDOMEN: soft, nt, nd EXTREMITIES: wwp, no peripheral edema or cyanosis SKIN: no suspicious rashes or lesions Pertinent Results: ADMISSION LABS: =============== [MASKED] 06:10AM PLT COUNT-323 [MASKED] 06:10AM WBC-7.3 RBC-2.76* HGB-8.3* HCT-25.9* MCV-94 MCH-30.1 MCHC-32.0 RDW-13.5 RDWSD-46.5* [MASKED] 06:10AM CYCLSPRN-168 [MASKED] 06:10AM CALCIUM-9.0 PHOSPHATE-4.3 MAGNESIUM-1.9 [MASKED] 06:10AM GLUCOSE-85 UREA N-49* CREAT-2.0* SODIUM-138 POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-31 ANION GAP-17 [MASKED] 05:45PM PLT COUNT-272 [MASKED] 05:45PM NEUTS-92.0* LYMPHS-3.0* MONOS-4.2* EOS-0.2* BASOS-0.1 IM [MASKED] AbsNeut-7.47* AbsLymp-0.24* AbsMono-0.34 AbsEos-0.02* AbsBaso-0.01 [MASKED] 05:45PM WBC-8.1 RBC-2.74* HGB-8.2* HCT-26.1* MCV-95 MCH-29.9 MCHC-31.4* RDW-13.8 RDWSD-48.3* [MASKED] 05:45PM ALBUMIN-3.2* CALCIUM-8.9 PHOSPHATE-3.9 MAGNESIUM-2.0 [MASKED] 05:45PM ALT(SGPT)-22 AST(SGOT)-20 ALK PHOS-81 TOT BILI-0.3 [MASKED] 05:45PM GLUCOSE-231* UREA N-48* CREAT-2.0* SODIUM-134 POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-26 ANION GAP-18 [MASKED] 05:52PM LACTATE-1.3 DISCHARGE LABS: =============== [MASKED] 05:24AM BLOOD WBC-6.1 RBC-2.43* Hgb-7.5* Hct-23.2* MCV-96 MCH-30.9 MCHC-32.3 RDW-13.4 RDWSD-46.5* Plt [MASKED] [MASKED] 05:24AM BLOOD Glucose-166* UreaN-42* Creat-1.8* Na-140 K-4.2 Cl-104 HCO3-26 AnGap-14 [MASKED] 07:44AM BLOOD ALT-17 AST-12 LD(LDH)-257* AlkPhos-75 TotBili-0.2 [MASKED] 05:24AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9 [MASKED] 05:24AM BLOOD Cyclspr-204 MICROBIOLOGY: ============= None IMAGING: ======== [MASKED] (PA & LAT) Stable mild cardiomegaly, decreased right pleural effusion, now tiny. [MASKED] TRANSPLANT U.S. The left lower quadrant transplant renal morphology is normal measuring 13.2 cm in length. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. Doppler: There is absent diastolic flow main renal artery as well as the intralobar branches, which is more convincing on todays exam compared with prior. The main renal vein is patent. Brief Hospital Course: Ms. [MASKED] is a [MASKED] with PMhx of [MASKED] s/p living kidney transplant [MASKED] on cyclosporine, cellcept, prednisone, CREST, PE previously on warfarin, CAD (s/p [MASKED] and OM [MASKED] who presents for hypotension and prescyncope in the setting of up-titrating her anti-hypertensives. On admission, the patient was given 1L NS and her nifedipine and Lasix were held. Her symptoms resolved. She remained significantly orthostatic, likely [MASKED] longstanding diabetes and autonomic dysfunction. Patient was discharged home on Carvedilol 12.5mg PO QAM, 25mg PO QPM and Lasix 20mg PO daily with plans to continue to adjust her blood pressure medications as an out-patient and possible outpatient ABPM. #Presyncope/hypotension: Patient presented with hypotension i/s/o starting multiple antihypertensives and a new diuretic regimen. Held antihypertensives and diuretics for [MASKED] and gave IVF with improvement of blood pressure. Likely d/t medication effect, as no evidence of infection. See "Hypertension" for discharge regimen. #Hypertension/Orthostasis: Essential hypertension in the setting of tacrolimus therapy with very poorly controlled blood pressures and difficult medication titration given orthostasis and hypotension. Patient initially hypotensive on admission but quickly became hypertensive to SBPs of 200s with IVF and holding antihypertensives. However patient was very orthostatic with drop to SBPS of 120s from 200s with standing, despite being asymptomatic. Concern for diabetes induced dysautonomia. Patient was maintained on carvedilol 12.5mg qAM, 25mg qPM and lasix 20mg PO daily on discharge with SBPs in the 160s-170s. Plan is forcontinued titration of BP meds and monitoring of orthostatics as an out-patient with ABPM. # CKD # S/p living unrelated donor kidney transplant [MASKED]: Recent admission with renal bx showing diabetic changes without signs of rejection. Her immunosuppressive regimen was increased and she was discharged with a more aggressive antidiabetic regimen and antihypertensive regimen. - Decreased cyclosporine to 50mg BID given levels - Continued home prednisone 5mg PO daily - Continued home MMF 500mg BID - Continued home diabetes regimen as below # DM1, hyperglycemia: A1C 7.5% ([MASKED]), had issues with hypoglycemia d/t poor intake. - Continued prior discharge regimen: * Lantus 22 units qAM and 17 units qhs * Humalog 8 units TID with meals * Humalog sliding scale TID with meals * [MASKED] c/s CHRONIC ISSUES =============== # Hypothyroidism: recent TSH 0.69 - Continued home levothyroxine 125 mcg QD # PE. Hx of provoked PE in 1990s, on warfarin until last admission [MASKED] at [MASKED]. Warfarin was stopped given hx of GIB on warfarin and negative anti-cardiolipin AB on repeat check. # CAD. S/p [MASKED] and OM [MASKED]. Completed 6 months on Plavix - Continued home ASA 81 mg QD - Continued home Ranexa ER 500 mg BID # Nausea - Continued home Zofran 8 mg QD:PRN, reglan 10 mg TID # Gout - Continued home allopurinol [MASKED] mg QD # HLD - Continued home atorvastatin 20 mg QD # CREST: - Held home esomeprazole 40 mg capsule BID - Pantoprazole 40 mg BID while inpatient # PVD - Continued home cilostazol 100 mg QAM, 50 mg QPM TRANSITIONAL ISSUES: ==================== NEW MEDICATIONS: - None ADJUSTED MEDICATIONS: - Cyclosporin 50mg PO Q12H - Lasix 20mg daily - Carvedilol 12.5mg PO QAM, 25mg PO QPM STOPPED MEDICATIONS: - Nifedipine CR 30mg daily TO-DOs: [ ] Monitor blood pressure and adjust anti-hypertensives accordingly [ ] Monitor weight and adjust Lasix accordingly - Dry weight 61.5 Kg [ ] Set-up patient for ABPM within [MASKED] weeks of discharge with Dr. [MASKED] appointment above) [ ] Recheck CMP and CsA levels on [MASKED] [ ] Recheck CMP and CsA levels on [MASKED] # CODE: Full # Contact: [MASKED] (sister/HCP) [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Calcitriol 0.25 mcg PO DAILY 5. Cilostazol 100 mg PO QAM 6. Cilostazol 50 mg PO QHS 7. Levothyroxine Sodium 125 mcg PO DAILY 8. Mycophenolate Mofetil 500 mg PO BID 9. PredniSONE 5 mg PO DAILY 10. Vitamin D [MASKED] UNIT PO DAILY 11. Carvedilol 25 mg PO BID 12. NIFEdipine CR 30 mg PO DAILY 13. Ascorbic Acid [MASKED] mg PO DAILY 14. Calcium Carbonate 500 mg PO BID 15. Esomeprazole Magnesium 40 mg oral BID 16. Ferrous Sulfate 325 mg PO DAILY 17. Ranolazine ER 500 mg PO BID 18. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H 19. Furosemide 20 mg PO BID 20. Glargine 22 Units Breakfast Glargine 15 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Carvedilol 25 mg PO QHS RX *carvedilol 25 mg 1 tablet(s) by mouth Daily at bedtime Disp #*30 Tablet Refills:*0 2. Carvedilol 12.5 mg PO QAM RX *carvedilol 12.5 mg 1 tablet(s) by mouth Daily in the morning Disp #*30 Tablet Refills:*0 3. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H RX *cyclosporine modified 25 mg 2 capsule(s) by mouth twice a day Disp #*120 Capsule Refills:*0 4. Furosemide 20 mg PO DAILY RX *furosemide 40 mg 0.5 (One half) tablet(s) by mouth Daily Disp #*15 Tablet Refills:*0 5. Glargine 22 Units Breakfast Glargine 17 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 7 Units Dinner Insulin SC Sliding Scale using HUM Insulin 6. Allopurinol [MASKED] mg PO DAILY 7. Ascorbic Acid [MASKED] mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Calcitriol 0.25 mcg PO DAILY 11. Calcium Carbonate 500 mg PO BID 12. Cilostazol 100 mg PO QAM 13. Cilostazol 50 mg PO QHS 14. Esomeprazole Magnesium 40 mg oral BID 15. Ferrous Sulfate 325 mg PO DAILY 16. Levothyroxine Sodium 125 mcg PO DAILY 17. Mycophenolate Mofetil 500 mg PO BID 18. PredniSONE 5 mg PO DAILY 19. Ranolazine ER 500 mg PO BID 20. Vitamin D [MASKED] UNIT PO DAILY 21.Outpatient Lab Work Z94.0 [MASKED]: CHEM10, Cyclosporin level Please fax to Dr. [MASKED] at [MASKED]. 22.Outpatient Lab Work Z94.0 [MASKED]: CHEM10, Cyclosporin level Please fax to Dr. [MASKED] at [MASKED]. Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary: ======== Hypotension Supine hypertension Orthostatic hypotension Secondary: ========== Status-post kidney transplant, uncontrolled DMI, 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 taking care of you during your stay at [MASKED] [MASKED]. You were admitted for lightheadedness and low pressure. This was likely due to your new blood pressure medications and the water pills. Some of these symptoms are also related to the longstanding diabetes that causes nerve damage that prevents you blood vessels from maintaining a stable blood pressure. You were give intravenous fluid and your blood pressure improved. We have stopped your nifedipine and decreased the dose of the carvedilol you were on. We restarted you on a small dose of the water pills to keep you from accumulating fluid. You should follow-up with your primary care physician [MASKED] 2 days of discharge. This appointment has been scheduled for you. We wish you all the best! Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"I129",
"N189",
"I2510",
"K219",
"I252",
"M109",
"G4733",
"E785",
"Z955",
"Z794",
"Y929"
] |
[
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"G903: Multi-system degeneration of the autonomic nervous system",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"M341: CR(E)ST syndrome",
"E1051: Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene",
"Z940: Kidney transplant status",
"K3184: Gastroparesis",
"I952: Hypotension due to drugs",
"E1065: Type 1 diabetes mellitus with hyperglycemia",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"N189: Chronic kidney disease, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"K219: Gastro-esophageal reflux disease without esophagitis",
"I252: Old myocardial infarction",
"M109: Gout, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"E861: Hypovolemia",
"N312: Flaccid neuropathic bladder, not elsewhere classified",
"E785: Hyperlipidemia, unspecified",
"E103593: Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral",
"T447X5A: Adverse effect of beta-adrenoreceptor antagonists, initial encounter",
"Z955: Presence of coronary angioplasty implant and graft",
"Z86711: Personal history of pulmonary embolism",
"Z794: Long term (current) use of insulin",
"Y929: Unspecified place or not applicable",
"T501X5A: Adverse effect of loop [high-ceiling] diuretics, initial encounter"
] |
10,030,753
| 25,709,479
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with ESRD s/p renal transplant ___, Cr baseline of 1.5-2.0
in past year (Biopsy with diabetic nephropathy and grade 2 IFTA
___, hx of CAD, HTN who presented to ___ for SOB.
Per HPI, reports SOB over last 3 days that was intermittent and
thought may be allergies due to nasal congestion. Reports today
symptoms were more persistent. Denies chest pain, fever. Denies
chills, n/v/d, cough. Denies dysuria, frequency or urgency.
Reports has LLQ abd pain over last 5 weeks. Reports was better
yesterday. Reports had some constipation and took some Go Lytely
which helped her constipation and had BM. Reports the abdominal
pain is crampy.
Upon evaluation at ___, she was found to have elevated Cr
2.33 (last Cr 1.8 2 weeks ago), therefore she was transferred
here for ___ and possible CHF.
In the ED, initial VS were: 97.5, 96, 188/102, 18, 98% RA
Exam notable for: None recorded
Labs showed:
- CBC: 13.2/___/300
- BNP 28,824
- AST 19
- Chem7: K 3.9, Mg 2, Cr 2.1
- Trp 0.26
Imaging showed:
- Renal Transplant normal renal transplant ultrasound. Patent
renal transplant vasculature without evidence of hydronephrosis.
- EKG: NSR, mild ST depression in I, aVL, V4-V5 which had been
unchanged since ___.
Received:
___ 21:25 IV Dextrose 50% 12.5 gm ___
___ 23:23 PO Metoprolol Succinate XL 25 mg ___
___ 23:23 PO Mycophenolate Mofetil 500 mg ___
Renal transplant was consulted: Recommended IV lasix 40 mg once
for diuresis if concerns for fluid overload compromising her
respiratory status. Please collect UA, urine Na, urine Urea,
urine creatinine to help evaluate ___ cause. Please hold ACEI,
___ if she is taking any. Continue her immunosuppressant home
dose.
Transfer VS were: 98.9, 97, 195/98, 17, 97% RA
On arrival to the floor, patient reports that she is
asymptomatic
at rest. Denies chest pain or SOB with head elevated. If she
were
to lye flat she would get SOB. She has noted increased lower
extremity swelling over the past several days. Denies fevers,
chills, dysuria, or any changes with urination. She tells me
that
her blood pressure medications are not to be adjusted without
first talking with her cardiologist. She denies current
headache,
vision changes. Endorsing some LLQ abdominal pain. no nausea,
vomiting.
Past Medical History:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___
DES to LAD and Cx/OM ___
3. OTHER PAST MEDICAL HISTORY. End-stage renal disease ___
diabetes s/p L-sided living kidney transplant in ___
- Scleroderma w/ CREST syndrome
- Gastroparesis/GERD/Hiatal hernia
- Gout diagnosed ___ years ago
- OSA
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
===================
Admission physical exam:
===================
VS: 97.9, 187/104, 90 18 96 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, JVP 12
HEART: RRR, soft systolic murmur.
LUNGS: Decreased breath sounds at bases bilaterally, otherwise
CTAB without wheezes or rhonchi.
ABDOMEN: nondistended, soft, +BS, kidney palpated in lower
quadrant, minimal tenderness to deep palpation of LLQ.
EXTREMITIES: WWP, 1+ pitting pretibial edema bilaterally.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
===================
Discharge physical exam:
===================
VS: T 98.1 HR 84 BP 197/87 RR 18 O2 SAT 95% on RA
GENERAL: Well appearing female in NAD
HEENT: Anicteric sclera, pink conjunctiva, MMM
HEART: RRR, Mild systolic murmur best appreciated at RUSB
LUNGS: CTAB.
ABDOMEN: soft, non tender, non distended. Normoactive bowel
sounds. Kidney palpated in lower quadrant w/ out tenderness
EXTREMITIES: 1+ pitting pretibial edema bilaterally.
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
==============
Admission labs:
==============
___ 05:30PM BLOOD WBC-13.2* RBC-3.25* Hgb-10.0* Hct-30.5*
MCV-94 MCH-30.8 MCHC-32.8 RDW-12.9 RDWSD-44.1 Plt ___
___ 05:30PM BLOOD Neuts-83.9* Lymphs-4.6* Monos-8.9 Eos-1.6
Baso-0.5 Im ___ AbsNeut-11.08* AbsLymp-0.61* AbsMono-1.18*
AbsEos-0.21 AbsBaso-0.06
___ 05:30PM BLOOD Plt ___
___ 03:00AM BLOOD ___ PTT-33.5 ___
___ 05:30PM BLOOD Glucose-70 UreaN-34* Creat-2.1* Na-142
K-3.9 Cl-105 HCO3-23 AnGap-14
___ 05:30PM BLOOD CK-MB-6 ___
___ 05:30PM BLOOD Albumin-2.8* Calcium-9.6 Phos-2.6* Mg-2.0
___ 03:00AM BLOOD Cyclspr-<30*
==============
Discharge labs:
==============
___ 05:59AM BLOOD WBC-7.5 RBC-2.75* Hgb-8.5* Hct-26.3*
MCV-96 MCH-30.9 MCHC-32.3 RDW-13.2 RDWSD-44.9 Plt ___
___ 05:59AM BLOOD Glucose-220* UreaN-49* Creat-2.2* Na-147*
K-3.8 Cl-107 HCO3-29 AnGap-11
___ 05:59AM BLOOD TotProt-4.5* Calcium-9.5 Phos-3.2 Mg-2.0
___ 05:59AM BLOOD Cyclspr-84*
==============
Other labs:
==============
___ 05:30PM BLOOD cTropnT-0.26*
___ 03:00AM BLOOD CK-MB-4 cTropnT-0.26*
___ 02:51PM BLOOD CK-MB-4 cTropnT-0.19*
___ 05:48AM BLOOD CK-MB-2 cTropnT-0.18*
___ 12:39PM BLOOD CK-MB-3 cTropnT-0.19*
___ 05:27AM BLOOD CK-MB-2 cTropnT-0.14*
___ 05:59AM BLOOD PEP-AWAITING F FreeKap-42.6*
FreeLam-47.9* Fr K/L-0.89 IgG-PND IgA-PND IgM-PND IFE-PND
==============
Micro:
==============
Blood and urine cultures negative
==============
Imaging:
==============
ECHO ___
The left atrium is normal in size. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Regional left ventricular wall motion is normal.
Quantitative (3D) LVEF = 41%. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is a small pericardial effusion.
IMPRESSION: Prominent symmetric LVH with mild global left
ventricular systolic dysfunction. Small pericardial effusion.
Elevated LVEDP.
Compared with the prior study (images reviewed) of ___, LV
wall are thicker. LV systolic function has declined and there is
now a pericardial effusion. Infiltrative cardiomyopathy, such as
cardiac amyloidosis should be considered.
Brief Hospital Course:
___ yo F with ESRD s/p renal transplant ___ (baseline Cr
1.5-2.0 w/biopsy with diabetic nephropathy and grade
2 IFTA ___, hx of CAD, and HTN who presented to ___
for
SOB, found to have ___ and elevated proBNP concerning for CHF
exacerbation.
#New systolic heart failure
#Acute on chronic heart failure
Pt presented w/three days of dyspnea and lower extremity edema.
CXR w/pulmonary vascular congestion and proBNP >28,000. Trigger
thought to be due to dietary non compliance (pt reported eating
a lot of salty foods) and pt has not been taking diuretics
despite worsening lower extremity swelling. Infectious triggers
were ruled out. Troponin was elevated but this was thought to be
d/t demand ischemia. An echo revealed new systolic dysfunction
and prominent symmetric LVH with elevated filling pressures. She
was diuresed with IV lasix during her hospitalization.
Cardiology was consulted due to worsening EF and heart failure
exacerbation. They recommended better blood pressure control
(see below). Discussion was had regarding cardiac MRI with
gadolinium given c/f infiltrative cardiomyopathy. Patient can
not get gadolinium and cardiology believed that most likely
etiology of wall thickening was related to hypertension and not
an infiltrative process. SPEP, UPEP and light chains were
checked but were pending at discharge. Furosemide was held upon
discharge.
#Hypertension
Patient has history of supine hypertension and orthostatic
hypotension, difficult to manage. She was only on metoprolol
upon admission. Other drugs such as nifedipine and carvedilol
have been tried in the past, but have caused
dizziness/hypotension upon standing. Given her new echo findings
and significant wall thickening, we adjusted her anti
hypertensive agents. Metoprolol was discontinued. An ___
was held due to ___. She was started on carvedilol 3.125 mg
PO BID. Her blood pressures were noticeably higher in the
evening. When we increased her carvedilol to 6.25 mg PO BID, her
blood pressures dropped with standing and she became very
symptomatic with dizziness. With this in mind, we reduced her
carvedilol back to 3.125 mg PO BID and started her on PO
hydralazine 10 mg and imdur 30 mg at night before bed. With this
regimen, she remained hypertensive, but was no longer
symptomatic upon standing and walking. Upon discharge, we
increased her hydralazine to 25 mg PO at night and prescribed a
nitroglycerin patch .2/hr to be worn only at night.
#Type 2 Demand Ischemia
Troponin peaked at .26 and CK MB remained flat. She had some STD
in I, AVL, V4-V5, but these resolved and troponins downtrended.
No regional wall motion abnormality on echo. Demand thought to
be related to uncontrolled hypertension and acute heart failure
exacerbation.
#Hypoglycemia
#Type 1 Diabetes
Patient has very brittle type 1 diabetes that was somewhat
difficult to manage during the hospital. She was kept on her
home dose of insulin and sugars improved.
#Acute kidney injury
#End stage renal disease s/p transplant
Cr slightly up upon admission to 2.1 (baseline 1.5 to 2.0).
Renal US was WNL. C/f cardiorenal syndrome although urine Na >
20.
Cr upon discharge was 2.2
Patient was continued on immunosuppression with prednisone,
mycophenolate, and cyclosporine. Cyclosporine was increased from
25 BID to 50 BID.
#Coronary artery disease
2V disease, s/p DES to LAD, Cx/OM in ___, in place of
CABG
per patient preference. Pt was continued on aspirin,
atrovastatin as well as ranexa 500 mg PO bid.
**Transitional issues**
[] MEDICATION CHANGES:
--> Stopped metoprolol
--> Stopped furosemide
--> Started carvedilol 3.125 BID
--> Started nitroglycerin patch (.2/hr) at night
--> Started hydralazine 25 mg at night
--> Increased cyclosporine from 25 mg BID to 50 mg BID
[] Patient should have follow up labs within one week of
discharge- CBC, CHEM 10
[] Patient should have follow up with cardiology
[] Consider stress test as an outpatient
[] Consider addition of an ___ as an outpatient
[] Follow up: UPEP, SPEP, Light chains
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Calcitriol 0.25 mcg PO DAILY
7. Calcium Carbonate 500 mg PO BID
8. Cilostazol 100 mg PO QAM
9. Cilostazol 50 mg PO QPM
10. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
11. Esomeprazole 40 mg Other BID
12. Ferrous Sulfate 325 mg PO DAILY
13. Mycophenolate Mofetil 500 mg PO BID
14. Levothyroxine Sodium 125 mcg PO DAILY
15. Metoprolol Succinate XL 25 mg PO DAILY
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. PredniSONE 5 mg PO DAILY
18. Ranolazine ER 500 mg PO BID
19. Promethazine 25 mg PO DAILY PRN nausea
20. Vitamin D ___ UNIT PO DAILY
21. Metoprolol Tartrate 12.5 mg PO QHS
22. Furosemide 20 mg PO DAILY PRN WEIGHT GAIN weight gain
23. Glargine 38 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Carvedilol 3.125 mg PO BID
RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
2. HydrALAZINE 25 mg PO DAILY
RX *hydralazine 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Nitroglycerin Patch 0.2 mg/hr TD Q24H
RX *nitroglycerin 0.2 mg/hour Place on chest each evening Disp
#*30 Patch Refills:*0
4. Glargine 38 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Allopurinol ___ mg PO DAILY
6. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
7. Ascorbic Acid ___ mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 20 mg PO QPM
10. Calcitriol 0.25 mcg PO DAILY
11. Calcium Carbonate 500 mg PO BID
12. Cilostazol 100 mg PO QAM
13. Cilostazol 50 mg PO QPM
14. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
RX *cyclosporine modified 50 mg 1 capsule(s) by mouth twice
daily Disp #*60 Capsule Refills:*0
15. Esomeprazole 40 mg Other BID
16. Ferrous Sulfate 325 mg PO DAILY
17. Levothyroxine Sodium 125 mcg PO DAILY
18. Mycophenolate Mofetil 500 mg PO BID
19. Ondansetron 4 mg PO Q8H:PRN nausea
20. PredniSONE 5 mg PO DAILY
21. Promethazine 25 mg PO DAILY PRN nausea
22. Ranolazine ER 500 mg PO BID
23. Vitamin D ___ UNIT PO DAILY
24. HELD- Furosemide 20 mg PO DAILY PRN WEIGHT GAIN weight gain
This medication was held. Do not restart Furosemide until you
have discussed this with your cardiologist
25.Outpatient Lab Work
Lab work: ___
___ fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Acute on chronic systolic heart failure exacerbation
Hypertension
Type 2 Demand Ischemia
Acute kidney injury
Secondary diagnoses:
Hypertension
Type 1 Diabetes
Coronary artery disease
End stage renal disease s/p renal transpalnt
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
What brought you into the hospital?
-You came to the hospital with difficulty breathing
What happened while you were in the hospital?
-We believe that your difficulty breathing was related to
dysfunction of the heart and we treated you with medications
called diuretics to help get rid of extra fluid.
-We also started you on new medications for your high blood
pressure.
What should you do when you leave the hospital?
-You should continue taking all of your home medications as
prescribed. We have NOT made any changes to your insulin. Please
take your insulin as prescribed by your endocrinologist.
-We have made some changes to your medications and these are
listed below.
-Take the hydralazine before going to bed. Put the nitroglycerin
patch on your chest (or arm) before going to bed. Remove the
patch in the morning before you get up. We also started you on
carvedilol, a medication that you will take twice per day. We
increased your cyclosporine to 50 mg twice per day. You can stop
taking your metoprolol and furosemide.
-You should weigh yourself every day. If you gain more than
three pounds in a day. Call your doctor.
-___ you get lightheaded or dizzy, please call your primary care
doctor or cardiologist. We may need to make some adjustments to
your medications.
-Please get your labs checked and have them sent to your kidney
doctor within one week.
It was a pleasure taking care of you.
-Your ___ team
Medication changes:
[] MEDICATION CHANGES:
--> Stopped metoprolol
--> Stopped furosemide
--> Started carvedilol 3.125 BID
--> Started nitroglycerin patch (.2/hr) at night
--> Started hydralazine 25 mg at night
--> Increased cyclosporine from 25 mg BID to 50 mg BID
Followup Instructions:
___
|
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"I5023",
"N179",
"N186",
"M341",
"E1043",
"K3184",
"E1022",
"I248",
"Z940",
"I951",
"E10649",
"M109",
"I2510",
"N318",
"E785",
"E039",
"D72829",
"G4733",
"Z87891",
"Z955",
"Z86711",
"I252",
"Z794"
] |
Allergies: Penicillins / Ativan Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with ESRD s/p renal transplant [MASKED], Cr baseline of 1.5-2.0 in past year (Biopsy with diabetic nephropathy and grade 2 IFTA [MASKED], hx of CAD, HTN who presented to [MASKED] for SOB. Per HPI, reports SOB over last 3 days that was intermittent and thought may be allergies due to nasal congestion. Reports today symptoms were more persistent. Denies chest pain, fever. Denies chills, n/v/d, cough. Denies dysuria, frequency or urgency. Reports has LLQ abd pain over last 5 weeks. Reports was better yesterday. Reports had some constipation and took some Go Lytely which helped her constipation and had BM. Reports the abdominal pain is crampy. Upon evaluation at [MASKED], she was found to have elevated Cr 2.33 (last Cr 1.8 2 weeks ago), therefore she was transferred here for [MASKED] and possible CHF. In the ED, initial VS were: 97.5, 96, 188/102, 18, 98% RA Exam notable for: None recorded Labs showed: - CBC: 13.2/[MASKED]/300 - BNP 28,824 - AST 19 - Chem7: K 3.9, Mg 2, Cr 2.1 - Trp 0.26 Imaging showed: - Renal Transplant normal renal transplant ultrasound. Patent renal transplant vasculature without evidence of hydronephrosis. - EKG: NSR, mild ST depression in I, aVL, V4-V5 which had been unchanged since [MASKED]. Received: [MASKED] 21:25 IV Dextrose 50% 12.5 gm [MASKED] [MASKED] 23:23 PO Metoprolol Succinate XL 25 mg [MASKED] [MASKED] 23:23 PO Mycophenolate Mofetil 500 mg [MASKED] Renal transplant was consulted: Recommended IV lasix 40 mg once for diuresis if concerns for fluid overload compromising her respiratory status. Please collect UA, urine Na, urine Urea, urine creatinine to help evaluate [MASKED] cause. Please hold ACEI, [MASKED] if she is taking any. Continue her immunosuppressant home dose. Transfer VS were: 98.9, 97, 195/98, 17, 97% RA On arrival to the floor, patient reports that she is asymptomatic at rest. Denies chest pain or SOB with head elevated. If she were to lye flat she would get SOB. She has noted increased lower extremity swelling over the past several days. Denies fevers, chills, dysuria, or any changes with urination. She tells me that her blood pressure medications are not to be adjusted without first talking with her cardiologist. She denies current headache, vision changes. Endorsing some LLQ abdominal pain. no nausea, vomiting. Past Medical History: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED] 3. OTHER PAST MEDICAL HISTORY. End-stage renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] - Scleroderma w/ CREST syndrome - Gastroparesis/GERD/Hiatal hernia - Gout diagnosed [MASKED] years ago - OSA Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: =================== Admission physical exam: =================== VS: 97.9, 187/104, 90 18 96 Ra GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, JVP 12 HEART: RRR, soft systolic murmur. LUNGS: Decreased breath sounds at bases bilaterally, otherwise CTAB without wheezes or rhonchi. ABDOMEN: nondistended, soft, +BS, kidney palpated in lower quadrant, minimal tenderness to deep palpation of LLQ. EXTREMITIES: WWP, 1+ pitting pretibial edema bilaterally. PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes =================== Discharge physical exam: =================== VS: T 98.1 HR 84 BP 197/87 RR 18 O2 SAT 95% on RA GENERAL: Well appearing female in NAD HEENT: Anicteric sclera, pink conjunctiva, MMM HEART: RRR, Mild systolic murmur best appreciated at RUSB LUNGS: CTAB. ABDOMEN: soft, non tender, non distended. Normoactive bowel sounds. Kidney palpated in lower quadrant w/ out tenderness EXTREMITIES: 1+ pitting pretibial edema bilaterally. NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ============== Admission labs: ============== [MASKED] 05:30PM BLOOD WBC-13.2* RBC-3.25* Hgb-10.0* Hct-30.5* MCV-94 MCH-30.8 MCHC-32.8 RDW-12.9 RDWSD-44.1 Plt [MASKED] [MASKED] 05:30PM BLOOD Neuts-83.9* Lymphs-4.6* Monos-8.9 Eos-1.6 Baso-0.5 Im [MASKED] AbsNeut-11.08* AbsLymp-0.61* AbsMono-1.18* AbsEos-0.21 AbsBaso-0.06 [MASKED] 05:30PM BLOOD Plt [MASKED] [MASKED] 03:00AM BLOOD [MASKED] PTT-33.5 [MASKED] [MASKED] 05:30PM BLOOD Glucose-70 UreaN-34* Creat-2.1* Na-142 K-3.9 Cl-105 HCO3-23 AnGap-14 [MASKED] 05:30PM BLOOD CK-MB-6 [MASKED] [MASKED] 05:30PM BLOOD Albumin-2.8* Calcium-9.6 Phos-2.6* Mg-2.0 [MASKED] 03:00AM BLOOD Cyclspr-<30* ============== Discharge labs: ============== [MASKED] 05:59AM BLOOD WBC-7.5 RBC-2.75* Hgb-8.5* Hct-26.3* MCV-96 MCH-30.9 MCHC-32.3 RDW-13.2 RDWSD-44.9 Plt [MASKED] [MASKED] 05:59AM BLOOD Glucose-220* UreaN-49* Creat-2.2* Na-147* K-3.8 Cl-107 HCO3-29 AnGap-11 [MASKED] 05:59AM BLOOD TotProt-4.5* Calcium-9.5 Phos-3.2 Mg-2.0 [MASKED] 05:59AM BLOOD Cyclspr-84* ============== Other labs: ============== [MASKED] 05:30PM BLOOD cTropnT-0.26* [MASKED] 03:00AM BLOOD CK-MB-4 cTropnT-0.26* [MASKED] 02:51PM BLOOD CK-MB-4 cTropnT-0.19* [MASKED] 05:48AM BLOOD CK-MB-2 cTropnT-0.18* [MASKED] 12:39PM BLOOD CK-MB-3 cTropnT-0.19* [MASKED] 05:27AM BLOOD CK-MB-2 cTropnT-0.14* [MASKED] 05:59AM BLOOD PEP-AWAITING F FreeKap-42.6* FreeLam-47.9* Fr K/L-0.89 IgG-PND IgA-PND IgM-PND IFE-PND ============== Micro: ============== Blood and urine cultures negative ============== Imaging: ============== ECHO [MASKED] The left atrium is normal in size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Quantitative (3D) LVEF = 41%. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. IMPRESSION: Prominent symmetric LVH with mild global left ventricular systolic dysfunction. Small pericardial effusion. Elevated LVEDP. Compared with the prior study (images reviewed) of [MASKED], LV wall are thicker. LV systolic function has declined and there is now a pericardial effusion. Infiltrative cardiomyopathy, such as cardiac amyloidosis should be considered. Brief Hospital Course: [MASKED] yo F with ESRD s/p renal transplant [MASKED] (baseline Cr 1.5-2.0 w/biopsy with diabetic nephropathy and grade 2 IFTA [MASKED], hx of CAD, and HTN who presented to [MASKED] for SOB, found to have [MASKED] and elevated proBNP concerning for CHF exacerbation. #New systolic heart failure #Acute on chronic heart failure Pt presented w/three days of dyspnea and lower extremity edema. CXR w/pulmonary vascular congestion and proBNP >28,000. Trigger thought to be due to dietary non compliance (pt reported eating a lot of salty foods) and pt has not been taking diuretics despite worsening lower extremity swelling. Infectious triggers were ruled out. Troponin was elevated but this was thought to be d/t demand ischemia. An echo revealed new systolic dysfunction and prominent symmetric LVH with elevated filling pressures. She was diuresed with IV lasix during her hospitalization. Cardiology was consulted due to worsening EF and heart failure exacerbation. They recommended better blood pressure control (see below). Discussion was had regarding cardiac MRI with gadolinium given c/f infiltrative cardiomyopathy. Patient can not get gadolinium and cardiology believed that most likely etiology of wall thickening was related to hypertension and not an infiltrative process. SPEP, UPEP and light chains were checked but were pending at discharge. Furosemide was held upon discharge. #Hypertension Patient has history of supine hypertension and orthostatic hypotension, difficult to manage. She was only on metoprolol upon admission. Other drugs such as nifedipine and carvedilol have been tried in the past, but have caused dizziness/hypotension upon standing. Given her new echo findings and significant wall thickening, we adjusted her anti hypertensive agents. Metoprolol was discontinued. An [MASKED] was held due to [MASKED]. She was started on carvedilol 3.125 mg PO BID. Her blood pressures were noticeably higher in the evening. When we increased her carvedilol to 6.25 mg PO BID, her blood pressures dropped with standing and she became very symptomatic with dizziness. With this in mind, we reduced her carvedilol back to 3.125 mg PO BID and started her on PO hydralazine 10 mg and imdur 30 mg at night before bed. With this regimen, she remained hypertensive, but was no longer symptomatic upon standing and walking. Upon discharge, we increased her hydralazine to 25 mg PO at night and prescribed a nitroglycerin patch .2/hr to be worn only at night. #Type 2 Demand Ischemia Troponin peaked at .26 and CK MB remained flat. She had some STD in I, AVL, V4-V5, but these resolved and troponins downtrended. No regional wall motion abnormality on echo. Demand thought to be related to uncontrolled hypertension and acute heart failure exacerbation. #Hypoglycemia #Type 1 Diabetes Patient has very brittle type 1 diabetes that was somewhat difficult to manage during the hospital. She was kept on her home dose of insulin and sugars improved. #Acute kidney injury #End stage renal disease s/p transplant Cr slightly up upon admission to 2.1 (baseline 1.5 to 2.0). Renal US was WNL. C/f cardiorenal syndrome although urine Na > 20. Cr upon discharge was 2.2 Patient was continued on immunosuppression with prednisone, mycophenolate, and cyclosporine. Cyclosporine was increased from 25 BID to 50 BID. #Coronary artery disease 2V disease, s/p DES to LAD, Cx/OM in [MASKED], in place of CABG per patient preference. Pt was continued on aspirin, atrovastatin as well as ranexa 500 mg PO bid. **Transitional issues** [] MEDICATION CHANGES: --> Stopped metoprolol --> Stopped furosemide --> Started carvedilol 3.125 BID --> Started nitroglycerin patch (.2/hr) at night --> Started hydralazine 25 mg at night --> Increased cyclosporine from 25 mg BID to 50 mg BID [] Patient should have follow up labs within one week of discharge- CBC, CHEM 10 [] Patient should have follow up with cardiology [] Consider stress test as an outpatient [] Consider addition of an [MASKED] as an outpatient [] Follow up: UPEP, SPEP, Light chains Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Allopurinol [MASKED] mg PO DAILY 2. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 3. Ascorbic Acid [MASKED] mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Calcitriol 0.25 mcg PO DAILY 7. Calcium Carbonate 500 mg PO BID 8. Cilostazol 100 mg PO QAM 9. Cilostazol 50 mg PO QPM 10. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 11. Esomeprazole 40 mg Other BID 12. Ferrous Sulfate 325 mg PO DAILY 13. Mycophenolate Mofetil 500 mg PO BID 14. Levothyroxine Sodium 125 mcg PO DAILY 15. Metoprolol Succinate XL 25 mg PO DAILY 16. Ondansetron 4 mg PO Q8H:PRN nausea 17. PredniSONE 5 mg PO DAILY 18. Ranolazine ER 500 mg PO BID 19. Promethazine 25 mg PO DAILY PRN nausea 20. Vitamin D [MASKED] UNIT PO DAILY 21. Metoprolol Tartrate 12.5 mg PO QHS 22. Furosemide 20 mg PO DAILY PRN WEIGHT GAIN weight gain 23. Glargine 38 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Carvedilol 3.125 mg PO BID RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 2. HydrALAZINE 25 mg PO DAILY RX *hydralazine 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Nitroglycerin Patch 0.2 mg/hr TD Q24H RX *nitroglycerin 0.2 mg/hour Place on chest each evening Disp #*30 Patch Refills:*0 4. Glargine 38 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 5. Allopurinol [MASKED] mg PO DAILY 6. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 7. Ascorbic Acid [MASKED] mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Calcitriol 0.25 mcg PO DAILY 11. Calcium Carbonate 500 mg PO BID 12. Cilostazol 100 mg PO QAM 13. Cilostazol 50 mg PO QPM 14. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H RX *cyclosporine modified 50 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills:*0 15. Esomeprazole 40 mg Other BID 16. Ferrous Sulfate 325 mg PO DAILY 17. Levothyroxine Sodium 125 mcg PO DAILY 18. Mycophenolate Mofetil 500 mg PO BID 19. Ondansetron 4 mg PO Q8H:PRN nausea 20. PredniSONE 5 mg PO DAILY 21. Promethazine 25 mg PO DAILY PRN nausea 22. Ranolazine ER 500 mg PO BID 23. Vitamin D [MASKED] UNIT PO DAILY 24. HELD- Furosemide 20 mg PO DAILY PRN WEIGHT GAIN weight gain This medication was held. Do not restart Furosemide until you have discussed this with your cardiologist 25.Outpatient Lab Work Lab work: [MASKED] [MASKED] fax: [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary diagnosis: Acute on chronic systolic heart failure exacerbation Hypertension Type 2 Demand Ischemia Acute kidney injury Secondary diagnoses: Hypertension Type 1 Diabetes Coronary artery disease End stage renal disease s/p renal transpalnt Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: What brought you into the hospital? -You came to the hospital with difficulty breathing What happened while you were in the hospital? -We believe that your difficulty breathing was related to dysfunction of the heart and we treated you with medications called diuretics to help get rid of extra fluid. -We also started you on new medications for your high blood pressure. What should you do when you leave the hospital? -You should continue taking all of your home medications as prescribed. We have NOT made any changes to your insulin. Please take your insulin as prescribed by your endocrinologist. -We have made some changes to your medications and these are listed below. -Take the hydralazine before going to bed. Put the nitroglycerin patch on your chest (or arm) before going to bed. Remove the patch in the morning before you get up. We also started you on carvedilol, a medication that you will take twice per day. We increased your cyclosporine to 50 mg twice per day. You can stop taking your metoprolol and furosemide. -You should weigh yourself every day. If you gain more than three pounds in a day. Call your doctor. -[MASKED] you get lightheaded or dizzy, please call your primary care doctor or cardiologist. We may need to make some adjustments to your medications. -Please get your labs checked and have them sent to your kidney doctor within one week. It was a pleasure taking care of you. -Your [MASKED] team Medication changes: [] MEDICATION CHANGES: --> Stopped metoprolol --> Stopped furosemide --> Started carvedilol 3.125 BID --> Started nitroglycerin patch (.2/hr) at night --> Started hydralazine 25 mg at night --> Increased cyclosporine from 25 mg BID to 50 mg BID Followup Instructions: [MASKED]
|
[] |
[
"N179",
"M109",
"I2510",
"E785",
"E039",
"G4733",
"Z87891",
"Z955",
"I252",
"Z794"
] |
[
"I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease",
"I5023: Acute on chronic systolic (congestive) heart failure",
"N179: Acute kidney failure, unspecified",
"N186: End stage renal disease",
"M341: CR(E)ST syndrome",
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"K3184: Gastroparesis",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"I248: Other forms of acute ischemic heart disease",
"Z940: Kidney transplant status",
"I951: Orthostatic hypotension",
"E10649: Type 1 diabetes mellitus with hypoglycemia without coma",
"M109: Gout, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"N318: Other neuromuscular dysfunction of bladder",
"E785: Hyperlipidemia, unspecified",
"E039: Hypothyroidism, unspecified",
"D72829: Elevated white blood cell count, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"Z87891: Personal history of nicotine dependence",
"Z955: Presence of coronary angioplasty implant and graft",
"Z86711: Personal history of pulmonary embolism",
"I252: Old myocardial infarction",
"Z794: Long term (current) use of insulin"
] |
10,030,753
| 26,512,817
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female with a complex medical history presenting for
evaluation of hyperglycemia and hallucinations overnight.
Patient reports that she woke up from sleep went to her bathroom
and felt it was "evil", and went to the kitchen to grab a knife
and defend herself. She checked her sugar and it was 500. She
ultimately went back to sleep and was feeling better in the
morning, rechecked her sugar and it was in the 300s. She called
her relatives and her doctor and ultimately was told to go to
the ER for evaluation.
She has not had thoughts of suicide, thoughts of hurting any
people, has not been hearing any voices, does not have any
specific fixed thought patterns she can identify, and has no
recent ingestions of alcohol, tobacco, drugs.
Of note, the patient has a history of insulin-dependent type 1
diabetes, chronic kidney disease status post renal transplant,
currently on prednisone and mycophenolate, and a history of an
unexplained month-long episode of confusion for which she was
admitted during the ___ and which was never definitively
diagnosed. Patient is concerned because hallucinations such as
the one she had last night were the initial symptoms she
experienced during the ___ before her month-long episode.
Also of note, patient has been in the hospital almost weekly
over the past few months by her description. She was recently
placed on Cipro and Flagyl for cellulitis, today is her last
day.
Review of symptoms is notable for peripheral neuropathy. She
otherwise does not have fever, chills, headache or neck
stiffness, any other acute changes in her health status.
In the ED, initial vitals were: 98.2 162/73 103 18 100%RA
- Exam notable for: Physical and neurologic exams unremarkable.
Steady gait, Romberg negative, no neck stiffness.
- Labs notable for:
CBC WNL, diff with 92%N
Chem7
136/103/35
----------<412
5.___/1.7
VBG ___ lactate 1.1
UA with large leuk, few bacteria, moderate blood, 300 protein,
1000glucose, no ketones, 5 epis
- Imaging was notable for:
CT head non-contrast: no acute intracranial process
CXR PA lateral: No acute cardiopulmonary process.
- Renal Transplant was consulted:
- Check blood cultures, UA, urine culture.
- Check a CXR
- Check a cyclosporine level in AM as well
- Agree with management of hyperglycemia wit insulin.
- Put on a low K diet.
- CT head.
- Neuro checks.
- Differential : infection vs immunosuppresive meds induced
versus other causes- possible primary CNS / ___ events.
- Check lactate as well. Cycle trops and check EKG
- Resume IS as at home for now.
___ decision making:
Medical decision making: Hallucinations and hyperglycemia of
unclear etiology
Given her hyperglycemia, will obtain labs for workup for
possible DKA, in addition we will look for triggers of
hyperglycemia with full toxic metabolic and infectious workup.
Given her altered mental status overnight, new onset headaches
that woke her from sleep, and extremely complex history, will
also obtain CT scan of the head. Will treat with initial bolus
of fluids for hyperglycemia and continue her on her home
medications while continuing the workup.
[x] Follow-up repeat fingerstick after 1 L fluid -___ given
that labs do not show evidence of DKA, will treat this as
hyperglycemia with additional fluids and with insulin as per
sliding scale 10 units subcu now
- Patient was given:
1L NS
atorvastatin 20mg
calcium carbonate 500mg
cyclosporine 50mg
Mycophenolate Mofetil 500 mg
Insulin 10U
cilostazol 50mg
- Vitals prior to transfer: 97.7 164/92 16 100%RA (last FSBG at
2301 was 382)
Upon arrival to the floor, patient reports waking up overnight
the day prior to presentation with a "bad headache." Checked her
fingerstick blood glucose which was greater than 500 so she took
15 units of Humalog and went back to sleep after taking an
Aleve. When she awoke the next morning she spoke with her
sister, who recommended that she seek evaluation. Called her
outpatient neurologist, ___, who recommended that
she speak with her PCP and nephrologist. Given she had a
month-long episode of confusion in ___, she sought
evaluation at the twice daily ___ emergency room today. Over the
past few days she has felt more orthostatic than usual, feeling
so lightheaded upon standing that she only felt comfortable
making short snacks and meals, because she otherwise felt too
unwell to stand. She remains at her baseline nausea and
vomiting, having her last episode of nonbloody emesis morning of
presentation.
She reports that the headache is similar to headache she has
had in the past centered on top of her head and radiating to her
forehead. It began as an 8 out of 10 and improved to 2 out of 10
with Aleve.
She describes her episode of confusion as feeling that her
bathroom was "evil and although she felt an urge to go to her
kitchen and grabbed a knife to defend herself, she felt this was
"crazy" and did not grab a knife. She currently denies feeling
abnormal or having any unusual thoughts. She states that aside
from a mild headache, she feels otherwise like her usual self.
She reports completing a course of antibiotics and remembers
that she was due to see the infectious disease clinic in the
morning.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___
DES to LAD and Cx/OM ___
3. OTHER PAST MEDICAL HISTORY
End-stage renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
- Scleroderma w/ CREST syndrome
- Gastroparesis/GERD/Hiatal hernia
- Gout diagnosed ___ years ago
- OSA
-NOT ACCURATE: - Antiphospholipid antibody syndrome and remote
PE
history on Coumadin ___ - this diagnosis viewed unlikely per
___ hematology/oncology note; warfarin discontinued ___
Social History:
___
Family History:
Per OMR:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
=======================
ADMISSION
=======================
Vital Signs: 98.2 189/82 98 18 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
R>L eyelid edema/erythema
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNIII-XII intact, normal finger-nose-finger, no sensation
below knees (chronic), no pronator drift
=======================
DISCHARGE
=======================
Vitals: 97.9 191/97 97 18 98 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
R>L eyelid edema/erythema, no evidence of infection. Decreased
oral aperture.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, clubbing to toenails, no
cyanosis or edema
Neuro: CNIII-XII intact, normal finger-nose-finger, no sensation
below knees (chronic), no pronator drift
Pertinent Results:
=====================
ADMISSION LABS
=====================
___ 07:06PM BLOOD WBC-7.7# RBC-3.75* Hgb-11.5 Hct-34.7
MCV-93 MCH-30.7 MCHC-33.1 RDW-14.1 RDWSD-48.0* Plt ___
___ 07:06PM BLOOD Neuts-91.9* Lymphs-4.6* Monos-2.7*
Eos-0.1* Baso-0.4 Im ___ AbsNeut-7.05*# AbsLymp-0.35*
AbsMono-0.21 AbsEos-0.01* AbsBaso-0.03
___ 07:06PM BLOOD Glucose-412* UreaN-35* Creat-1.7* Na-136
K-5.7* Cl-103 HCO3-23 AnGap-16
___ 07:17PM BLOOD Lactate-1.1 K-5.6*
=====================
PERTINENT RESULTS
=====================
___ 07:35AM BLOOD TSH-0.60
___ 07:35AM BLOOD Cyclspr-74*
=====================
MICROBIOLOGY
=====================
__________________________________________________________
___ 10:55 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 7:06 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
=====================
IMAGING
=====================
CXR (___): No acute cardiopulmonary process.
===
NCHCT (___): No acute intracranial process.
=====================
DISCHARGE LABS
=====================
___ 07:35AM BLOOD WBC-5.4 RBC-3.27* Hgb-9.8* Hct-30.4*
MCV-93 MCH-30.0 MCHC-32.2 RDW-14.5 RDWSD-49.1* Plt ___
___ 07:35AM BLOOD Glucose-150* UreaN-35* Creat-1.5* Na-138
K-4.3 Cl-106 HCO3-25 AnGap-11
___ 07:35AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.9
Brief Hospital Course:
The patient is a ___ y/o woman with history of ESRD s/p living
renal transplant in ___ on immunosuppression, DM1,
scleroderma/CREST, and CAD s/p MI presenting after an episode of
confusion and headache with associated hyperglycemia to the
400s.
After the patient was admitted to the hospital, she noted that
her confusion and headache had improved and that she felt to be
back at her baseline. She was noted to be hypertensive when
lying flat, however this improved when sitting up, consistent
with her known diagnosis of autonomic dysfunction. She was
continued on her home medications.
She was found to have a positive urinalysis on admission. She
was started on ciprofloxacin, with plan to continue for 5 day
course.
In regards to her preseptal cellulitis, she was scheduled to
follow up with ID on ___, however she missed her appointment
due to her hospitalization. She completed her antibiotic course
and her cellulitis was noted to have greatly improved since her
hospital discharge.
==========================
TRANSITIONAL ISSUES:
==========================
-patient was found to have a urinary tract infection. She was
started on ciprofloxacin on ___ for total 5 day course. Her
urine culture was contaminated.
-she was noted to be hyperglycemic and hypertensive on
admission, both of which improved during her hospital stay
-her cyclosporine level was noted to be 74 on ___. She will
have her next cyclosporine level checked on ___, ___ at the
transplant clinic. Please repeat CBC and chemistries at next
outpatient appointment.
-she was discharged on her home dose of insulin and her home
dose of immunosuppressants
-she had been placed on Plavix last year, however this was
discontinued in the setting of bleeding in addition to
concurrent warfarin use. The patient is no longer on Plavix.
Recommend discussion with outpatient cardiologist regarding
indication for Plavix and if appropriate to restart in this
patient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Calcitriol 0.25 mcg PO DAILY
5. Calcium Carbonate 500 mg PO BID
6. Cilostazol 100 mg PO QAM
7. Cilostazol 50 mg PO QPM
8. Esomeprazole 40 mg Other BID
9. Furosemide 20 mg PO DAILY PRN WEIGHT GAIN weight gain
10. Ferrous Sulfate 325 mg PO DAILY
11. Levothyroxine Sodium 125 mcg PO DAILY
12. PredniSONE 5 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. Mycophenolate Mofetil 500 mg PO BID
15. Metoprolol Succinate XL 25 mg PO DAILY
16. Promethazine 25 mg PO DAILY PRN nausea
17. Ranolazine ER 500 mg PO BID
18. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
19. Cefpodoxime Proxetil 200 mg PO Q12H
20. MetroNIDAZOLE 500 mg PO Q8H
21. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
22. Metoprolol Tartrate 12.5 mg PO QHS
23. Ondansetron 4 mg PO Q8H
24. Allopurinol ___ mg PO DAILY
25. Glargine 20 Units Breakfast
Glargine 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
Please take for 5 days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*10 Tablet Refills:*0
2. Allopurinol ___ mg PO DAILY
3. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
4. Ascorbic Acid ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 20 mg PO QPM
7. Calcitriol 0.25 mcg PO DAILY
8. Calcium Carbonate 500 mg PO BID
9. Cilostazol 100 mg PO QAM
10. Cilostazol 50 mg PO QPM
11. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
12. Esomeprazole 40 mg Other BID
13. Ferrous Sulfate 325 mg PO DAILY
14. Furosemide 20 mg PO DAILY PRN WEIGHT GAIN weight gain
15. Glargine 20 Units Breakfast
Glargine 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
16. Levothyroxine Sodium 125 mcg PO DAILY
17. Metoprolol Succinate XL 25 mg PO DAILY
18. Metoprolol Tartrate 12.5 mg PO QHS
19. Mycophenolate Mofetil 500 mg PO BID
20. Ondansetron 4 mg PO Q8H
21. PredniSONE 5 mg PO DAILY
22. Promethazine 25 mg PO DAILY PRN nausea
23. Ranolazine ER 500 mg PO BID
24. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary Tract Infection
Hyperglycemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you. You were admitted to the
___ for your symptoms of
hallucinations, hyperglycemia, and hypertension. While you were
here lab tests were performed. You were closely monitored in the
hospital. Your blood pressure was noted to be stable compared to
your home blood pressure readings, and your blood glucose
improved.
You were found to have a urinary tract infection. You were
started on antibiotics for this. Please continue these
antibiotics for 5 days. Please continue to check your blood
glucose regularly. Please continue to check your blood pressure
regularly.
Please report to the transplant clinic on ___ to
have your labs drawn, including your cyclosporine level.
Please be sure to follow up with your primary care doctor within
___ weeks after hospital discharge.
We wish you the best in your health,
Your ___ Care Team
Followup Instructions:
___
|
[
"N390",
"E1065",
"E1022",
"I120",
"N186",
"Z940",
"L03213",
"Z955",
"Z87891",
"I252",
"Z7902",
"Z794",
"N319",
"M341",
"R51",
"G901",
"I2510",
"E785",
"E039",
"M109",
"Z86711",
"E10319",
"K219",
"K449",
"E1043",
"K3184",
"E1042",
"G4733"
] |
Allergies: Penicillins / Ativan Chief Complaint: Confusion Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] female with a complex medical history presenting for evaluation of hyperglycemia and hallucinations overnight. Patient reports that she woke up from sleep went to her bathroom and felt it was "evil", and went to the kitchen to grab a knife and defend herself. She checked her sugar and it was 500. She ultimately went back to sleep and was feeling better in the morning, rechecked her sugar and it was in the 300s. She called her relatives and her doctor and ultimately was told to go to the ER for evaluation. She has not had thoughts of suicide, thoughts of hurting any people, has not been hearing any voices, does not have any specific fixed thought patterns she can identify, and has no recent ingestions of alcohol, tobacco, drugs. Of note, the patient has a history of insulin-dependent type 1 diabetes, chronic kidney disease status post renal transplant, currently on prednisone and mycophenolate, and a history of an unexplained month-long episode of confusion for which she was admitted during the [MASKED] and which was never definitively diagnosed. Patient is concerned because hallucinations such as the one she had last night were the initial symptoms she experienced during the [MASKED] before her month-long episode. Also of note, patient has been in the hospital almost weekly over the past few months by her description. She was recently placed on Cipro and Flagyl for cellulitis, today is her last day. Review of symptoms is notable for peripheral neuropathy. She otherwise does not have fever, chills, headache or neck stiffness, any other acute changes in her health status. In the ED, initial vitals were: 98.2 162/73 103 18 100%RA - Exam notable for: Physical and neurologic exams unremarkable. Steady gait, Romberg negative, no neck stiffness. - Labs notable for: CBC WNL, diff with 92%N Chem7 136/103/35 ----------<412 5.[MASKED]/1.7 VBG [MASKED] lactate 1.1 UA with large leuk, few bacteria, moderate blood, 300 protein, 1000glucose, no ketones, 5 epis - Imaging was notable for: CT head non-contrast: no acute intracranial process CXR PA lateral: No acute cardiopulmonary process. - Renal Transplant was consulted: - Check blood cultures, UA, urine culture. - Check a CXR - Check a cyclosporine level in AM as well - Agree with management of hyperglycemia wit insulin. - Put on a low K diet. - CT head. - Neuro checks. - Differential : infection vs immunosuppresive meds induced versus other causes- possible primary CNS / [MASKED] events. - Check lactate as well. Cycle trops and check EKG - Resume IS as at home for now. [MASKED] decision making: Medical decision making: Hallucinations and hyperglycemia of unclear etiology Given her hyperglycemia, will obtain labs for workup for possible DKA, in addition we will look for triggers of hyperglycemia with full toxic metabolic and infectious workup. Given her altered mental status overnight, new onset headaches that woke her from sleep, and extremely complex history, will also obtain CT scan of the head. Will treat with initial bolus of fluids for hyperglycemia and continue her on her home medications while continuing the workup. [x] Follow-up repeat fingerstick after 1 L fluid -[MASKED] given that labs do not show evidence of DKA, will treat this as hyperglycemia with additional fluids and with insulin as per sliding scale 10 units subcu now - Patient was given: 1L NS atorvastatin 20mg calcium carbonate 500mg cyclosporine 50mg Mycophenolate Mofetil 500 mg Insulin 10U cilostazol 50mg - Vitals prior to transfer: 97.7 164/92 16 100%RA (last FSBG at 2301 was 382) Upon arrival to the floor, patient reports waking up overnight the day prior to presentation with a "bad headache." Checked her fingerstick blood glucose which was greater than 500 so she took 15 units of Humalog and went back to sleep after taking an Aleve. When she awoke the next morning she spoke with her sister, who recommended that she seek evaluation. Called her outpatient neurologist, [MASKED], who recommended that she speak with her PCP and nephrologist. Given she had a month-long episode of confusion in [MASKED], she sought evaluation at the twice daily [MASKED] emergency room today. Over the past few days she has felt more orthostatic than usual, feeling so lightheaded upon standing that she only felt comfortable making short snacks and meals, because she otherwise felt too unwell to stand. She remains at her baseline nausea and vomiting, having her last episode of nonbloody emesis morning of presentation. She reports that the headache is similar to headache she has had in the past centered on top of her head and radiating to her forehead. It began as an 8 out of 10 and improved to 2 out of 10 with Aleve. She describes her episode of confusion as feeling that her bathroom was "evil and although she felt an urge to go to her kitchen and grabbed a knife to defend herself, she felt this was "crazy" and did not grab a knife. She currently denies feeling abnormal or having any unusual thoughts. She states that aside from a mild headache, she feels otherwise like her usual self. She reports completing a course of antibiotics and remembers that she was due to see the infectious disease clinic in the morning. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED] 3. OTHER PAST MEDICAL HISTORY End-stage renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] - Scleroderma w/ CREST syndrome - Gastroparesis/GERD/Hiatal hernia - Gout diagnosed [MASKED] years ago - OSA -NOT ACCURATE: - Antiphospholipid antibody syndrome and remote PE history on Coumadin [MASKED] - this diagnosis viewed unlikely per [MASKED] hematology/oncology note; warfarin discontinued [MASKED] Social History: [MASKED] Family History: Per OMR: Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: ======================= ADMISSION ======================= Vital Signs: 98.2 189/82 98 18 97%RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. R>L eyelid edema/erythema Neck: Supple. JVP not elevated. no LAD CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNIII-XII intact, normal finger-nose-finger, no sensation below knees (chronic), no pronator drift ======================= DISCHARGE ======================= Vitals: 97.9 191/97 97 18 98 RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. R>L eyelid edema/erythema, no evidence of infection. Decreased oral aperture. Neck: Supple. JVP not elevated. no LAD CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, clubbing to toenails, no cyanosis or edema Neuro: CNIII-XII intact, normal finger-nose-finger, no sensation below knees (chronic), no pronator drift Pertinent Results: ===================== ADMISSION LABS ===================== [MASKED] 07:06PM BLOOD WBC-7.7# RBC-3.75* Hgb-11.5 Hct-34.7 MCV-93 MCH-30.7 MCHC-33.1 RDW-14.1 RDWSD-48.0* Plt [MASKED] [MASKED] 07:06PM BLOOD Neuts-91.9* Lymphs-4.6* Monos-2.7* Eos-0.1* Baso-0.4 Im [MASKED] AbsNeut-7.05*# AbsLymp-0.35* AbsMono-0.21 AbsEos-0.01* AbsBaso-0.03 [MASKED] 07:06PM BLOOD Glucose-412* UreaN-35* Creat-1.7* Na-136 K-5.7* Cl-103 HCO3-23 AnGap-16 [MASKED] 07:17PM BLOOD Lactate-1.1 K-5.6* ===================== PERTINENT RESULTS ===================== [MASKED] 07:35AM BLOOD TSH-0.60 [MASKED] 07:35AM BLOOD Cyclspr-74* ===================== MICROBIOLOGY ===================== [MASKED] [MASKED] 10:55 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] [MASKED] 7:06 pm BLOOD CULTURE Blood Culture, Routine (Pending): ===================== IMAGING ===================== CXR ([MASKED]): No acute cardiopulmonary process. === NCHCT ([MASKED]): No acute intracranial process. ===================== DISCHARGE LABS ===================== [MASKED] 07:35AM BLOOD WBC-5.4 RBC-3.27* Hgb-9.8* Hct-30.4* MCV-93 MCH-30.0 MCHC-32.2 RDW-14.5 RDWSD-49.1* Plt [MASKED] [MASKED] 07:35AM BLOOD Glucose-150* UreaN-35* Creat-1.5* Na-138 K-4.3 Cl-106 HCO3-25 AnGap-11 [MASKED] 07:35AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.9 Brief Hospital Course: The patient is a [MASKED] y/o woman with history of ESRD s/p living renal transplant in [MASKED] on immunosuppression, DM1, scleroderma/CREST, and CAD s/p MI presenting after an episode of confusion and headache with associated hyperglycemia to the 400s. After the patient was admitted to the hospital, she noted that her confusion and headache had improved and that she felt to be back at her baseline. She was noted to be hypertensive when lying flat, however this improved when sitting up, consistent with her known diagnosis of autonomic dysfunction. She was continued on her home medications. She was found to have a positive urinalysis on admission. She was started on ciprofloxacin, with plan to continue for 5 day course. In regards to her preseptal cellulitis, she was scheduled to follow up with ID on [MASKED], however she missed her appointment due to her hospitalization. She completed her antibiotic course and her cellulitis was noted to have greatly improved since her hospital discharge. ========================== TRANSITIONAL ISSUES: ========================== -patient was found to have a urinary tract infection. She was started on ciprofloxacin on [MASKED] for total 5 day course. Her urine culture was contaminated. -she was noted to be hyperglycemic and hypertensive on admission, both of which improved during her hospital stay -her cyclosporine level was noted to be 74 on [MASKED]. She will have her next cyclosporine level checked on [MASKED], [MASKED] at the transplant clinic. Please repeat CBC and chemistries at next outpatient appointment. -she was discharged on her home dose of insulin and her home dose of immunosuppressants -she had been placed on Plavix last year, however this was discontinued in the setting of bleeding in addition to concurrent warfarin use. The patient is no longer on Plavix. Recommend discussion with outpatient cardiologist regarding indication for Plavix and if appropriate to restart in this patient Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ascorbic Acid [MASKED] mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Calcitriol 0.25 mcg PO DAILY 5. Calcium Carbonate 500 mg PO BID 6. Cilostazol 100 mg PO QAM 7. Cilostazol 50 mg PO QPM 8. Esomeprazole 40 mg Other BID 9. Furosemide 20 mg PO DAILY PRN WEIGHT GAIN weight gain 10. Ferrous Sulfate 325 mg PO DAILY 11. Levothyroxine Sodium 125 mcg PO DAILY 12. PredniSONE 5 mg PO DAILY 13. Vitamin D [MASKED] UNIT PO DAILY 14. Mycophenolate Mofetil 500 mg PO BID 15. Metoprolol Succinate XL 25 mg PO DAILY 16. Promethazine 25 mg PO DAILY PRN nausea 17. Ranolazine ER 500 mg PO BID 18. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 19. Cefpodoxime Proxetil 200 mg PO Q12H 20. MetroNIDAZOLE 500 mg PO Q8H 21. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 22. Metoprolol Tartrate 12.5 mg PO QHS 23. Ondansetron 4 mg PO Q8H 24. Allopurinol [MASKED] mg PO DAILY 25. Glargine 20 Units Breakfast Glargine 8 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days Please take for 5 days RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*10 Tablet Refills:*0 2. Allopurinol [MASKED] mg PO DAILY 3. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 4. Ascorbic Acid [MASKED] mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. Calcitriol 0.25 mcg PO DAILY 8. Calcium Carbonate 500 mg PO BID 9. Cilostazol 100 mg PO QAM 10. Cilostazol 50 mg PO QPM 11. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 12. Esomeprazole 40 mg Other BID 13. Ferrous Sulfate 325 mg PO DAILY 14. Furosemide 20 mg PO DAILY PRN WEIGHT GAIN weight gain 15. Glargine 20 Units Breakfast Glargine 8 Units Dinner Insulin SC Sliding Scale using HUM Insulin 16. Levothyroxine Sodium 125 mcg PO DAILY 17. Metoprolol Succinate XL 25 mg PO DAILY 18. Metoprolol Tartrate 12.5 mg PO QHS 19. Mycophenolate Mofetil 500 mg PO BID 20. Ondansetron 4 mg PO Q8H 21. PredniSONE 5 mg PO DAILY 22. Promethazine 25 mg PO DAILY PRN nausea 23. Ranolazine ER 500 mg PO BID 24. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Urinary Tract Infection Hyperglycemia Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], [MASKED] was a pleasure taking care of you. You were admitted to the [MASKED] for your symptoms of hallucinations, hyperglycemia, and hypertension. While you were here lab tests were performed. You were closely monitored in the hospital. Your blood pressure was noted to be stable compared to your home blood pressure readings, and your blood glucose improved. You were found to have a urinary tract infection. You were started on antibiotics for this. Please continue these antibiotics for 5 days. Please continue to check your blood glucose regularly. Please continue to check your blood pressure regularly. Please report to the transplant clinic on [MASKED] to have your labs drawn, including your cyclosporine level. Please be sure to follow up with your primary care doctor within [MASKED] weeks after hospital discharge. We wish you the best in your health, Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"N390",
"Z955",
"Z87891",
"I252",
"Z7902",
"Z794",
"I2510",
"E785",
"E039",
"M109",
"K219",
"G4733"
] |
[
"N390: Urinary tract infection, site not specified",
"E1065: Type 1 diabetes mellitus with hyperglycemia",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease",
"N186: End stage renal disease",
"Z940: Kidney transplant status",
"L03213: Periorbital cellulitis",
"Z955: Presence of coronary angioplasty implant and graft",
"Z87891: Personal history of nicotine dependence",
"I252: Old myocardial infarction",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"Z794: Long term (current) use of insulin",
"N319: Neuromuscular dysfunction of bladder, unspecified",
"M341: CR(E)ST syndrome",
"R51: Headache",
"G901: Familial dysautonomia [Riley-Day]",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"E785: Hyperlipidemia, unspecified",
"E039: Hypothyroidism, unspecified",
"M109: Gout, unspecified",
"Z86711: Personal history of pulmonary embolism",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"K219: Gastro-esophageal reflux disease without esophagitis",
"K449: Diaphragmatic hernia without obstruction or gangrene",
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"K3184: Gastroparesis",
"E1042: Type 1 diabetes mellitus with diabetic polyneuropathy",
"G4733: Obstructive sleep apnea (adult) (pediatric)"
] |
10,030,753
| 26,611,680
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___
Chief Complaint:
Urosepsis
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Ms. ___ is a ___ yo woman with history of ESRD (s/p LURT
___ on cyclosporine, prednisone 5 mg daily), anemia, CAD s/p
___ 4 (most recently ___, HFrEF (EF ~40%), IPMN (___),
HTN,
T1DM complicated by neuropathy, retinopathy, neurogenic bladder
(intermittent straight catheterization), autonomic dysfunction
and h/o multiple UTIs(Klebsiella, E.coli, Enterococcus), OSA,
recent ischemic stroke, and scleroderma/CREST who presents to
the
ICU with altered mental status requiring intubation in the
emergency department.
Per her sisters, the pt has not been at her mental baseline
since
her recent discharge from the hospital. She had previously been
using a rolling walker, but instead was now using Hoyer lifts.
Per the sisters, pt had also recently started on linezolid for
presumed UTI a few days prior to presentation.
The patient was seen by her cardiologist (Dr ___ in
clinic on the day of presentation (___) and was found to by
hypotensive to 78/58 and was thought to be cool on exam. Her
mental status at the office visit was "falling asleep in the
wheel chair with no response to questions and intermittently
opening eyes." The patient was urgently referred to the
emergency
department.
She presented to ___ and ___ pressures had
spontaneously
improved to 169/90. She was promptly transferred to ___.
In the ED, the ED resident reports her initial exam was notable
for disconjugate gaze and LUE rigidity as well as marked
obtundation. She was hypoxemic to 89%. She was intubated for
airway control and code stroke was called. She was briefly
started on nifedipine drip due to concern for ICH. CT showed no
acute changes, but global volume loss and changes consistent
with
known prior strokes. The blood glucose on her chemistry panel
was
34.
It was then recognized that her L hemiparesis is from a recent
stroke.
Labs as below. Her urine from ___ was positive for
nitrites, leuk esterase, and WBC and she was started on
linezolid. She was then transferred to the ICU.
Of note, she had been seen extensively by palliative care during
her last admission and recently as an outpatient. She has been
having some functional decline for several months to years, and
at one point considered enrolling in hospice.
In the ED,
- Initial Vitals:
T 98.2 HR75 BP171/82 RR18 97% RA
- Exam: per ED resident, initial exam with disconjugate gaze,
LUE rigidity.
- Labs:
143 / 104 / 87
--------------<34 AGap=18
4.4 / ___ / 4.0
Wbc 6.4 Hgb 8.6 plt 103
Lactate:1.2
UA here: Large leuks, large blood, positive nitrites, > 50 WBC,
many bacteria
- Imaging:
1. No acute intracranial process.
2. Redemonstration of multiple chronic infarcts, global
parenchymal volume loss and sequela of chronic small vessel
disease.
3. Unchanged moderate paranasal sinus disease.
- Consults: Renal Transplant
- Interventions:
___ 22:20 IV Dextrose 50% 25 gm
___ 02:00 IV Etomidate 20 mg
___ 02:00 IV Succinylcholine 100 mg
___ 02:25 IV Dextrose 50% 25 gm
___ 03:17 IV DRIP NiCARdipine ___ mcg/kg/min ordered)
___ 03:17 IV DRIP Fentanyl Citrate ___ mcg/hr ordered)
___ 03:17 IV DRIP Propofol ___ mcg/kg/min ordered)
___ 03:21 IV Linezolid ___ mg ___
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
-CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___ DES to LAD ___
PCI of Cx and OM with ___
-___ renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
-Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
-Dysautonomia
-Hypertension
-Dyslipidemia
-Scleroderma w/ CREST syndrome
-Gastroparesis/GERD/Hiatal hernia
-Gout diagnosed ___ years ago
-OSA
-Pancreatic cyst
-Non convulsive status epilepticus
-stroke
-BPPV
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T 98.8 HR 81 BP 152/59 100% on FiO2 40%, CMV ___
GEN: intubated and sedated
EYES: anicteric
HENNT: poor dentition, ETT in place
CV: RRR with ___ at LUSB
RESP: Anterior lung fields are clear
GI: Soft and non-distended
SKIN: LLQ bruise and vaginal winer
NEURO: non-responsive, not following commands
DISCHARGE PHYSICAL EXAM:
VS: ___ 0729 Temp: 98.2 PO BP: 125/59 L Lying HR: 78 RR: 18
O2 sat: 96% O2 delivery: Ra
GEN: NAD, appears comfortable, sitting up in bed,
LUNGS: CTAB
HEART: RRR, nl S1, S2. III/VI SEM
EXTREMITIES: Trace ___ edema. WWP. tenderness on palpation of the
left forearm. Multiple wounds on ___ with eschar (lateral Rt and
Lt thigh the worst), improving from previously
NEURO: AOx2-3, no spontaneous conversation but answers
appropriate with elaborate answers
Pertinent Results:
ADMISSION LABS
===============
___ 08:54PM BLOOD WBC-6.4 RBC-2.52* Hgb-8.6* Hct-27.5*
MCV-109* MCH-34.1* MCHC-31.3* RDW-13.5 RDWSD-54.4* Plt ___
___ 01:15AM BLOOD ___ PTT-28.2 ___
___ 08:54PM BLOOD Glucose-34* UreaN-87* Creat-4.0* Na-143
K-4.4 Cl-104 HCO3-21* AnGap-18
___ 01:15AM BLOOD ALT-23 AST-21 CK(CPK)-158 AlkPhos-84
TotBili-0.5
___ 07:49AM BLOOD Calcium-8.2* Phos-4.7* Mg-2.1
___ 01:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:30AM BLOOD ___ pO2-64* pCO2-43 pH-7.35
calTCO2-25 Base XS--1
___ 09:09PM BLOOD Lactate-1.2
___ 01:30AM BLOOD Glucose-52* Creat-4.1* Na-139 K-4.3
Cl-108 calHCO3-23
___ 01:30AM BLOOD O2 Sat-86
DISCHARGE LABS
===============
___ 06:20AM BLOOD WBC-8.7 RBC-3.14* Hgb-10.1* Hct-32.7*
MCV-104* MCH-32.2* MCHC-30.9* RDW-19.4* RDWSD-73.3* Plt ___
___ 06:02AM BLOOD ___ PTT-29.8 ___
___ 10:27AM BLOOD Glucose-155* UreaN-55* Creat-2.7* Na-146
K-5.1 Cl-107 HCO3-27 AnGap-12
___ 06:20AM BLOOD ALT-5 AST-10 AlkPhos-104 TotBili-0.2
___ 06:02AM BLOOD Cyclspr-65*
OTHER RELEVANT LABS
===================
___ 7:54 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Preliminary):
RARE GROWTH Commensal Respiratory Flora.
ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH.
Piperacillin/Tazobactam test result performed by ___
___.
Levofloxacin REQUESTED BY ___ (___) ON ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFTAZIDIME----------- =>___ R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
LEVOFLOXACIN----------<=0.12 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 2:30 am URINE
URINE CULTURE (Preliminary):
PSEUDOMONAS AERUGINOSA.
>100,000 CFU/mL OF TWO COLONIAL MORPHOLOGIES.
Piperacillin/Tazobactam test result performed by ___
___.
Levofloxacin Susceptibility testing requested per ___.
___
(___), ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
___ 8:20 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Culture (Preliminary):
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
___ 10:35 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL.
Piperacillin/Tazobactam test result performed by ___
___.
cefepime test result confirmed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 8 S
CEFTRIAXONE----------- 8 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING/STUDIES
================
___ MRI
1. No acute infarct or intracranial hemorrhage.
2. Numerous late subacute to chronic infarcts, as previously
seen.
3. Chronic microvascular angiopathy changes.
4. Moderate paranasal sinus disease, as above.
___ EEG
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because
of diffuse background slowing indicative of mild to moderate
encephalopathy,
nonspecific as to etiology. Common causes include
toxic/metabolic
disturbances, medication effects and/or infection. Frequent
generalized
epileptiform discharges with a frontal predominance are
indicative of diffuse
cortical irritability. There are no electrographic seizures
___ US
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ CXR
Unchanged left pleural effusion with associated atelectasis. No
new focal
consolidations.
___ Lumbar XR
No previous images. The vertebra, intervertebral disc spaces,
and alignment
are essentially within normal limits with minimal hypertrophic
spurring. No evidence of compression fracture.
Extensive vascular calcification.
___ CXR
Interval decrease in extent of pulmonary vascular congestion.
No new
consolidation. Persisting retrocardiac opacities likely
reflecting
atelectasis/consolidation and pleural fluid.
___ RUQUS
No ascites.
Pancreatic cystic lesions as seen previously.
Left pleural effusion.
================
PATHOLOGY
Skin, right thigh ___:
___ Mild dermal sclerosis and fat necrosis (see comment).
Comment. Sections show a small punch biopsy consisting of
epidermis, dermis and minimal
subcutaneous fat. The histologic changes are not well developed
nor are they specifically diagnostic.
There is mild dermal sclerosis, minimal perivascular lymphocytic
inflammation and mild fat necrosis
at the biopsy base. Definitive vascular, perivascular or
perieccrine calcification to support a
diagnosis of calciphylaxis is not identified on ___ stains
(performed x 3). Intravascular thrombi
are not seen on multiple routine stains taken through the entire
tissue block, or on a PAS stain.
Given the possibility that this small and relatively superficial
biopsy is not representative of
immediately adjacent or underlying pathology, if there is
continuing concern for calciphylaxis a
repeat biopsy to include the subcutaneous fat may yield
additional information. Correlation with the
clinical findings is suggested.
Preliminary case findings discussed with Dr. ___
team by Dr. ___ on ___ and
___, respectively.
.
Final case findings sent by ___ internal email to Dr. ___
___ by Dr. ___ on ___.
Brief Hospital Course:
SUMMARY:
___ poorly-controlled T1DM c/b ESRD s/p LURT on
immunosuppression c/b chronic allograft dysfunction, recurrent
MDR UTI's, CAD s/p DES x4, HFrEF (LVEF 40% in ___,
scleroderma/CREST, prior ischemic strokes c/b L hemiparesis, and
HTN who was admitted to the MICU with acute encephalopathy
requiring intubation likely ___ pseudomonal urosepsis, now s/p
antibiotic treatment for complicated UTI. She also developed a
ventilator associated pneumonia, which was treated with
antibiotics as below. She was then transferred to the medical
service for ongoing toxic metabolic encephalopathy, which slowly
improved by the time of discharge. She did develop volume
overload (in the setting of known CKD and HFmrEF) requiring IV
diuresis and was transitioned to PO diuresis. She also developed
worsening lower extremity pain, with thorough workup for
calciphyalxis including skin biopsy which was negative. She also
developed recurrent UTI with enterobacter, treated with
ciprofloxacin course to end ___. She will then transition to
fosfomycin qweekly with ID follow up.
TRANSITIONAL ISSUES:
==================
- F/u Appts: PCP after rehab, ID, Cardiology, Renal Transplant
- F/u Labs: CBC, Chem, cyclosporine level ___ (fax cyclosporine
to ___ renal tx as below)
ID:
[ ] Ciprofloxacin x14d ending ___. Then resume fosfomycin 3g
QWK indefinitely to prevent recurrence of UTI (fris dose ___.
ID will follow as outpatient to consider changing agents given
pt had UTI on fosfomycin
BP:
[ ] While inpt labile blood pressure currently controlled with
clonidine patch, hydralazine, metoprolol and isosorbide. These
medications should be titrated as needed for adequate control
CHF:
[ ] On discharge: Cr ___, wt ___ kg.
[ ] Volume status is difficult to control. Continue to follow
based on volume exam and chemistry weekly. If Cr goes up hold
torsemide or if increased cough, edema, increase torsemide to 40
mg
[ ] Ensure patient follows up at above renal and cardiovascular
appointments
Immunosuppression:
[ ] Continue cyclosporine 50 mg BID with goal cyclosporine
troughs of 50. Check weekly and fax to ___ Kidney Transplant
Center, attn: ___, MD fax: fax number: ___,
ph: ___
[ ] MMF will be held indefinitely pending renal followup given
recurrent UTIs
Pain management/Alertness
[ ] Patient was restarted on gabapentin 100 mg BID, which can be
titrated up to total daily dose of 700 mg, assuming stable
mental status as dosing are uptitrated
[ ] Started on modafinil to increase alertness. Continue to
address need
[ ] Please administer oxycodone 5 mg prior to ___ and dressing
changes
Wounds
[ ] Pt will need continued aggressive wound management and
monitoring per RN report
[ ] Please administer oxycodone 5 mg prior to dressing changes
[ ] If worsening, consider dermatology referral for repeat skin
biopsy for calciphylaxis (bx ___ negative) vs vascular surgery
for PAD evaluation
#CODE: DNR/OK to intubate with limited trial (confirmed)
#CONTACT: ___ (sister), ___ (home),
___ (cell)
ACUTE ISSUES:
=============
#Recurrent UTIs
#Acute complicated Pseudomonal UTI:
History of MDR UTI's, likely iso neurogenic bladder, now found
to have Pseudomonal UTI c/b urosepsis. S/p IV cefepime from
___. Completed meropenem course on ___, then transitioned
to weekly prophylactic fosfomycin 3g. She did develop another
UTI with fever, eventually growing Enterobacter. She was treated
with cefepime and transitioned to cipro to complete 10d course
___. ID consulted and plan to return to fosfomycin 3g weekly
pending ID f/u as outpt.
#Ventilator-associated Enterobacter PNA: Course c/b Enterobacter
VAP given new fevers, increasing WBC, and consolidation on CXR
s/p intubation. Sputum culture with Enterobacter. Now extubated
and clinically improving without supplemental O2 requirement.
MRSA negative. s/p IV meropenem course as above.
#Acute toxic-metabolic encephalopathy: Most likely ___ sepsis
superimposed on poor neurologic baseline, exacerbated by uremia,
episodes of hypoglycemia, and likely poor clearance of sedatives
___ renal dysfunction. Dedicated cerebral imaging and cvEEG
otherwise reassuring. SLP previously recommended NPO given
aspiration risk. After NGT removed, passed patient SLP swallow
eval and did not require NGT replacement. She continued to
improve but required pain management for ___ wounds causing
sleepiness. She was started on modafinil with improvement.
#HFmrEF
The patient developed worsening volume overload requiring IV
diuresis. She was transitioned to PO diuresis with PO torsemide
at 40 mg, but eventually her Cr slowly rose. It was held with Cr
return to baseline 2.7. She was then restarted on torsemide 20.
Cr ___, wt ___ kg. Her volume status, electrolytes, and
renal function should be monitored closely at rehab and her
diuretic adjusted accordingly.
# Leg Wounds
# ___ Pain
Patient developed worsening leg ulcerations and pain. Initial
concern for calciphylaxis and underwent dermatologic workup with
biopsy ___, which was ultimately negative. Derm felt confident
that this was not calciphylaxis and repeat bx was not pursued.
Her wounds continued to evolve but eventually stabilized with
aggressive wound care. Her pain was controlled with Tylenol,
standing tramadol, gabapentin, oxycodone breakthrough as needed.
#Subacute-on-chronic renal failure
#ESRD s/p LURT (___)
Has chronic allograft dysfunction ___ diabetic nephropathy and
interstitial fibrosis/tubular atrophy seen on ___ kidney
biopsy. Admission renal ultrasound redemonstrated graft
dysfunction. Continued home calcitriol, cyclosporine with daily
level checks (increased now to cyclosporine 50 mg BID). Continue
home prednisone 5mg qd. Held home MMF in the setting of
recurrent infections; and will hold indefinitely pending renal
transplant followup.
#Brittle T1DM
#Hypoglycemia episodes:
Controlled with glargine and sliding scale per ___ rec's.
CHRONIC ISSUES:
===============
#HTN: History of labile blood pressures. Continued hydralazine,
isosorbide dinitrate, metoprolol tartrate, home clonidine patch.
#Macrocytic anemia, hypo proliferative: Baseline Hgb ___.
Likely anemia of chronic kidney disease and ___
immunosuppressive medications. S/p 1 unit pRBC on ___ and ___
without evidence of active bleeding. Has been receiving ESA as
an
outpatient which should be continued.
#CAD s/p DES x4: Continue home ASA and pravastatin
#H/o multiple ischemic infarcts: Diagnosed in ___. Thought
to be ongoing watershed infarcts ___ intracranial stenosis
exacerbated by labile blood pressure. Managed with
anti-hypertensives as above. Continued home ASA + pravastatin.
#Epilepsy with h/o NCSE: Continued valproic acid and keppra.
#Gout: Ccontinued allopurinol
#Hypothyroidism: Continued levothyroxine
#GERD: Continue omeprazole
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM
5. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM
6. Divalproex (DELayed Release) 750 mg PO BID
7. Isosorbide Mononitrate (Extended Release) 120 mg PO QHS
8. LevETIRAcetam 250 mg PO BID
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Levothyroxine Sodium 125 mcg PO DAILY
11. Mycophenolate Mofetil 500 mg PO BID
12. Pravastatin 30 mg PO QPM
13. PredniSONE 5 mg PO DAILY
14. Senna 8.6 mg PO BID
15. Sodium Bicarbonate 650 mg PO BID
16. HydrALAZINE 50 mg PO TID
17. Metoprolol Succinate XL 50 mg PO DAILY
18. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QTUES
19. Multivitamins 1 TAB PO DAILY
20. melatonin 10 mg oral QHS
21. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
22. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
23. Aspart 5 Units Breakfast
Aspart 5 Units Dinner
Detemir 16 Units Breakfast
Detemir 16 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
24. Omeprazole 40 mg PO DAILY
25. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN
Pain - Mild
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Ciprofloxacin HCl 250 mg PO Q24H Duration: 7 Doses
Last dose on ___. Fosfomycin Tromethamine 3 g PO 1X/WEEK (WE)
4. Gabapentin 100 mg PO BID
RX *gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp #*6
Capsule Refills:*0
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
6. Isosorbide Dinitrate 20 mg PO TID Duration: 2 Doses
7. Lidocaine 5% Ointment 1 Appl TP BID:PRN pain
8. Metoprolol Tartrate 25 mg PO Q6H Duration: 1 Dose
9. Modafinil 200 mg PO DAILY
RX *modafinil 200 mg 1 tablet(s) by mouth QAM Disp #*3 Tablet
Refills:*0
10. Mupirocin Ointment 2% 1 Appl TP TID
11. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN
BREAKTHROUGH PAIN
Hold for sedation and RR<10
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*18 Tablet Refills:*0
12. Polyethylene Glycol 17 g PO DAILY
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
14. Torsemide 20 mg PO DAILY
15. TraMADol 50 mg PO TID
RX *tramadol 50 mg 1 tablet(s) by mouth three times a day Disp
#*9 Tablet Refills:*0
16. Allopurinol ___ mg PO EVERY OTHER DAY
17. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QSAT
18. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
19. Glargine 2 Units Breakfast
Glargine 3 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
20. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
21. Metoprolol Succinate XL 100 mg PO DAILY
1st dose ___ @ 10PM
22. Aspirin 81 mg PO DAILY
23. Calcitriol 0.25 mcg PO DAILY
24. Divalproex (DELayed Release) 750 mg PO BID
25. HydrALAZINE 50 mg PO TID
26. LevETIRAcetam 250 mg PO BID
27. Levothyroxine Sodium 125 mcg PO DAILY
28. Lidocaine 5% Patch 1 PTCH TD QAM
29. melatonin 10 mg oral QHS
30. Multivitamins 1 TAB PO DAILY
31. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
32. Omeprazole 40 mg PO DAILY
33. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
34. Pravastatin 30 mg PO QPM
35. PredniSONE 5 mg PO DAILY
36. Senna 8.6 mg PO BID
37. Sodium Bicarbonate 650 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
=================
Acute complicated Pseudomonal UTI
Sepsis
Ventilator-associated PNA
SECONDARY DIAGNOSIS:
===================
Acute toxic-metabolic encephalopathy
Subacute-on-chronic renal failure
ESRD
T1DM
Hypertension
Microcytic anemia
Thrombocytopenia
CAD
Gout
Hypothyroidism
GERD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear. Ms. ___,
You were admitted because:
- You have a severe urinary infection.
During your stay:
- You were intubated in the ICU.
- You received IV antibiotics and improved. You were transferred
out of the ICU.
- You had a feeding tube for a while when you were very drowsy
and we needed to protect you from swallowing down the wrong
tube. The feeding tube was removed and you became much more
alert and were able to eat food.
- Your blood sugars were managed by our ___ Diabetes experts.
- You received medications to help you pee and remove fluid from
your body
- You had worsening leg pain and leg wounds, and were evaluated
by our dermatology team who determined that it was NOT a serious
condition called calciphylaxis.
- You had another urinary tract infection which was treated with
an antibiotic and you improved. We spoke with the ID team who
recommended you continue taking an antibiotic called fosfomycin
to prevent infections in the future.
- Your pain improved with medication but made you sleepy
- Your sleepiness improved with a different medication and you
were doing better and ready to go to rehab
After you leave:
- Please continue taking your medications as prescribed. You
need to take fosfomycin every week to prevent recurrence of a
urinary tract infection.
- Please attend the following outpatient appointments.
It was a pleasure participating in your care! We wish you the
very best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
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Allergies: Penicillins / Ativan / carvedilol / amlodipine Chief Complaint: Urosepsis Major Surgical or Invasive Procedure: Intubation History of Present Illness: Ms. [MASKED] is a [MASKED] yo woman with history of ESRD (s/p LURT [MASKED] on cyclosporine, prednisone 5 mg daily), anemia, CAD s/p [MASKED] 4 (most recently [MASKED], HFrEF (EF ~40%), IPMN ([MASKED]), HTN, T1DM complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization), autonomic dysfunction and h/o multiple UTIs(Klebsiella, E.coli, Enterococcus), OSA, recent ischemic stroke, and scleroderma/CREST who presents to the ICU with altered mental status requiring intubation in the emergency department. Per her sisters, the pt has not been at her mental baseline since her recent discharge from the hospital. She had previously been using a rolling walker, but instead was now using Hoyer lifts. Per the sisters, pt had also recently started on linezolid for presumed UTI a few days prior to presentation. The patient was seen by her cardiologist (Dr [MASKED] in clinic on the day of presentation ([MASKED]) and was found to by hypotensive to 78/58 and was thought to be cool on exam. Her mental status at the office visit was "falling asleep in the wheel chair with no response to questions and intermittently opening eyes." The patient was urgently referred to the emergency department. She presented to [MASKED] and [MASKED] pressures had spontaneously improved to 169/90. She was promptly transferred to [MASKED]. In the ED, the ED resident reports her initial exam was notable for disconjugate gaze and LUE rigidity as well as marked obtundation. She was hypoxemic to 89%. She was intubated for airway control and code stroke was called. She was briefly started on nifedipine drip due to concern for ICH. CT showed no acute changes, but global volume loss and changes consistent with known prior strokes. The blood glucose on her chemistry panel was 34. It was then recognized that her L hemiparesis is from a recent stroke. Labs as below. Her urine from [MASKED] was positive for nitrites, leuk esterase, and WBC and she was started on linezolid. She was then transferred to the ICU. Of note, she had been seen extensively by palliative care during her last admission and recently as an outpatient. She has been having some functional decline for several months to years, and at one point considered enrolling in hospice. In the ED, - Initial Vitals: T 98.2 HR75 BP171/82 RR18 97% RA - Exam: per ED resident, initial exam with disconjugate gaze, LUE rigidity. - Labs: 143 / 104 / 87 --------------<34 AGap=18 4.4 / [MASKED] / 4.0 Wbc 6.4 Hgb 8.6 plt 103 Lactate:1.2 UA here: Large leuks, large blood, positive nitrites, > 50 WBC, many bacteria - Imaging: 1. No acute intracranial process. 2. Redemonstration of multiple chronic infarcts, global parenchymal volume loss and sequela of chronic small vessel disease. 3. Unchanged moderate paranasal sinus disease. - Consults: Renal Transplant - Interventions: [MASKED] 22:20 IV Dextrose 50% 25 gm [MASKED] 02:00 IV Etomidate 20 mg [MASKED] 02:00 IV Succinylcholine 100 mg [MASKED] 02:25 IV Dextrose 50% 25 gm [MASKED] 03:17 IV DRIP NiCARdipine [MASKED] mcg/kg/min ordered) [MASKED] 03:17 IV DRIP Fentanyl Citrate [MASKED] mcg/hr ordered) [MASKED] 03:17 IV DRIP Propofol [MASKED] mcg/kg/min ordered) [MASKED] 03:21 IV Linezolid [MASKED] mg [MASKED] ROS: Positives as per HPI; otherwise negative. Past Medical History: -CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED] DES to LAD [MASKED] PCI of Cx and OM with [MASKED] -[MASKED] renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] -Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) -Dysautonomia -Hypertension -Dyslipidemia -Scleroderma w/ CREST syndrome -Gastroparesis/GERD/Hiatal hernia -Gout diagnosed [MASKED] years ago -OSA -Pancreatic cyst -Non convulsive status epilepticus -stroke -BPPV Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION PHYSICAL EXAM VS: T 98.8 HR 81 BP 152/59 100% on FiO2 40%, CMV [MASKED] GEN: intubated and sedated EYES: anicteric HENNT: poor dentition, ETT in place CV: RRR with [MASKED] at LUSB RESP: Anterior lung fields are clear GI: Soft and non-distended SKIN: LLQ bruise and vaginal winer NEURO: non-responsive, not following commands DISCHARGE PHYSICAL EXAM: VS: [MASKED] 0729 Temp: 98.2 PO BP: 125/59 L Lying HR: 78 RR: 18 O2 sat: 96% O2 delivery: Ra GEN: NAD, appears comfortable, sitting up in bed, LUNGS: CTAB HEART: RRR, nl S1, S2. III/VI SEM EXTREMITIES: Trace [MASKED] edema. WWP. tenderness on palpation of the left forearm. Multiple wounds on [MASKED] with eschar (lateral Rt and Lt thigh the worst), improving from previously NEURO: AOx2-3, no spontaneous conversation but answers appropriate with elaborate answers Pertinent Results: ADMISSION LABS =============== [MASKED] 08:54PM BLOOD WBC-6.4 RBC-2.52* Hgb-8.6* Hct-27.5* MCV-109* MCH-34.1* MCHC-31.3* RDW-13.5 RDWSD-54.4* Plt [MASKED] [MASKED] 01:15AM BLOOD [MASKED] PTT-28.2 [MASKED] [MASKED] 08:54PM BLOOD Glucose-34* UreaN-87* Creat-4.0* Na-143 K-4.4 Cl-104 HCO3-21* AnGap-18 [MASKED] 01:15AM BLOOD ALT-23 AST-21 CK(CPK)-158 AlkPhos-84 TotBili-0.5 [MASKED] 07:49AM BLOOD Calcium-8.2* Phos-4.7* Mg-2.1 [MASKED] 01:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 01:30AM BLOOD [MASKED] pO2-64* pCO2-43 pH-7.35 calTCO2-25 Base XS--1 [MASKED] 09:09PM BLOOD Lactate-1.2 [MASKED] 01:30AM BLOOD Glucose-52* Creat-4.1* Na-139 K-4.3 Cl-108 calHCO3-23 [MASKED] 01:30AM BLOOD O2 Sat-86 DISCHARGE LABS =============== [MASKED] 06:20AM BLOOD WBC-8.7 RBC-3.14* Hgb-10.1* Hct-32.7* MCV-104* MCH-32.2* MCHC-30.9* RDW-19.4* RDWSD-73.3* Plt [MASKED] [MASKED] 06:02AM BLOOD [MASKED] PTT-29.8 [MASKED] [MASKED] 10:27AM BLOOD Glucose-155* UreaN-55* Creat-2.7* Na-146 K-5.1 Cl-107 HCO3-27 AnGap-12 [MASKED] 06:20AM BLOOD ALT-5 AST-10 AlkPhos-104 TotBili-0.2 [MASKED] 06:02AM BLOOD Cyclspr-65* OTHER RELEVANT LABS =================== [MASKED] 7:54 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [MASKED]: <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Preliminary): RARE GROWTH Commensal Respiratory Flora. ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH. Piperacillin/Tazobactam test result performed by [MASKED] [MASKED]. Levofloxacin REQUESTED BY [MASKED] ([MASKED]) ON [MASKED]. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROBACTER CLOACAE COMPLEX | CEFTAZIDIME----------- =>[MASKED] R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S LEVOFLOXACIN----------<=0.12 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- I TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [MASKED] 2:30 am URINE URINE CULTURE (Preliminary): PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL OF TWO COLONIAL MORPHOLOGIES. Piperacillin/Tazobactam test result performed by [MASKED] [MASKED]. Levofloxacin Susceptibility testing requested per [MASKED]. [MASKED] ([MASKED]), [MASKED]. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 8 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM------------- 1 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S [MASKED] 8:20 am Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. Respiratory Viral Culture (Preliminary): Respiratory Viral Antigen Screen (Final [MASKED]: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. [MASKED] 10:35 am URINE Source: Catheter. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL. Piperacillin/Tazobactam test result performed by [MASKED] [MASKED]. cefepime test result confirmed by [MASKED]. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROBACTER CLOACAE COMPLEX | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 8 S CEFTRIAXONE----------- 8 R CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING/STUDIES ================ [MASKED] MRI 1. No acute infarct or intracranial hemorrhage. 2. Numerous late subacute to chronic infarcts, as previously seen. 3. Chronic microvascular angiopathy changes. 4. Moderate paranasal sinus disease, as above. [MASKED] EEG IMPRESSION: This is an abnormal continuous ICU EEG monitoring study because of diffuse background slowing indicative of mild to moderate encephalopathy, nonspecific as to etiology. Common causes include toxic/metabolic disturbances, medication effects and/or infection. Frequent generalized epileptiform discharges with a frontal predominance are indicative of diffuse cortical irritability. There are no electrographic seizures [MASKED] US No evidence of deep venous thrombosis in the left lower extremity veins. [MASKED] CXR Unchanged left pleural effusion with associated atelectasis. No new focal consolidations. [MASKED] Lumbar XR No previous images. The vertebra, intervertebral disc spaces, and alignment are essentially within normal limits with minimal hypertrophic spurring. No evidence of compression fracture. Extensive vascular calcification. [MASKED] CXR Interval decrease in extent of pulmonary vascular congestion. No new consolidation. Persisting retrocardiac opacities likely reflecting atelectasis/consolidation and pleural fluid. [MASKED] RUQUS No ascites. Pancreatic cystic lesions as seen previously. Left pleural effusion. ================ PATHOLOGY Skin, right thigh [MASKED]: [MASKED] Mild dermal sclerosis and fat necrosis (see comment). Comment. Sections show a small punch biopsy consisting of epidermis, dermis and minimal subcutaneous fat. The histologic changes are not well developed nor are they specifically diagnostic. There is mild dermal sclerosis, minimal perivascular lymphocytic inflammation and mild fat necrosis at the biopsy base. Definitive vascular, perivascular or perieccrine calcification to support a diagnosis of calciphylaxis is not identified on [MASKED] stains (performed x 3). Intravascular thrombi are not seen on multiple routine stains taken through the entire tissue block, or on a PAS stain. Given the possibility that this small and relatively superficial biopsy is not representative of immediately adjacent or underlying pathology, if there is continuing concern for calciphylaxis a repeat biopsy to include the subcutaneous fat may yield additional information. Correlation with the clinical findings is suggested. Preliminary case findings discussed with Dr. [MASKED] team by Dr. [MASKED] on [MASKED] and [MASKED], respectively. . Final case findings sent by [MASKED] internal email to Dr. [MASKED] [MASKED] by Dr. [MASKED] on [MASKED]. Brief Hospital Course: SUMMARY: [MASKED] poorly-controlled T1DM c/b ESRD s/p LURT on immunosuppression c/b chronic allograft dysfunction, recurrent MDR UTI's, CAD s/p DES x4, HFrEF (LVEF 40% in [MASKED], scleroderma/CREST, prior ischemic strokes c/b L hemiparesis, and HTN who was admitted to the MICU with acute encephalopathy requiring intubation likely [MASKED] pseudomonal urosepsis, now s/p antibiotic treatment for complicated UTI. She also developed a ventilator associated pneumonia, which was treated with antibiotics as below. She was then transferred to the medical service for ongoing toxic metabolic encephalopathy, which slowly improved by the time of discharge. She did develop volume overload (in the setting of known CKD and HFmrEF) requiring IV diuresis and was transitioned to PO diuresis. She also developed worsening lower extremity pain, with thorough workup for calciphyalxis including skin biopsy which was negative. She also developed recurrent UTI with enterobacter, treated with ciprofloxacin course to end [MASKED]. She will then transition to fosfomycin qweekly with ID follow up. TRANSITIONAL ISSUES: ================== - F/u Appts: PCP after rehab, ID, Cardiology, Renal Transplant - F/u Labs: CBC, Chem, cyclosporine level [MASKED] (fax cyclosporine to [MASKED] renal tx as below) ID: [ ] Ciprofloxacin x14d ending [MASKED]. Then resume fosfomycin 3g QWK indefinitely to prevent recurrence of UTI (fris dose [MASKED]. ID will follow as outpatient to consider changing agents given pt had UTI on fosfomycin BP: [ ] While inpt labile blood pressure currently controlled with clonidine patch, hydralazine, metoprolol and isosorbide. These medications should be titrated as needed for adequate control CHF: [ ] On discharge: Cr [MASKED], wt [MASKED] kg. [ ] Volume status is difficult to control. Continue to follow based on volume exam and chemistry weekly. If Cr goes up hold torsemide or if increased cough, edema, increase torsemide to 40 mg [ ] Ensure patient follows up at above renal and cardiovascular appointments Immunosuppression: [ ] Continue cyclosporine 50 mg BID with goal cyclosporine troughs of 50. Check weekly and fax to [MASKED] Kidney Transplant Center, attn: [MASKED], MD fax: fax number: [MASKED], ph: [MASKED] [ ] MMF will be held indefinitely pending renal followup given recurrent UTIs Pain management/Alertness [ ] Patient was restarted on gabapentin 100 mg BID, which can be titrated up to total daily dose of 700 mg, assuming stable mental status as dosing are uptitrated [ ] Started on modafinil to increase alertness. Continue to address need [ ] Please administer oxycodone 5 mg prior to [MASKED] and dressing changes Wounds [ ] Pt will need continued aggressive wound management and monitoring per RN report [ ] Please administer oxycodone 5 mg prior to dressing changes [ ] If worsening, consider dermatology referral for repeat skin biopsy for calciphylaxis (bx [MASKED] negative) vs vascular surgery for PAD evaluation #CODE: DNR/OK to intubate with limited trial (confirmed) #CONTACT: [MASKED] (sister), [MASKED] (home), [MASKED] (cell) ACUTE ISSUES: ============= #Recurrent UTIs #Acute complicated Pseudomonal UTI: History of MDR UTI's, likely iso neurogenic bladder, now found to have Pseudomonal UTI c/b urosepsis. S/p IV cefepime from [MASKED]. Completed meropenem course on [MASKED], then transitioned to weekly prophylactic fosfomycin 3g. She did develop another UTI with fever, eventually growing Enterobacter. She was treated with cefepime and transitioned to cipro to complete 10d course [MASKED]. ID consulted and plan to return to fosfomycin 3g weekly pending ID f/u as outpt. #Ventilator-associated Enterobacter PNA: Course c/b Enterobacter VAP given new fevers, increasing WBC, and consolidation on CXR s/p intubation. Sputum culture with Enterobacter. Now extubated and clinically improving without supplemental O2 requirement. MRSA negative. s/p IV meropenem course as above. #Acute toxic-metabolic encephalopathy: Most likely [MASKED] sepsis superimposed on poor neurologic baseline, exacerbated by uremia, episodes of hypoglycemia, and likely poor clearance of sedatives [MASKED] renal dysfunction. Dedicated cerebral imaging and cvEEG otherwise reassuring. SLP previously recommended NPO given aspiration risk. After NGT removed, passed patient SLP swallow eval and did not require NGT replacement. She continued to improve but required pain management for [MASKED] wounds causing sleepiness. She was started on modafinil with improvement. #HFmrEF The patient developed worsening volume overload requiring IV diuresis. She was transitioned to PO diuresis with PO torsemide at 40 mg, but eventually her Cr slowly rose. It was held with Cr return to baseline 2.7. She was then restarted on torsemide 20. Cr [MASKED], wt [MASKED] kg. Her volume status, electrolytes, and renal function should be monitored closely at rehab and her diuretic adjusted accordingly. # Leg Wounds # [MASKED] Pain Patient developed worsening leg ulcerations and pain. Initial concern for calciphylaxis and underwent dermatologic workup with biopsy [MASKED], which was ultimately negative. Derm felt confident that this was not calciphylaxis and repeat bx was not pursued. Her wounds continued to evolve but eventually stabilized with aggressive wound care. Her pain was controlled with Tylenol, standing tramadol, gabapentin, oxycodone breakthrough as needed. #Subacute-on-chronic renal failure #ESRD s/p LURT ([MASKED]) Has chronic allograft dysfunction [MASKED] diabetic nephropathy and interstitial fibrosis/tubular atrophy seen on [MASKED] kidney biopsy. Admission renal ultrasound redemonstrated graft dysfunction. Continued home calcitriol, cyclosporine with daily level checks (increased now to cyclosporine 50 mg BID). Continue home prednisone 5mg qd. Held home MMF in the setting of recurrent infections; and will hold indefinitely pending renal transplant followup. #Brittle T1DM #Hypoglycemia episodes: Controlled with glargine and sliding scale per [MASKED] rec's. CHRONIC ISSUES: =============== #HTN: History of labile blood pressures. Continued hydralazine, isosorbide dinitrate, metoprolol tartrate, home clonidine patch. #Macrocytic anemia, hypo proliferative: Baseline Hgb [MASKED]. Likely anemia of chronic kidney disease and [MASKED] immunosuppressive medications. S/p 1 unit pRBC on [MASKED] and [MASKED] without evidence of active bleeding. Has been receiving ESA as an outpatient which should be continued. #CAD s/p DES x4: Continue home ASA and pravastatin #H/o multiple ischemic infarcts: Diagnosed in [MASKED]. Thought to be ongoing watershed infarcts [MASKED] intracranial stenosis exacerbated by labile blood pressure. Managed with anti-hypertensives as above. Continued home ASA + pravastatin. #Epilepsy with h/o NCSE: Continued valproic acid and keppra. #Gout: Ccontinued allopurinol #Hypothyroidism: Continued levothyroxine #GERD: Continue omeprazole Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO EVERY OTHER DAY 2. Aspirin 81 mg PO DAILY 3. Calcitriol 0.25 mcg PO DAILY 4. CycloSPORINE (Neoral) MODIFIED 50 mg PO QPM 5. CycloSPORINE (Neoral) MODIFIED 25 mg PO QAM 6. Divalproex (DELayed Release) 750 mg PO BID 7. Isosorbide Mononitrate (Extended Release) 120 mg PO QHS 8. LevETIRAcetam 250 mg PO BID 9. Lidocaine 5% Patch 1 PTCH TD QAM 10. Levothyroxine Sodium 125 mcg PO DAILY 11. Mycophenolate Mofetil 500 mg PO BID 12. Pravastatin 30 mg PO QPM 13. PredniSONE 5 mg PO DAILY 14. Senna 8.6 mg PO BID 15. Sodium Bicarbonate 650 mg PO BID 16. HydrALAZINE 50 mg PO TID 17. Metoprolol Succinate XL 50 mg PO DAILY 18. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QTUES 19. Multivitamins 1 TAB PO DAILY 20. melatonin 10 mg oral QHS 21. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 22. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 23. Aspart 5 Units Breakfast Aspart 5 Units Dinner Detemir 16 Units Breakfast Detemir 16 Units Dinner Insulin SC Sliding Scale using HUM Insulin 24. Omeprazole 40 mg PO DAILY 25. HYDROcodone-Acetaminophen (5mg-325mg) [MASKED] TAB PO Q6H:PRN Pain - Mild Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Ciprofloxacin HCl 250 mg PO Q24H Duration: 7 Doses Last dose on [MASKED]. Fosfomycin Tromethamine 3 g PO 1X/WEEK (WE) 4. Gabapentin 100 mg PO BID RX *gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp #*6 Capsule Refills:*0 5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea 6. Isosorbide Dinitrate 20 mg PO TID Duration: 2 Doses 7. Lidocaine 5% Ointment 1 Appl TP BID:PRN pain 8. Metoprolol Tartrate 25 mg PO Q6H Duration: 1 Dose 9. Modafinil 200 mg PO DAILY RX *modafinil 200 mg 1 tablet(s) by mouth QAM Disp #*3 Tablet Refills:*0 10. Mupirocin Ointment 2% 1 Appl TP TID 11. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN BREAKTHROUGH PAIN Hold for sedation and RR<10 RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*18 Tablet Refills:*0 12. Polyethylene Glycol 17 g PO DAILY 13. sevelamer CARBONATE 800 mg PO TID W/MEALS 14. Torsemide 20 mg PO DAILY 15. TraMADol 50 mg PO TID RX *tramadol 50 mg 1 tablet(s) by mouth three times a day Disp #*9 Tablet Refills:*0 16. Allopurinol [MASKED] mg PO EVERY OTHER DAY 17. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QSAT 18. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H 19. Glargine 2 Units Breakfast Glargine 3 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 20. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 21. Metoprolol Succinate XL 100 mg PO DAILY 1st dose [MASKED] @ 10PM 22. Aspirin 81 mg PO DAILY 23. Calcitriol 0.25 mcg PO DAILY 24. Divalproex (DELayed Release) 750 mg PO BID 25. HydrALAZINE 50 mg PO TID 26. LevETIRAcetam 250 mg PO BID 27. Levothyroxine Sodium 125 mcg PO DAILY 28. Lidocaine 5% Patch 1 PTCH TD QAM 29. melatonin 10 mg oral QHS 30. Multivitamins 1 TAB PO DAILY 31. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 32. Omeprazole 40 mg PO DAILY 33. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 34. Pravastatin 30 mg PO QPM 35. PredniSONE 5 mg PO DAILY 36. Senna 8.6 mg PO BID 37. Sodium Bicarbonate 650 mg PO BID Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: PRIMARY DIAGNOSIS: ================= Acute complicated Pseudomonal UTI Sepsis Ventilator-associated PNA SECONDARY DIAGNOSIS: =================== Acute toxic-metabolic encephalopathy Subacute-on-chronic renal failure ESRD T1DM Hypertension Microcytic anemia Thrombocytopenia CAD Gout Hypothyroidism GERD Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear. Ms. [MASKED], You were admitted because: - You have a severe urinary infection. During your stay: - You were intubated in the ICU. - You received IV antibiotics and improved. You were transferred out of the ICU. - You had a feeding tube for a while when you were very drowsy and we needed to protect you from swallowing down the wrong tube. The feeding tube was removed and you became much more alert and were able to eat food. - Your blood sugars were managed by our [MASKED] Diabetes experts. - You received medications to help you pee and remove fluid from your body - You had worsening leg pain and leg wounds, and were evaluated by our dermatology team who determined that it was NOT a serious condition called calciphylaxis. - You had another urinary tract infection which was treated with an antibiotic and you improved. We spoke with the ID team who recommended you continue taking an antibiotic called fosfomycin to prevent infections in the future. - Your pain improved with medication but made you sleepy - Your sleepiness improved with a different medication and you were doing better and ready to go to rehab After you leave: - Please continue taking your medications as prescribed. You need to take fosfomycin every week to prevent recurrence of a urinary tract infection. - Please attend the following outpatient appointments. It was a pleasure participating in your care! We wish you the very best! Sincerely, Your [MASKED] Healthcare Team Followup Instructions: [MASKED]
|
[] |
[
"N390",
"N179",
"I130",
"Z66",
"D509",
"D696",
"I2510",
"K219",
"E039",
"N189",
"G4733",
"Z794",
"Z955",
"Z87891"
] |
[
"A4152: Sepsis due to Pseudomonas",
"G92: Toxic encephalopathy",
"J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia",
"I5023: Acute on chronic systolic (congestive) heart failure",
"N390: Urinary tract infection, site not specified",
"N179: Acute kidney failure, unspecified",
"I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease",
"T8619: Other complication of kidney transplant",
"I69354: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side",
"J95851: Ventilator associated pneumonia",
"I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"L97118: Non-pressure chronic ulcer of right thigh with other specified severity",
"E870: Hyperosmolality and hypernatremia",
"R6520: Severe sepsis without septic shock",
"Z66: Do not resuscitate",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"D509: Iron deficiency anemia, unspecified",
"D696: Thrombocytopenia, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"K219: Gastro-esophageal reflux disease without esophagitis",
"E039: Hypothyroidism, unspecified",
"B9689: Other specified bacterial agents as the cause of diseases classified elsewhere",
"N319: Neuromuscular dysfunction of bladder, unspecified",
"E1021: Type 1 diabetes mellitus with diabetic nephropathy",
"D631: Anemia in chronic kidney disease",
"N189: Chronic kidney disease, unspecified",
"G40909: Epilepsy, unspecified, not intractable, without status epilepticus",
"M1A9XX0: Chronic gout, unspecified, without tophus (tophi)",
"E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"E10649: Type 1 diabetes mellitus with hypoglycemia without coma",
"M341: CR(E)ST syndrome",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"H548: Legal blindness, as defined in USA",
"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",
"Z794: Long term (current) use of insulin",
"Z955: Presence of coronary angioplasty implant and graft",
"Z87891: Personal history of nicotine dependence"
] |
10,030,753
| 27,165,162
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Cath ___
History of Present Illness:
INITIAL ED PRESENTATION:
=======================
Ms. ___ is a ___ y/o female with a history of ESRD (s/p LURT
___ on immunosuppression), anemia (weekly transusions and epo
injections), CAD s/p ___ 4 (most recently ___, HFpEF (EF
55% ___, IPMN (___), HTN, T1DM, and h/o multiple MDR UTIs
(Klebsiella, E.coli, Enterococcus), scleroderma/CREST who
presents with diarrhea and abdominal pain.
The patient was recently treated with Bactrim for a UTI about a
week ago. Around that same time, the patient began having
diarrhea and abdominal pain. The pain is described as ___,
located over the lower bilateral quadrants. It is intermittent
without known triggers. Nothing makes it worse, including food
or
movements. She has also had profuse diarrhea, described as large
volume episodes occurring almost every hour. It has been
associated with fecal urgency. No hematochezia or melena. She
reports decreased enteral intake over this time. No new nausea,
vomiting, fever, chills, dysuria or hematuria. No history of
similar symptoms or c.diff infections. No recent travel, sick
contacts, new foods or medications.
Patient was seen at ___ on ___. She was given
1L
IVF with plan to follow up at ___ for repeat labs in a day.
She continued to have symptoms. On ___, she developed new
right-sided chest pain described as ___, dull/ache while
sleeping. Her pain was unchanged with palpation, deep breaths,
or
movement and it felt similar to prior cardiac pain. She took SL
nitro with resolution. She also began feeling lightheaded,
particularly with bowel movements. Given her ongoing symptoms
and
new chest pain, she presented to the ___ ED.
In the ED, initial VS were: T 97.6, HR 86, BP 126/73, RR 12,
SpO2
100% RA
NEUROLOGY CONSULT ___:
========================
Ms. ___ sister notes that while admitted here in the CCU,
starting ___ hours ago, Ms. ___ began develop instances of
pausing mid activity. She has a video that documents Ms. ___
eating soup; she is shown to pause mid bite with the spoon held
in the air for ~6 seconds before returning to a conversation she
was having, speaking fluently. This happened twice in the span
of
a ~30 second video. Her sister reports that Ms. ___ had no
memory of these event at the time, was not frustrated by them.
Nothing similar to this has happened in the past. Over the
course
of today, she has become less fluent, primarily only speaking in
yes/no answers, and not always consistently. She also had been
sleepy, often lying with her eyes closed but still awake. She
has
also started to experience body jerks which occur almost every
minute in both the arms and legs. These have not changed in
frequency since onset.
Ms. ___ presented on ___ with dyspnea, cough,
chest tightness and low-grade fever. She also had worsening leg
edema and increased weight concerning for HF exacerbation (EF
dropped from 55 to 47%, type 2 NSTEMI, and acute complicated
cystitis. More recently on ___ Ms. ___ received a right
heart catheterization for which she received conscious sedation
with fentanyl.
Prior to this Ms. ___ was hospitalized for ischemic colitis
thought to be ___ hypoperfusion from HF. Following discharge,
she
stayed with her sister who noticed that Ms. ___ was much
more
confused than usual, not oriented to place, had trouble
administering her insulin as well as taking her blood sugar
regularly. She remained disoriented and requiring assistance for
1 week before starting to improve; in her second week at home
she
was able to start taking her insulin by herself, monitor her
blood sugar regularly, was speaking coherently and was fully
oriented. This improvement occurred over a week until Labor Day
when she developed fever, SOB, CP prompting family to take her
to
___.
Ms. ___ sister notes that while admitted here in the CCU,
starting 48 hours ago, Ms. ___ began develop instances of
pausing mid activity. She has a video that documents Ms. ___
eating soup; she is shown to pause mid bite with the spoon held
in the air for ~6 seconds before returning to a conversation she
was having, speaking fluently. This happened twice in the span
of
a ~30 second video. Her sister reports that Ms. ___ had no
memory of these event at the time, was not frustrated by them,
and that the video well documents their frequency and duration.
Nothing similar to this has happened in the past. In the past 24
hours Ms. ___ has begun to experience myoclonic jerks which
occur ___ times each minute in both the arms and legs. These
have
not changed in frequency since onset. At this same time, Ms.
___ has become less articulate with her speech eventually
becoming non-fluent and halted with large pauses when responding
to questions.
Past Medical History:
-CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___ DES to LAD ___
PCI of Cx and OM with ___
-___ renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
-Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
-Hypertension
-Dyslipidemia
-Scleroderma w/ CREST syndrome
-Gastroparesis/GERD/Hiatal hernia
-Gout diagnosed ___ years ago
-OSA
-Pancreatic cyst
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
Admission Physical Exam:
VS: T102.9 HR105 RR25 SPO2 99% 6LNC
GEN: uncomfortable, thin cachectic female. older than stated
age.
mild distress.
HEENT: PERRLA, EOMI. No erythema or exudate in posterior
pharynx;
dry mucous membranes.
Neck: +JVD 10cm at 45 deg. +AJR.
Resp: No increased WOB, Lungs CTAB, No wheezes or rhonchi.
Crackles in bilateral bases.
CV: Normal S1/S2. no murmurs rubs or gallops.
Abd: Soft, mild suprapubic tenderness Nondistended with no
organomegaly; no guarding. bulging flanks.
MSK: ___ warm, with 1+ pitting edema to the knees bilaterally
Skin: No rash, Warm and dry, No petechiae. 1+ ___ pulses in ___
b/l.
Neuro: AOx3, speech fluent, no obvious facial asymmetry, moves
all 4 ext to command.
===================================================
Discharge Physical Exam:
24 HR Data (last updated ___ @ 1217)
Temp: 98.6 (Tm 98.6), BP: 138/72 (130-172/71-83), HR: 83
(80-90), RR: 16 (___), O2 sat: 96% (94-99), Wt: 122.3 lb/55.48
kg
General: Awake, NAD
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx or on tongue
Pulmonary: Breathing comfortably on RA
Cardiac: WWP, no pallor nor cyanosis
Abdomen: soft, NT/ND
Extremities: No ___ edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to name, day, month, year, and
___. Able to perform DOWB and MOYB without errors, with serial
subtraction of threes from 20, she makes one error and completes
the task slowly. Language
more spontaneous speech output today. Naming intact.
Comprehension intact to simple two step commands.
-Cranial Nerves:
II, III, IV, VI: Bilateral pupils 5mm -> 4.5mm minimally
reactive. EOMI intact. Frequent eye blinking. Left field of
vision reduced to movement nasally, temporally, superiorly,
inferiorly, right visual field also diffusely impaired and
unable to count fingers in all visual fields.
V: Sensation intact to light touch in all three distributions
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to instructions and finger rub
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. Occasional asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 4+ ___- 4 3 4 5
R 5 ___- 4 4+ 5 5
-Sensory: Sensation absent to light touch below b/l ankles,
decreased temperature throughout.
-DTRs: 2+ throughout
-Coordination: Mild dysmetria with FNF bilaterally, in
proportion to weakness/sensory loss.
-Gait: Deferred
Pertinent Results:
ADMISSION LABS:
================
___ 07:47PM BLOOD WBC-4.6 RBC-2.59* Hgb-8.2* Hct-26.7*
MCV-103* MCH-31.7 MCHC-30.7* RDW-15.9* RDWSD-58.7* Plt ___
___ 07:47PM BLOOD Neuts-75.5* Lymphs-5.2* Monos-16.7*
Eos-1.1 Baso-0.4 Im ___ AbsNeut-3.49 AbsLymp-0.24*
AbsMono-0.77 AbsEos-0.05 AbsBaso-0.02
___ 07:47PM BLOOD ___ PTT-36.9* ___
___ 07:47PM BLOOD Glucose-102* UreaN-60* Creat-2.7* Na-145
K-5.0 Cl-107 HCO3-23 AnGap-15
___ 07:47PM BLOOD ALT-16 AST-25 CK(CPK)-129 AlkPhos-74
TotBili-0.2
___ 07:47PM BLOOD Albumin-2.4* Calcium-8.5 Phos-3.6 Mg-1.7
Important Interval Labs
=======================
___ 06:51AM BLOOD TSH-2.0
___ 06:30AM BLOOD %HbA1c-6.5* eAG-140*
___ 06:30AM BLOOD Triglyc-92 HDL-69 CHOL/HD-2.7 LDLcalc-102
___ 08:54AM BLOOD Cyclspr-64*
Important Discharge labs
=========================
___ 07:30AM BLOOD Valproa-31*
___ 07:30AM BLOOD WBC-6.6 RBC-2.77* Hgb-8.8* Hct-28.5*
MCV-103* MCH-31.8 MCHC-30.9* RDW-15.1 RDWSD-57.0* Plt ___
___ 06:45AM BLOOD ___ PTT-26.2 ___
___ 07:30AM BLOOD Glucose-221* UreaN-63* Creat-3.0* Na-146
K-4.4 Cl-109* HCO3-27 AnGap-10
___ 06:45AM BLOOD ALT-11 AST-9 AlkPhos-74 TotBili-<0.2
___ 07:24AM BLOOD cTropnT-0.44*
___ 07:30AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9
___ 06:30AM BLOOD %HbA1c-6.5* eAG-140*
___ 06:30AM BLOOD Triglyc-92 HDL-69 CHOL/HD-2.7 LDLcalc-102
___ 08:54AM BLOOD Ammonia-18
___ 06:51AM BLOOD TSH-2.0
___ 06:51AM BLOOD Vanco-13.3
___ 07:30AM BLOOD Cyclspr-PND
___ 08:54AM BLOOD Cyclspr-64*
Imaging
========
___ TTE
The estimated right atrial pressure is ___ mmHg. There is mild
global left ventricular hypokinesis. The visually estimated left
ventricular ejection fraction is 35-40%. Global longitudinal
strain is depressed (-9.6 %; normal
less than -20%) Tissue Doppler suggests an increased left
ventricular filling pressure (PCWP greater than 18mmHg). There
is Grade II diastolic dysfunction. Normal right ventricular
cavity size with normal free wall
motion. 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 trivial tricuspid regurgitation. There is no
pericardial effusion.
IMPRESSION: 1) No structural cardiac source of embolism
(e.g.patent foramen ovale/atrial septal defect, intracardiac
thrombus, or vegetation) seen. 2) Moderate global LV systolic
dysfunction both by LVEF and
global longitudinal strain imaging with grade II LV diastolic
dysfunction and elevated LVEDP. Compared with the prior TTE
(images reviewed) of ___, visualized findings are
similar., the findings are similar.
___ MRA neck w/o
Within confines of 2D time-of-flight technique and limited
field of view
obscuring the mid to distal bilateral cervical internal carotid
arteries:
1. Unremarkable MRA of the neck without evidence of stenosis of
the cervical internal carotid arteries by NASCET criteria.
2. Additional findings as described above.
___ MRI MRA brain w/o
1. Acute/subacute on chronic thromboembolic ischemic changes in
the right
frontal and right parietal lobes as described detail above.
2. No acute intracranial hemorrhage.
3. Unchanged left SCA focal stenosis. Otherwise, patent circle
___ with
no evidence of aneurysm formation.
___ RUQ us
1. Coarsened liver echotexture. This can be seen in the setting
of early
cirrhosis.
2. Surgically absent gallbladder.
3. At least 2 hypoechoic pancreatic cystic lesions (within the
body and
uncinate process) for which non emergent outpatient MRCP further
characterization may be performed if not previously evaluated.
4. Trace left pleural effusion.
5. No ascites.
___ CT Head
1. No acute intracranial abnormality.
2. Re-demonstration of chronic findings, as above.
___ Cardiac R cath
Elevated right heart filling pressure.
Preserved cardiac function.
Moderate pulmonary hypertension.
elevated filling pressures, pulmonary htn, PROMINENT v WAVES
ON WEDGE TRACINGS
___ CT abd pelvis
1. Small bilateral pleural effusions with overlying atelectasis.
Partially imaged lingula/inferior left upper lobe contains
scattered ground-glass opacities which could be due to
infection, but are not fully imaged.
2. Equivocal subtle perinephric stranding/haziness involving the
left iliac fossa transplant kidney. Correlate with urinalysis
to assess for infection. No hydronephrosis.
3. No bowel obstruction or bowel wall thickening.
4. Cardiac ventricular blood pool is hypodense in relation to
the myocardium, suggesting underlying anemia.
Brief Hospital Course:
BRIEF SUMMARY
=====================
___ yo F with sig PMHx of Type 1DM, ESRD s/p LURT in ___ on
cyclosporine/MMF, transfusion dependent anemia, CAD s/p ___
recently in ___, HFpEF with EF of 55% in ___, IPMN, HTN,
scleroderma/crest, and multiple recurrent MDR UTI who presented
with acute decompensated heart failure ___ inadequate PO
diuresis, acute complicated cystitis further complicated by a
likely type 2 NSTEMI. Ms. ___ was initially treated by the
cardiology service where she was diuresed and underwent right
heart cath on ___. Details of her cardiology course are below.
She was transferred to Neurology on ___ after had acute mental
status changes and twitching which were non-convulsive status.
She was started on AEDs including keppra and valproic acid,
monitored on EEG (___) and her seizures became well
controlled. She had an MRI which showed multiple acute and
subacute infarcts. She underwent stroke work-up which included
risk factor screening (Alc 6.5, LDL elevated, echo normal
without PFO).
ACUTE ISSUES:
======================
#Acute Decompensated HFpEF:
Last ECHO prior to admission was in ___ with EF 55%. BNP
elevated to ___ at OS___ prior to transfer, previous admissions
BNP elevated to ___. Likely etiology of this exacerbation was
inadequate PO diuretic dosing. She was diuresed, requiring Lasix
IV up to 100mg IV. Diuresis was complicated by a worsening ___.
She was taken for a on ___ RHC which revealed Elevated right
heart filling pressure, Preserved cardiac function, moderate
pulmonary hypertension, elevated filling pressures, pulmonary
htn and prominent V waves on wedge tracings. She continued to
diurese and was transitioned back to her home regimen.
# NSTEMI type II, & CAD s/p DES:
Mrs. ___ is s/p multiple stents, most recently ___,
anti-platelet therapy stopped in ___ per cardiology in
advance of EUS/biopsy for pancreatic mass. ECG on admission with
new lateral precordial TWI from prior, troponins elevated 0.21
-> 0.45. Received nitro and started on heparin gtt in ED. Not on
ACE-I given CKD. A heparin gtt was discontinued after hospital
day 1 and she was without further episodes of chest pain. She
was continued on her home regimen of ranolazine, aspirin 81 mg,
metop 6.25mg q6hr
#Hypertension:
History of labile, difficult to control BP. BPs frequently in
180s-190s during this admission. We uptitrated Hydral/isosorbide
dinitrate to Hydral 75 q8 and isosorbide dinitrate 40mg TID.
Given her chronic orthostatic hypotension, goal SBP was 140-160.
#Acute Complicated Cystitis:
Patient with a history of MDR E. Coli sensitive to cefepime. She
had suprapubic tenderness and CT evidence of perinephric
stranding. No leukocytosis, but patient febrile to 100.5F in ED.
CT A/P in ED showed no bowel obstruction or bowel wall
thickening. Also showed partially imaged lingula/inferior left
upper lobe which contained scattered ground-glass opacitie,
possibly ___ infection. Received Vanc/Flagyl in ED. Transplant
nephrology following and recommended based on lung exam to add
on atypical coverage and treat for a pneumonia. We sent a broad
infectious workup including stool cultures, serum/stool CMV, C.
diff, pjp smear and Urine culture negative. We treated for a
presumed pnuemonia given her lung exam and fevers. Treatment
included Cefepime (___) which was discontinued in the
setting of seizures, vanc d/ced ___ after MRSA nares negative
and Azithromycin 250mg daily (End date ___. She was afebrile
during her time on the Neurology service.
# ___ with ESRD s/p LURT ___, CKD 4:
Renal transplant followed throughout the hospitalization.
Pre-admission baseline Cr around 3.0, ISO chronic allograft
dysfunction from diabetic nephropathy and grade 2 IFTA. During
her time on cardiology her creatinine was elevated above
baseline and slightly uptrending during hospitalization. Some of
this was likely related to diueresis. FeUrea was 40 which was
suggestive of intrinsic renal disease, has muddy brown casts and
acanthocytes on urine microscopy c/w component of ATN on top of
diabetic GN. She continued on cyclosporine, MMF and prednisone.
Cyclosporine levels were trended daily. Goal cyclosporine level
50-100 per transplant nephrology.
#Seizure and stroke:
She triggered for acute mental status changes on HD#4 and HD#5.
She was minimally responsive with diffuse myoclonic jerks. Her
presentation initially appeared to wax and wane, then on ___
she became more persistently altered. CT head was negative.
Neurology was consulted who recommended EEG to assess for
subclinical status epilepticus which was confirmed. She received
Valium (Ativan allergy) twice over that first 24 hours and was
loaded/started on Keppra and Valproic Acid for seizure control
which was obtained around ___. Her EEG had initially shown
generalized 5 hz spike and wave complexes. She had an MRI which
showed two subacute infarcts in the right periventricular
pericollosal artery territory and punctate infarct in pons.
Given distribution, highest suspicion was for small vessel
etiology, though pericallosal infarct could also possibly be
embolic. Given this and timing related to right heart cath, TTE
with bubble was performed, which showed no e/o PFO. It was
therefore felt that the infarcts are unlikely related to the
right heart catheterization. MRA head/neck without severe
stenosis. A1c 6.5, LDL 102, TSH 2.0. Telemetry without
arrhythmia. Given LDL above goal, pravastatin was uptitrated to
30mg qhs in discussion with her outpatient neurologist. Higher
intensity statin contraindicated given interaction with
cyclosporine. She was continued on ASA 81mg daily. Cardiac
embolus related to decreased EF cannot be ruled out, though is
felt less likely.
She was continued on valproate and keppra for seizures. She was
discharged on keppra 500mg BID and Divalproex (DELayed Release)
750mg BID.
#DM1
Her blood sugars were quite brittle throughout this
hospitalization with frequent episodes of symptomatic
hypoglycemia at BS readings of 80+. ___ was consulted for
assistance with management of her insulin.
# Chronic Anemia: Secondary to ESRD. Receiving weekly Epo
infusions.
#Gout: initially held allopurinol ___ given asymptomatic and
possible UTI, but this was restarted on discharge.
#Hypothyroidism: she continued on her levothyroxine 125 mcg
#Scleroderma/CREST: continued on her home prednisone 5mg daily
#GERD/Gastroparesis: Continued pantoprazole (esomeprazole NF)
and promethazine
# PAD: Initially held home cilastazol 50mg qAM and 25mg qPM,
this was restarted on discharge.
Transitional Issues
=====================
Kidney transplant
-------------------
[] Please check cyclosporine level(12 hrs after pm dose), BUN,
Cr on ___
[] Goal cyclosporine trough 50-100 do not hold AM dose while
waiting for trough.
[] monitor urine output, patient has history of urinary
retention. If retaining consider straight cath.
Neuro (stroke and seizures)
[] check valproate trough in 1 week (___), get LFTs and ammonia
with this trough. Goal valproate 50-70, if LFTs or Ammonia are
elevated please call neurology at ___.
[] monitor for muscle aches. If develops would check CK.
Pravastatin interaction with cyclosporine increases risk of
rhabdomyolysis
[] Seizure semiology: behavioral arrest.
HFrEF
-------
[] Continue to hold furosemide on discharge, please monitor
daily weights and volume status.
[] discharge weight: 55.48kg, 122.3lb
[] please check orthostatics before making further changes to BP
regimen, as has historically had significant orthostatic
hypotension. ___ not tolerate significantly more BP medication
[] If Cr worsens consider reducing insulin to avoid hypoglycemia
d/t reduced clearance of insulin
========================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 102) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[x] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist--
interaction with cyclosporine
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. Cilostazol 50 mg PO BID
6. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
7. esomeprazole magnesium 40 mg oral BID
8. Furosemide 20 mg PO DAILY
9. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL SC Prior
to meals
10. ___ Solostar U-300 26 Units Breakfast
11. Levothyroxine Sodium 125 mcg PO DAILY
12. Lidocaine 5% Patch ___ PTCH TD QAM
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Mycophenolate Mofetil 500 mg PO BID
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. Pravastatin 10 mg PO QPM
17. Promethazine 25 mg PO Q6 HR-Q8HR
18. Promethazine ___ID:PRN nause
19. Ranolazine ER 500 mg PO BID
20. trimethobenzamide 300 mg oral Q6H:PRN
21. Aspirin 81 mg PO DAILY
22. Vitamin D ___ UNIT PO DAILY
23. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
24. Ferrous Sulfate 325 mg PO DAILY
25. melatonin 10 mg oral QHS
26. pen needle, diabetic 32 gauge x ___ miscellaneous Other
27. Sodium Bicarbonate 1300 mg PO BID
Discharge Medications:
1. Divalproex (DELayed Release) 750 mg PO BID
2. HydrALAZINE 75 mg PO Q8H
3. Isosorbide Dinitrate 40 mg PO TID
4. LevETIRAcetam 500 mg PO BID
5. ___ Solostar U-300 26 Units Breakfast
6. Pravastatin 30 mg PO QPM
7. Allopurinol ___ mg PO DAILY
8. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
9. Aspirin 81 mg PO DAILY
10. Calcitriol 0.25 mcg PO DAILY
11. Calcium Carbonate 500 mg PO DAILY
12. Cilostazol 50 mg PO BID
13. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
14. Esomeprazole Magnesium 40 mg oral BID
15. Ferrous Sulfate 325 mg PO DAILY
16. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL SC
Prior to meals
17. Levothyroxine Sodium 125 mcg PO DAILY
18. Lidocaine 5% Patch ___ PTCH TD QAM
19. melatonin 10 mg oral QHS
20. Metoprolol Succinate XL 25 mg PO DAILY
21. Mycophenolate Mofetil 500 mg PO BID
22. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
23. pen needle, diabetic 32 gauge x ___ miscellaneous Other
24. PredniSONE 5 mg PO DAILY
25. Promethazine 25 mg PO Q6 HR-Q8HR
26. Ranolazine ER 500 mg PO BID
27. Sodium Bicarbonate 1300 mg PO BID
28. trimethobenzamide 300 mg oral Q6H:PRN
29. Vitamin D ___ UNIT PO DAILY
30. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until directed by your MD
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
acute ischemic stroke
type 2 NSTEMI
Congestive heart failure exacerbation
non-convulsive status epilepticus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
You were admitted with trouble breathing. You had too much fluid
in your body and it lead to shortness of breath and some stress
on your heart. You had a right heart catheterization.
You then developed continuous seizures without shaking, called
non-convulsive status epilepticus. While figuring out why this
happened, we discovered that you had two small areas of stroke
in your brain. We cannot be 100% sure why the strokes happened.
the possibilities are that it is either from the long term
changes from diabetes, high blood pressure and high cholesterol,
or it is related to the reduced function of your heart. We do
not think it is from the right heart catheterization.
Please follow up with Neurology and your primary care physician
as listed below.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
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Allergies: Penicillins / Ativan / carvedilol / amlodipine Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Cath [MASKED] History of Present Illness: INITIAL ED PRESENTATION: ======================= Ms. [MASKED] is a [MASKED] y/o female with a history of ESRD (s/p LURT [MASKED] on immunosuppression), anemia (weekly transusions and epo injections), CAD s/p [MASKED] 4 (most recently [MASKED], HFpEF (EF 55% [MASKED], IPMN ([MASKED]), HTN, T1DM, and h/o multiple MDR UTIs (Klebsiella, E.coli, Enterococcus), scleroderma/CREST who presents with diarrhea and abdominal pain. The patient was recently treated with Bactrim for a UTI about a week ago. Around that same time, the patient began having diarrhea and abdominal pain. The pain is described as [MASKED], located over the lower bilateral quadrants. It is intermittent without known triggers. Nothing makes it worse, including food or movements. She has also had profuse diarrhea, described as large volume episodes occurring almost every hour. It has been associated with fecal urgency. No hematochezia or melena. She reports decreased enteral intake over this time. No new nausea, vomiting, fever, chills, dysuria or hematuria. No history of similar symptoms or c.diff infections. No recent travel, sick contacts, new foods or medications. Patient was seen at [MASKED] on [MASKED]. She was given 1L IVF with plan to follow up at [MASKED] for repeat labs in a day. She continued to have symptoms. On [MASKED], she developed new right-sided chest pain described as [MASKED], dull/ache while sleeping. Her pain was unchanged with palpation, deep breaths, or movement and it felt similar to prior cardiac pain. She took SL nitro with resolution. She also began feeling lightheaded, particularly with bowel movements. Given her ongoing symptoms and new chest pain, she presented to the [MASKED] ED. In the ED, initial VS were: T 97.6, HR 86, BP 126/73, RR 12, SpO2 100% RA NEUROLOGY CONSULT [MASKED]: ======================== Ms. [MASKED] sister notes that while admitted here in the CCU, starting [MASKED] hours ago, Ms. [MASKED] began develop instances of pausing mid activity. She has a video that documents Ms. [MASKED] eating soup; she is shown to pause mid bite with the spoon held in the air for ~6 seconds before returning to a conversation she was having, speaking fluently. This happened twice in the span of a ~30 second video. Her sister reports that Ms. [MASKED] had no memory of these event at the time, was not frustrated by them. Nothing similar to this has happened in the past. Over the course of today, she has become less fluent, primarily only speaking in yes/no answers, and not always consistently. She also had been sleepy, often lying with her eyes closed but still awake. She has also started to experience body jerks which occur almost every minute in both the arms and legs. These have not changed in frequency since onset. Ms. [MASKED] presented on [MASKED] with dyspnea, cough, chest tightness and low-grade fever. She also had worsening leg edema and increased weight concerning for HF exacerbation (EF dropped from 55 to 47%, type 2 NSTEMI, and acute complicated cystitis. More recently on [MASKED] Ms. [MASKED] received a right heart catheterization for which she received conscious sedation with fentanyl. Prior to this Ms. [MASKED] was hospitalized for ischemic colitis thought to be [MASKED] hypoperfusion from HF. Following discharge, she stayed with her sister who noticed that Ms. [MASKED] was much more confused than usual, not oriented to place, had trouble administering her insulin as well as taking her blood sugar regularly. She remained disoriented and requiring assistance for 1 week before starting to improve; in her second week at home she was able to start taking her insulin by herself, monitor her blood sugar regularly, was speaking coherently and was fully oriented. This improvement occurred over a week until Labor Day when she developed fever, SOB, CP prompting family to take her to [MASKED]. Ms. [MASKED] sister notes that while admitted here in the CCU, starting 48 hours ago, Ms. [MASKED] began develop instances of pausing mid activity. She has a video that documents Ms. [MASKED] eating soup; she is shown to pause mid bite with the spoon held in the air for ~6 seconds before returning to a conversation she was having, speaking fluently. This happened twice in the span of a ~30 second video. Her sister reports that Ms. [MASKED] had no memory of these event at the time, was not frustrated by them, and that the video well documents their frequency and duration. Nothing similar to this has happened in the past. In the past 24 hours Ms. [MASKED] has begun to experience myoclonic jerks which occur [MASKED] times each minute in both the arms and legs. These have not changed in frequency since onset. At this same time, Ms. [MASKED] has become less articulate with her speech eventually becoming non-fluent and halted with large pauses when responding to questions. Past Medical History: -CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED] DES to LAD [MASKED] PCI of Cx and OM with [MASKED] -[MASKED] renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] -Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) -Hypertension -Dyslipidemia -Scleroderma w/ CREST syndrome -Gastroparesis/GERD/Hiatal hernia -Gout diagnosed [MASKED] years ago -OSA -Pancreatic cyst Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: Admission Physical Exam: VS: T102.9 HR105 RR25 SPO2 99% 6LNC GEN: uncomfortable, thin cachectic female. older than stated age. mild distress. HEENT: PERRLA, EOMI. No erythema or exudate in posterior pharynx; dry mucous membranes. Neck: +JVD 10cm at 45 deg. +AJR. Resp: No increased WOB, Lungs CTAB, No wheezes or rhonchi. Crackles in bilateral bases. CV: Normal S1/S2. no murmurs rubs or gallops. Abd: Soft, mild suprapubic tenderness Nondistended with no organomegaly; no guarding. bulging flanks. MSK: [MASKED] warm, with 1+ pitting edema to the knees bilaterally Skin: No rash, Warm and dry, No petechiae. 1+ [MASKED] pulses in [MASKED] b/l. Neuro: AOx3, speech fluent, no obvious facial asymmetry, moves all 4 ext to command. =================================================== Discharge Physical Exam: 24 HR Data (last updated [MASKED] @ 1217) Temp: 98.6 (Tm 98.6), BP: 138/72 (130-172/71-83), HR: 83 (80-90), RR: 16 ([MASKED]), O2 sat: 96% (94-99), Wt: 122.3 lb/55.48 kg General: Awake, NAD HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx or on tongue Pulmonary: Breathing comfortably on RA Cardiac: WWP, no pallor nor cyanosis Abdomen: soft, NT/ND Extremities: No [MASKED] edema Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented to name, day, month, year, and [MASKED]. Able to perform DOWB and MOYB without errors, with serial subtraction of threes from 20, she makes one error and completes the task slowly. Language more spontaneous speech output today. Naming intact. Comprehension intact to simple two step commands. -Cranial Nerves: II, III, IV, VI: Bilateral pupils 5mm -> 4.5mm minimally reactive. EOMI intact. Frequent eye blinking. Left field of vision reduced to movement nasally, temporally, superiorly, inferiorly, right visual field also diffusely impaired and unable to count fingers in all visual fields. V: Sensation intact to light touch in all three distributions VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to instructions and finger rub IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. Occasional asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc L 4+ [MASKED]- 4 3 4 5 R 5 [MASKED]- 4 4+ 5 5 -Sensory: Sensation absent to light touch below b/l ankles, decreased temperature throughout. -DTRs: 2+ throughout -Coordination: Mild dysmetria with FNF bilaterally, in proportion to weakness/sensory loss. -Gait: Deferred Pertinent Results: ADMISSION LABS: ================ [MASKED] 07:47PM BLOOD WBC-4.6 RBC-2.59* Hgb-8.2* Hct-26.7* MCV-103* MCH-31.7 MCHC-30.7* RDW-15.9* RDWSD-58.7* Plt [MASKED] [MASKED] 07:47PM BLOOD Neuts-75.5* Lymphs-5.2* Monos-16.7* Eos-1.1 Baso-0.4 Im [MASKED] AbsNeut-3.49 AbsLymp-0.24* AbsMono-0.77 AbsEos-0.05 AbsBaso-0.02 [MASKED] 07:47PM BLOOD [MASKED] PTT-36.9* [MASKED] [MASKED] 07:47PM BLOOD Glucose-102* UreaN-60* Creat-2.7* Na-145 K-5.0 Cl-107 HCO3-23 AnGap-15 [MASKED] 07:47PM BLOOD ALT-16 AST-25 CK(CPK)-129 AlkPhos-74 TotBili-0.2 [MASKED] 07:47PM BLOOD Albumin-2.4* Calcium-8.5 Phos-3.6 Mg-1.7 Important Interval Labs ======================= [MASKED] 06:51AM BLOOD TSH-2.0 [MASKED] 06:30AM BLOOD %HbA1c-6.5* eAG-140* [MASKED] 06:30AM BLOOD Triglyc-92 HDL-69 CHOL/HD-2.7 LDLcalc-102 [MASKED] 08:54AM BLOOD Cyclspr-64* Important Discharge labs ========================= [MASKED] 07:30AM BLOOD Valproa-31* [MASKED] 07:30AM BLOOD WBC-6.6 RBC-2.77* Hgb-8.8* Hct-28.5* MCV-103* MCH-31.8 MCHC-30.9* RDW-15.1 RDWSD-57.0* Plt [MASKED] [MASKED] 06:45AM BLOOD [MASKED] PTT-26.2 [MASKED] [MASKED] 07:30AM BLOOD Glucose-221* UreaN-63* Creat-3.0* Na-146 K-4.4 Cl-109* HCO3-27 AnGap-10 [MASKED] 06:45AM BLOOD ALT-11 AST-9 AlkPhos-74 TotBili-<0.2 [MASKED] 07:24AM BLOOD cTropnT-0.44* [MASKED] 07:30AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9 [MASKED] 06:30AM BLOOD %HbA1c-6.5* eAG-140* [MASKED] 06:30AM BLOOD Triglyc-92 HDL-69 CHOL/HD-2.7 LDLcalc-102 [MASKED] 08:54AM BLOOD Ammonia-18 [MASKED] 06:51AM BLOOD TSH-2.0 [MASKED] 06:51AM BLOOD Vanco-13.3 [MASKED] 07:30AM BLOOD Cyclspr-PND [MASKED] 08:54AM BLOOD Cyclspr-64* Imaging ======== [MASKED] TTE The estimated right atrial pressure is [MASKED] mmHg. There is mild global left ventricular hypokinesis. The visually estimated left ventricular ejection fraction is 35-40%. Global longitudinal strain is depressed (-9.6 %; normal less than -20%) Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). There is Grade II diastolic dysfunction. Normal right ventricular cavity size with normal free wall motion. 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 trivial tricuspid regurgitation. There is no pericardial effusion. IMPRESSION: 1) No structural cardiac source of embolism (e.g.patent foramen ovale/atrial septal defect, intracardiac thrombus, or vegetation) seen. 2) Moderate global LV systolic dysfunction both by LVEF and global longitudinal strain imaging with grade II LV diastolic dysfunction and elevated LVEDP. Compared with the prior TTE (images reviewed) of [MASKED], visualized findings are similar., the findings are similar. [MASKED] MRA neck w/o Within confines of 2D time-of-flight technique and limited field of view obscuring the mid to distal bilateral cervical internal carotid arteries: 1. Unremarkable MRA of the neck without evidence of stenosis of the cervical internal carotid arteries by NASCET criteria. 2. Additional findings as described above. [MASKED] MRI MRA brain w/o 1. Acute/subacute on chronic thromboembolic ischemic changes in the right frontal and right parietal lobes as described detail above. 2. No acute intracranial hemorrhage. 3. Unchanged left SCA focal stenosis. Otherwise, patent circle [MASKED] with no evidence of aneurysm formation. [MASKED] RUQ us 1. Coarsened liver echotexture. This can be seen in the setting of early cirrhosis. 2. Surgically absent gallbladder. 3. At least 2 hypoechoic pancreatic cystic lesions (within the body and uncinate process) for which non emergent outpatient MRCP further characterization may be performed if not previously evaluated. 4. Trace left pleural effusion. 5. No ascites. [MASKED] CT Head 1. No acute intracranial abnormality. 2. Re-demonstration of chronic findings, as above. [MASKED] Cardiac R cath Elevated right heart filling pressure. Preserved cardiac function. Moderate pulmonary hypertension. elevated filling pressures, pulmonary htn, PROMINENT v WAVES ON WEDGE TRACINGS [MASKED] CT abd pelvis 1. Small bilateral pleural effusions with overlying atelectasis. Partially imaged lingula/inferior left upper lobe contains scattered ground-glass opacities which could be due to infection, but are not fully imaged. 2. Equivocal subtle perinephric stranding/haziness involving the left iliac fossa transplant kidney. Correlate with urinalysis to assess for infection. No hydronephrosis. 3. No bowel obstruction or bowel wall thickening. 4. Cardiac ventricular blood pool is hypodense in relation to the myocardium, suggesting underlying anemia. Brief Hospital Course: BRIEF SUMMARY ===================== [MASKED] yo F with sig PMHx of Type 1DM, ESRD s/p LURT in [MASKED] on cyclosporine/MMF, transfusion dependent anemia, CAD s/p [MASKED] recently in [MASKED], HFpEF with EF of 55% in [MASKED], IPMN, HTN, scleroderma/crest, and multiple recurrent MDR UTI who presented with acute decompensated heart failure [MASKED] inadequate PO diuresis, acute complicated cystitis further complicated by a likely type 2 NSTEMI. Ms. [MASKED] was initially treated by the cardiology service where she was diuresed and underwent right heart cath on [MASKED]. Details of her cardiology course are below. She was transferred to Neurology on [MASKED] after had acute mental status changes and twitching which were non-convulsive status. She was started on AEDs including keppra and valproic acid, monitored on EEG ([MASKED]) and her seizures became well controlled. She had an MRI which showed multiple acute and subacute infarcts. She underwent stroke work-up which included risk factor screening (Alc 6.5, LDL elevated, echo normal without PFO). ACUTE ISSUES: ====================== #Acute Decompensated HFpEF: Last ECHO prior to admission was in [MASKED] with EF 55%. BNP elevated to [MASKED] at OS prior to transfer, previous admissions BNP elevated to [MASKED]. Likely etiology of this exacerbation was inadequate PO diuretic dosing. She was diuresed, requiring Lasix IV up to 100mg IV. Diuresis was complicated by a worsening [MASKED]. She was taken for a on [MASKED] RHC which revealed Elevated right heart filling pressure, Preserved cardiac function, moderate pulmonary hypertension, elevated filling pressures, pulmonary htn and prominent V waves on wedge tracings. She continued to diurese and was transitioned back to her home regimen. # NSTEMI type II, & CAD s/p DES: Mrs. [MASKED] is s/p multiple stents, most recently [MASKED], anti-platelet therapy stopped in [MASKED] per cardiology in advance of EUS/biopsy for pancreatic mass. ECG on admission with new lateral precordial TWI from prior, troponins elevated 0.21 -> 0.45. Received nitro and started on heparin gtt in ED. Not on ACE-I given CKD. A heparin gtt was discontinued after hospital day 1 and she was without further episodes of chest pain. She was continued on her home regimen of ranolazine, aspirin 81 mg, metop 6.25mg q6hr #Hypertension: History of labile, difficult to control BP. BPs frequently in 180s-190s during this admission. We uptitrated Hydral/isosorbide dinitrate to Hydral 75 q8 and isosorbide dinitrate 40mg TID. Given her chronic orthostatic hypotension, goal SBP was 140-160. #Acute Complicated Cystitis: Patient with a history of MDR E. Coli sensitive to cefepime. She had suprapubic tenderness and CT evidence of perinephric stranding. No leukocytosis, but patient febrile to 100.5F in ED. CT A/P in ED showed no bowel obstruction or bowel wall thickening. Also showed partially imaged lingula/inferior left upper lobe which contained scattered ground-glass opacitie, possibly [MASKED] infection. Received Vanc/Flagyl in ED. Transplant nephrology following and recommended based on lung exam to add on atypical coverage and treat for a pneumonia. We sent a broad infectious workup including stool cultures, serum/stool CMV, C. diff, pjp smear and Urine culture negative. We treated for a presumed pnuemonia given her lung exam and fevers. Treatment included Cefepime ([MASKED]) which was discontinued in the setting of seizures, vanc d/ced [MASKED] after MRSA nares negative and Azithromycin 250mg daily (End date [MASKED]. She was afebrile during her time on the Neurology service. # [MASKED] with ESRD s/p LURT [MASKED], CKD 4: Renal transplant followed throughout the hospitalization. Pre-admission baseline Cr around 3.0, ISO chronic allograft dysfunction from diabetic nephropathy and grade 2 IFTA. During her time on cardiology her creatinine was elevated above baseline and slightly uptrending during hospitalization. Some of this was likely related to diueresis. FeUrea was 40 which was suggestive of intrinsic renal disease, has muddy brown casts and acanthocytes on urine microscopy c/w component of ATN on top of diabetic GN. She continued on cyclosporine, MMF and prednisone. Cyclosporine levels were trended daily. Goal cyclosporine level 50-100 per transplant nephrology. #Seizure and stroke: She triggered for acute mental status changes on HD#4 and HD#5. She was minimally responsive with diffuse myoclonic jerks. Her presentation initially appeared to wax and wane, then on [MASKED] she became more persistently altered. CT head was negative. Neurology was consulted who recommended EEG to assess for subclinical status epilepticus which was confirmed. She received Valium (Ativan allergy) twice over that first 24 hours and was loaded/started on Keppra and Valproic Acid for seizure control which was obtained around [MASKED]. Her EEG had initially shown generalized 5 hz spike and wave complexes. She had an MRI which showed two subacute infarcts in the right periventricular pericollosal artery territory and punctate infarct in pons. Given distribution, highest suspicion was for small vessel etiology, though pericallosal infarct could also possibly be embolic. Given this and timing related to right heart cath, TTE with bubble was performed, which showed no e/o PFO. It was therefore felt that the infarcts are unlikely related to the right heart catheterization. MRA head/neck without severe stenosis. A1c 6.5, LDL 102, TSH 2.0. Telemetry without arrhythmia. Given LDL above goal, pravastatin was uptitrated to 30mg qhs in discussion with her outpatient neurologist. Higher intensity statin contraindicated given interaction with cyclosporine. She was continued on ASA 81mg daily. Cardiac embolus related to decreased EF cannot be ruled out, though is felt less likely. She was continued on valproate and keppra for seizures. She was discharged on keppra 500mg BID and Divalproex (DELayed Release) 750mg BID. #DM1 Her blood sugars were quite brittle throughout this hospitalization with frequent episodes of symptomatic hypoglycemia at BS readings of 80+. [MASKED] was consulted for assistance with management of her insulin. # Chronic Anemia: Secondary to ESRD. Receiving weekly Epo infusions. #Gout: initially held allopurinol [MASKED] given asymptomatic and possible UTI, but this was restarted on discharge. #Hypothyroidism: she continued on her levothyroxine 125 mcg #Scleroderma/CREST: continued on her home prednisone 5mg daily #GERD/Gastroparesis: Continued pantoprazole (esomeprazole NF) and promethazine # PAD: Initially held home cilastazol 50mg qAM and 25mg qPM, this was restarted on discharge. Transitional Issues ===================== Kidney transplant ------------------- [] Please check cyclosporine level(12 hrs after pm dose), BUN, Cr on [MASKED] [] Goal cyclosporine trough 50-100 do not hold AM dose while waiting for trough. [] monitor urine output, patient has history of urinary retention. If retaining consider straight cath. Neuro (stroke and seizures) [] check valproate trough in 1 week ([MASKED]), get LFTs and ammonia with this trough. Goal valproate 50-70, if LFTs or Ammonia are elevated please call neurology at [MASKED]. [] monitor for muscle aches. If develops would check CK. Pravastatin interaction with cyclosporine increases risk of rhabdomyolysis [] Seizure semiology: behavioral arrest. HFrEF ------- [] Continue to hold furosemide on discharge, please monitor daily weights and volume status. [] discharge weight: 55.48kg, 122.3lb [] please check orthostatics before making further changes to BP regimen, as has historically had significant orthostatic hypotension. [MASKED] not tolerate significantly more BP medication [] If Cr worsens consider reducing insulin to avoid hypoglycemia d/t reduced clearance of insulin ======================================== AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No. If no, reason why: 2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not (I.e. bleeding risk, hemorrhage, etc.) 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No. If not, why not? (I.e. bleeding risk, hemorrhage, etc.) 4. LDL documented? (x) Yes (LDL = 102) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL >70, reason not given: [ ] Statin medication allergy [x] Other reasons documented by physician/advanced practice nurse/physician [MASKED] (physician/APN/PA) or pharmacist-- interaction with cyclosporine [ ] LDL-c less than 70 mg/dL 6. Smoking cessation counseling given? (x) Yes - () No [reason () non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician [MASKED] (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - If no, why not (I.e. bleeding risk, etc.) (x) N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY 2. Allopurinol [MASKED] mg PO DAILY 3. Calcium Carbonate 500 mg PO DAILY 4. Calcitriol 0.25 mcg PO DAILY 5. Cilostazol 50 mg PO BID 6. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 7. esomeprazole magnesium 40 mg oral BID 8. Furosemide 20 mg PO DAILY 9. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL SC Prior to meals 10. [MASKED] Solostar U-300 26 Units Breakfast 11. Levothyroxine Sodium 125 mcg PO DAILY 12. Lidocaine 5% Patch [MASKED] PTCH TD QAM 13. Metoprolol Succinate XL 25 mg PO DAILY 14. Mycophenolate Mofetil 500 mg PO BID 15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 16. Pravastatin 10 mg PO QPM 17. Promethazine 25 mg PO Q6 HR-Q8HR 18. Promethazine ID:PRN nause 19. Ranolazine ER 500 mg PO BID 20. trimethobenzamide 300 mg oral Q6H:PRN 21. Aspirin 81 mg PO DAILY 22. Vitamin D [MASKED] UNIT PO DAILY 23. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 24. Ferrous Sulfate 325 mg PO DAILY 25. melatonin 10 mg oral QHS 26. pen needle, diabetic 32 gauge x [MASKED] miscellaneous Other 27. Sodium Bicarbonate 1300 mg PO BID Discharge Medications: 1. Divalproex (DELayed Release) 750 mg PO BID 2. HydrALAZINE 75 mg PO Q8H 3. Isosorbide Dinitrate 40 mg PO TID 4. LevETIRAcetam 500 mg PO BID 5. [MASKED] Solostar U-300 26 Units Breakfast 6. Pravastatin 30 mg PO QPM 7. Allopurinol [MASKED] mg PO DAILY 8. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 9. Aspirin 81 mg PO DAILY 10. Calcitriol 0.25 mcg PO DAILY 11. Calcium Carbonate 500 mg PO DAILY 12. Cilostazol 50 mg PO BID 13. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 14. Esomeprazole Magnesium 40 mg oral BID 15. Ferrous Sulfate 325 mg PO DAILY 16. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL SC Prior to meals 17. Levothyroxine Sodium 125 mcg PO DAILY 18. Lidocaine 5% Patch [MASKED] PTCH TD QAM 19. melatonin 10 mg oral QHS 20. Metoprolol Succinate XL 25 mg PO DAILY 21. Mycophenolate Mofetil 500 mg PO BID 22. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 23. pen needle, diabetic 32 gauge x [MASKED] miscellaneous Other 24. PredniSONE 5 mg PO DAILY 25. Promethazine 25 mg PO Q6 HR-Q8HR 26. Ranolazine ER 500 mg PO BID 27. Sodium Bicarbonate 1300 mg PO BID 28. trimethobenzamide 300 mg oral Q6H:PRN 29. Vitamin D [MASKED] UNIT PO DAILY 30. HELD- Furosemide 20 mg PO DAILY This medication was held. Do not restart Furosemide until directed by your MD Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: acute ischemic stroke type 2 NSTEMI Congestive heart failure exacerbation non-convulsive status epilepticus Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [MASKED], You were admitted with trouble breathing. You had too much fluid in your body and it lead to shortness of breath and some stress on your heart. You had a right heart catheterization. You then developed continuous seizures without shaking, called non-convulsive status epilepticus. While figuring out why this happened, we discovered that you had two small areas of stroke in your brain. We cannot be 100% sure why the strokes happened. the possibilities are that it is either from the long term changes from diabetes, high blood pressure and high cholesterol, or it is related to the reduced function of your heart. We do not think it is from the right heart catheterization. Please follow up with Neurology and your primary care physician as listed below. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your [MASKED] Neurology Team Followup Instructions: [MASKED]
|
[] |
[
"I130",
"I2510",
"M109",
"E039",
"K219",
"E785",
"G4700",
"G4733",
"Z955",
"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",
"I5041: Acute combined systolic (congestive) and diastolic (congestive) heart failure",
"I21A1: Myocardial infarction type 2",
"I63421: Cerebral infarction due to embolism of right anterior cerebral artery",
"I6312: Cerebral infarction due to embolism of basilar artery",
"N170: Acute kidney failure with tubular necrosis",
"J189: Pneumonia, unspecified organism",
"G92: Toxic encephalopathy",
"N184: Chronic kidney disease, stage 4 (severe)",
"G40801: Other epilepsy, not intractable, with status epilepticus",
"Z940: Kidney transplant status",
"N3000: Acute cystitis without hematuria",
"R64: Cachexia",
"Z6824: Body mass index [BMI] 24.0-24.9, adult",
"Z006: Encounter for examination for normal comparison and control in clinical research program",
"I160: Hypertensive urgency",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"E1021: Type 1 diabetes mellitus with diabetic nephropathy",
"E10649: Type 1 diabetes mellitus with hypoglycemia without coma",
"E1051: Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene",
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"K3184: Gastroparesis",
"N319: Neuromuscular dysfunction of bladder, unspecified",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"E1065: Type 1 diabetes mellitus with hyperglycemia",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"I2720: Pulmonary hypertension, unspecified",
"I951: Orthostatic hypotension",
"D631: Anemia in chronic kidney disease",
"M109: Gout, unspecified",
"E039: Hypothyroidism, unspecified",
"M341: CR(E)ST syndrome",
"K219: Gastro-esophageal reflux disease without esophagitis",
"E785: Hyperlipidemia, unspecified",
"G4700: Insomnia, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"Z955: Presence of coronary angioplasty implant and graft",
"Z87891: Personal history of nicotine dependence",
"Z86711: Personal history of pulmonary embolism"
] |
10,030,753
| 27,218,915
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___.
Chief Complaint:
abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o female with a history of ESRD (s/p LURT
___ on immunosuppression), anemia (weekly transusions and epo
injections), CAD s/p ___ 4 (most recently ___, HFpEF (EF
55% ___, IPMN (___), HTN, T1DM, and h/o multiple MDR UTIs
(Klebsiella, E.coli, Enterococcus), scleroderma/CREST who
presents with diarrhea and abdominal pain.
The patient was recently treated with Bactrim for a UTI about a
week ago. Around that same time, the patient began having
diarrhea and abdominal pain. The pain is described as ___,
located over the lower bilateral quadrants. It is intermittent
without known triggers. Nothing makes it worse, including food
or
movements. She has also had profuse diarrhea, described as large
volume episodes occurring almost every hour. It has been
associated with fecal urgency. No hematochezia or melena. She
reports decreased enteral intake over this time. No new nausea,
vomiting, fever, chills, dysuria or hematuria. No history of
similar symptoms or c.diff infections. No recent travel, sick
contacts, new foods or medications.
Patient was seen at ___ on ___. She was given
1L
IVF with plan to follow up at ___ for repeat labs in a day.
She continued to have symptoms. On ___, she developed new
right-sided chest pain described as ___, dull/ache while
sleeping. Her pain was unchanged with palpation, deep breaths,
or
movement and it felt similar to prior cardiac pain. She took SL
nitro with resolution. She also began feeling lightheaded,
particularly with bowel movements. Given her ongoing symptoms
and
new chest pain, she presented to the ___ ED.
In the ED, initial VS were: T 97.6, HR 86, BP 126/73, RR 12,
SpO2
100% RA
Exam notable for: Soft, NT/ ND
ECG: Rate 84. NSR, Left axis deviation. ST depression in I and
aVL with TWI, STE in III, ST elevation in aVR, V1- V2 (similar
to
prior)
Labs showed:
-CBC: WBC 6.7, Hgb 11.1, Plt 284
-Chem: HCO3 12, Cl 113, BUN 68, Cr 3.2
-VBG: ___
-TropT 0.12->0.12, MB 8
-Lactate 1.2
Imaging showed:
CT ABD & PELVIS W/O CONTRAST
1. Portal venous gas and gas within the IMV, concerning for
bowel
ischemia. Nondependent gas along the rectal wall is suspicious
for pneumatosis in the setting of venous gas.
2. Mildly dilated, fluid-filled large colon, most consistent
with
given history of diarrhea. No bowel obstruction.
3. Evidence of bowel wall thickening of the distal ileum in the
right lower quadrant, which may be related to enteritis of
infectious or inflammatory etiology. However, given extensive
vascular disease, ischemia is also on the differential.
4. Pancreatic cystic lesions, better assessed on MRI from ___. Please refer to the MRI report for follow-up
recommendations.
5. Unremarkable transplant kidney.
Consults:
-Transplant surgery: recommended guaiac stools (trace positive
yellow stool in ED), trend trops, stool culture, c. diff, CMV VL
Patient received:
___ 18:36 IV Promethazine 6.25 mg ___
___ 20:04 IVF NS 500 mL
___ 20:20 IV Dextrose 50% 25 gm ___
___ 22:05 PO CycloSPORINE (Neoral) MODIFIED 25 mg
___ 22:05 PO Mycophenolate Mofetil 500 mg
___ 22:11 IVF LR Started 150 mL/hr
___ 23:42 IV MetroNIDAZOLE (500 mg ordered)
___ 23:42 IV Ciprofloxacin 400 mg ___
___ 00:47 IVF NS (500 mL ordered)
Transfer VS were: T 98.1, HR 95, BP 160/60, RR 16, SpO2 99% RA
On arrival to the floor, patient reports persistent symptoms.
Her
abdominal pain is currently resolved but she continues to have
diarrhea. No fever, chills, new nausea or vomiting. No recurrent
chest pain, shortness of breath, or cough. She notes recent
lightheadedness, particularly with diarrhea. No syncope. She
describes a history of PE in ___ following an angioplasty. No
family history of blood clots and no personal history of atrial
fibrillation. Notes her blood glucose has been running lower at
home, prompting her to downtitrate her insulin.
Past Medical History:
-CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___ DES to LAD ___
PCI of Cx and OM with ___
-___ renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
-Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
-Hypertension
-Dyslipidemia
-Scleroderma w/ CREST syndrome
-Gastroparesis/GERD/Hiatal hernia
-Gout diagnosed ___ years ago
-OSA
-Pancreatic cyst
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 97.5 BP 136/72 HR 102 RR 18 96% on RA
GENERAL: Ill appearing female in NAD. Lying comfortably in bed.
HEENT: AT/NC, anicteric sclera, PERRL. Dry mucous membranes.
Oropharynx clear.
NECK: supple, no LAD
CV: RRR with normal S1/S2. II/VI systolic murmur over RUSB and
LUSB. No rubs or gallops.
PULM: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi.
GI: Soft, moderately distended. Moderate TTP over lower
quadrants. No guarding or rebound tenderness. Normoactive BS. No
masses appreciated. No significant pain over renal transplant.
EXTREMITIES: Warm, well perfused. No ___ edema or erythema.
PULSES: 2+ radial pulses bilaterally
NEURO: Alert and interactive. CN II-XII grossly intact. Moves
___
extremities.
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 821)
Temp: 97.7 (Tm 98.9), BP: 158/82 (106-158/70-82), HR: 95
(79-95), RR: 18, O2 sat: 99% (96-99), O2 delivery: Ra, Wt: 131.2
lb/59.51 kg
GENERAL: female in NAD, lying in bed
HEENT: AT/NC, anicteric sclera, PERRL. Oropharynx clear.
NECK: supple, no LAD
CV: RRR with normal S1/S2. II/VI systolic murmur over RUSB and
LUSB. No rubs or gallops.
PULM: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi.
GI: Soft, moderately distended. Non-tender. No guarding or
rebound tenderness. +BS. No masses appreciated. No pain over
renal graft
EXTREMITIES: Warm, well perfused. 1+ pitting ___ edema b/l.
PULSES: 2+ radial pulses bilaterally
NEURO: Alert and interactive. Moves ___
extremities.
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 02:26PM BLOOD WBC-6.7 RBC-3.47* Hgb-11.1* Hct-34.3
MCV-99* MCH-32.0 MCHC-32.4 RDW-15.4 RDWSD-55.9* Plt ___
___ 02:26PM BLOOD Neuts-80.2* Lymphs-3.6* Monos-11.4
Eos-2.6 Baso-0.2 Im ___ AbsNeut-5.34 AbsLymp-0.24*
AbsMono-0.76 AbsEos-0.17 AbsBaso-0.01
___ 12:40PM BLOOD ___ PTT-31.5 ___
___ 02:26PM BLOOD Glucose-97 UreaN-68* Creat-3.2* Na-140
K-3.7 Cl-113* HCO3-12* AnGap-15
___ 02:26PM BLOOD ALT-9 AST-9 CK(CPK)-58 AlkPhos-114*
TotBili-<0.2
___ 02:26PM BLOOD CK-MB-7 cTropnT-0.12*
___ 02:26PM BLOOD Albumin-2.4*
___ 05:52AM BLOOD Calcium-7.6* Phos-4.9* Mg-1.0*
___ 10:01PM BLOOD pO2-26* pCO2-37 pH-7.14* calTCO2-13* Base
XS--17
___ 12:48PM BLOOD ___ pO2-203* pCO2-15* pH-7.32*
calTCO2-8* Base XS--15 Comment-GREEN TOP
___ 06:05PM BLOOD Lactate-1.2
___ 12:48PM BLOOD Lactate-1.5
INTERVAL/DISCHARGE LABS & STUDIES:
CT ABD & PELVIS W/O CONTRASTStudy Date of ___ 7:56 ___
1. Portal venous gas and gas within the IMV, concerning for
bowel ischemia. Nondependent gas along the rectal wall is
suspicious for pneumatosis in the setting of venous gas.
2. Mildly dilated, fluid-filled large colon, most consistent
with given
history of diarrhea. No bowel obstruction.
3. Evidence of bowel wall thickening of the distal ileum in the
right lower quadrant, which may be related to enteritis of
infectious or inflammatory etiology. However, given extensive
vascular disease, ischemia is also on the differential.
4. Pancreatic cystic lesions, better assessed on MRI from ___. Please refer to the MRI report for follow-up
recommendations.
5. Unremarkable transplant kidney.
DUPLEX DOPP ABD/PELStudy Date of ___ 8:49 AM
1. Patent celiac axis and common hepatic arteries with
appropriate waveforms.
2. SMA is patent with absent diastolic flow, likely secondary to
extensive arteriosclerotic/atherosclerotic calcifications as
seen on recent CT.
3. Inferior mesenteric artery is not visualized.
INTERVAL/DISCHARGE LABS
___ 10:01PM BLOOD pO2-26* pCO2-37 pH-7.14* calTCO2-13* Base
XS--17
___ 12:48PM BLOOD ___ pO2-203* pCO2-15* pH-7.32*
calTCO2-8* Base XS--15 Comment-GREEN TOP
___ 04:43PM BLOOD ___ pO2-102 pCO2-32* pH-7.18*
calTCO2-13* Base XS--15 Comment-GREEN TOP
___ 08:04PM BLOOD ___ pO2-40* pCO2-34* pH-7.24*
calTCO2-15* Base XS--11
___ 04:11AM BLOOD ___ pO2-59* pCO2-28* pH-7.33*
calTCO2-15* Base XS--9
___ 05:10PM BLOOD ___ pO2-27* pCO2-34* pH-7.26*
calTCO2-16* Base XS--11
___ 08:35PM BLOOD ___ pO2-30* pCO2-34* pH-7.26*
calTCO2-16* Base XS--11
___ 04:16AM BLOOD ___ pO2-61* pCO2-32* pH-7.31*
calTCO2-17* Base XS--9
___ 02:26PM BLOOD Glucose-97 UreaN-68* Creat-3.2* Na-140
K-3.7 Cl-113* HCO3-12* AnGap-15
___ 05:52AM BLOOD Glucose-51* UreaN-61* Creat-3.3* Na-140
K-3.2* Cl-116* HCO3-10* AnGap-14
___ 12:40PM BLOOD Glucose-152* UreaN-60* Creat-3.3* Na-138
K-3.1* Cl-113* HCO3-8* AnGap-17
___ 07:47PM BLOOD Glucose-75 UreaN-56* Creat-3.2* Na-141
K-3.3* Cl-111* HCO3-15* AnGap-15
___ 08:50AM BLOOD Glucose-98 UreaN-50* Creat-3.2* Na-137
K-3.0* Cl-107 HCO3-14* AnGap-16
___ 08:18PM BLOOD Glucose-101* UreaN-46* Creat-3.0* Na-137
K-4.4 Cl-112* HCO3-11* AnGap-14
___ 03:55AM BLOOD Glucose-80 UreaN-43* Creat-2.8* Na-140
K-3.6 Cl-114* HCO3-12* AnGap-14
___ 06:39AM BLOOD Glucose-291* UreaN-38* Creat-2.7* Na-141
K-3.8 Cl-112* HCO3-14* AnGap-15
___ 04:32AM BLOOD Glucose-358* UreaN-42* Creat-3.0* Na-145
K-3.6 Cl-115* HCO3-18* AnGap-12
___ 04:32AM BLOOD WBC-7.8 RBC-2.69* Hgb-8.4* Hct-26.2*
MCV-97 MCH-31.2 MCHC-32.1 RDW-15.9* RDWSD-56.1* Plt ___ y/o female with a history of ESRD (s/p LURT ___ on
immunosuppression), anemia (weekly transusions and epo
injections), CAD s/p ___ 4 (most recently ___, HFpEF (EF
55% ___, IPMN (___), HTN, T1DM, and h/o multiple MDR UTIs
(Klebsiella, E.coli, Enterococcus), scleroderma/CREST who
presented on ___ with diarrhea and abdominal pain x7 days. CT
scan on admission showed portal venous gas in the liver and
pneumatosis with concern for bowel ischemia. Transplant surgery
was consulted she was started on bowel rest with empiric
ciprofloxacin and Flagyl. Her pH was initially very low at 7.14
with poor respiratory compensation and severe non-gap metabolic
acidosis likely in the setting of continued diarrhea. She was
started on oral and IV bicarb repletion. She also was given 80%
of her long-acting insulin as she was n.p.o. and type I
diabetic, but continued to be persistently hypoglycemic,
requiring D10 drip. She continued to be acidemic with poor
respiratory compensation, and she was transferred to the ICU.
There she had an abdominal ultrasound which demonstrated absent
diastolic flow in the SMA. Vascular surgery was consulted and
felt that there was no need for procedural intervention at this
time, but that she should restart a statin. ___ was consulted
for blood sugar management. In the ICU her respiratory status
improved as did her acidemia. She was sent back to the floor and
transitioned to regular diet and oral antibiotics to complete a
7 day course of ciprofloxacin and Flagyl. She was started on
pravastatin 10 mg nightly after discussion with transplant
pharmacy and transplant nephrology.
TRANSITIONAL ISSUES
-------------------
[] Patient is type I diabetes and should have close follow-up
with ___ with Dr. ___
[] Discharge insulin regimen: Glargine 15U at breakfast. Humalog
5U with breakfast/lunch/dinner with sliding scale.
[] Patient discharged on furosemide 20 mg p.o. daily. Should
follow-up with PCP about titration of medication and follow-up
electrolytes
[] Patient started on pravastatin 10 mg nightly
[] Patient currently on sodium bicarbonate 1300 twice daily for
non-gap metabolic acidosis.
[] Patient should have electrolytes checked in 1 week of
discharge to look for resolution of metabolic acidosis. His
bicarbonate has returned to normal, she should stop oral sodium
bicarbonate
[] Will need to clarify if she has a history of APLS (per
medical records) and if she needs anticoagulation
[] Discharge Cr: 3.0
[] Discharge weight: 132 lbs (reported dry weight 124 lbs)
#CODE: Full (presumed)
#CONTACT: ___ (SISTER) ___
ACTIVE ISSUES
-------------
# Diarrhea
# Nausea
# Abdominal pain
# Colitis
CT on admission with evidence of colitis and concern for
possible bowel ischemic. Clinical condition was stable and
without any peritoneal signs on exam. She was seen by vascular
surgery who recommended medical management. The patient was
treated with bowel rest and started empirically on ciprofloxacin
/ Flagyl (day 1 = ___. CMV VL and C. Diff negative. Mesenteric
duplex demonstrated normal flow velocities and waveforms in the
celiac artery. SMA was patent with absent diastolic flow, likely
secondary to extensive arteriosclerotic/ atherosclerotic
calcifications as seen on recent CT, for which she was started
on pravastatin 10 mg nightly. She was transitioned back to
normal diet and completed 7 day course of ciprofloxacin and
Flagyl.
# ___ on CKD
# ESRD s/p LURT ___
Most recent creatinine was around 3.0. Chronic allograft
dysfunction from diabetic nephropathy and grade 2 IFTA per
biopsy in ___. Current ___ likely pre-renal in the setting of
diarrhea. Treated with hydration with subsequent improvement
back to baseline. Transplant nephrology was following. Continued
cyclosporine(neoral) 25 mg bid, MMF 500 mg bid, prednisone 5 mg
qd.
# Metabolic acidosis
# Respiratory acidosis
Non-gap acidosis likely secondary to profound diarrhea. ___
likely also contributing. Lactate normal. No signs of DKA.
Initially treated with bicarbonate gtt, subsequently
discontinued with improvement in acidosis. Patient continued on
sodium bicarbonate p.o. 1300 twice daily and should continue on
this as an outpatient until labs are checked in 1 week of
discharge.
# Hypokalemia
Likley in the setting of profound diarrhea / bicarbonate
administration. Repleted prn.
# Peripheral edema
Developed mostly in the setting of fluid resuscitation, sodium
bicarbonate drip, D10 drip to treat acute metabolic
derangements. Started on furosemide 20 mg p.o. daily. Will need
to have electrolytes checked and follow-up titration of
medication as an outpatient. Discharge creatinine 3.0, discharge
weight 132 pounds with reported dry weight of 124 pounds.
# DM type I
# Hypoglycemia
Low blood sugars likely in the setting of critical illness, npo
status, ___, and continuation of home lantus. ___ was
consulted who recommended decreasing lantus and continue to
titrate her insulin accordingly.
# Chest pain
# Elevated Troponin
# CAD s/p DES x4
Troponins stable (0.12 x2 on admission). EKG at baseline. Likely
demand in the setting of CAD and hypovolemia / hypoperfusion
from profound diarrhea as above.
- Continued home aspirin 81 mg daily
- Continued home metoprolol
- Continued home ranolazine
- Not on statin secondary to interaction with immunosuppression
per prior notes
CHRONIC ISSUES
--------------
#Anemia: Iso ESRD, getting weekly Epo infusions, following w/
heme
#Gout: continue allopurinol (renally dosed)
#Hypothyroidism: continue levothyroxine
#Scleroderma: continue home prednisone
#GERD/Gastroparesis: continue pantoprazole (esomeprazole
equivalent) and promethazine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
5. FoLIC Acid 1 mg PO DAILY
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Mycophenolate Mofetil 500 mg PO BID
11. PredniSONE 5 mg PO DAILY
12. Promethazine 25 mg PO DAILY:PRN nausea
13. Ranolazine ER 500 mg PO BID
14. Vitamin D ___ UNIT PO DAILY
15. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
16. Cilostazol 25 mg PO QPM
17. Cilostazol 50 mg PO QAM
18. melatonin 10 mg oral QHS
19. naftifine 2 % topical BID To soles of feet and between toe
webs
20. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
21. trimethobenzamide 300 mg oral TID:PRN nausea
22. Calcium Carbonate 500 mg PO BID
23. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
24. Esomeprazole 40 mg Other BID
25. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
26. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*10 Tablet
Refills:*0
2. Pravastatin 10 mg PO QPM
RX *pravastatin 10 mg 1 tablet(s) by mouth at bedtime Disp #*10
Tablet Refills:*0
3. Sodium Bicarbonate 1300 mg PO BID
RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth twice a day
Disp #*40 Tablet Refills:*0
4. Glargine 15 Units Breakfast
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Allopurinol ___ mg PO DAILY
6. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
7. Aspirin 81 mg PO DAILY
8. Calcitriol 0.25 mcg PO DAILY
9. Calcium Carbonate 500 mg PO BID
10. Cilostazol 25 mg PO QPM
11. Cilostazol 50 mg PO QAM
12. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
13. Esomeprazole 40 mg Other BID
14. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
15. FoLIC Acid 1 mg PO DAILY
16. Levothyroxine Sodium 125 mcg PO DAILY
17. Lidocaine 5% Patch 1 PTCH TD QAM
18. melatonin 10 mg oral QHS
19. Metoprolol Succinate XL 25 mg PO DAILY
20. Multivitamins 1 TAB PO DAILY
21. Mycophenolate Mofetil 500 mg PO BID
22. naftifine 2 % topical BID To soles of feet and between toe
webs
23. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
24. PredniSONE 5 mg PO DAILY
25. Promethazine 25 mg PO DAILY:PRN nausea
26. Ranolazine ER 500 mg PO BID
27. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
28. trimethobenzamide 300 mg oral TID:PRN nausea
29. Vitamin D ___ UNIT PO DAILY
30.Outpatient Physical Therapy
ICD 9 557.9, ischemic colitis
Outpatient physical therapy, 12 sessions
31.Outpatient Lab Work
E87.2, acidosis
Will need outpatient labs for: sodium, potassium, chloride,
bicarbonate, BUN, creatinine, glucose
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIAMRY DIAGNOSIS
-----------------
# Ischemic Colitis
SECONDARY DIAGNOSES
-------------------
# ___ on CKD
# ESRD s/p LURT ___
# Metabolic acidosis
# Respiratory acidosis
# DM type I
# Hypoglycemia
# Chest pain
# Elevated Troponin
# CAD s/p DES x4
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you at ___!
Why was I admitted to the hospital?
- You had severe diarrhea and were found to have inflammation
and low blood flow to your colon for which you were started on
antibiotics
- You also had chest pain that resolved with the treatment of
your diarrhea
What should I do after discharge?
- Please take ___ of your medications as prescribed
- Please follow up with your doctors as detailed below
___ the best!
Your ___ care team
Followup Instructions:
___
|
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"G92",
"I130",
"I5032",
"N184",
"Z940",
"N179",
"E874",
"E1022",
"Z794",
"Z87891",
"E876",
"E10649",
"E10319",
"E1040",
"E1043",
"E1021",
"K3184",
"I2510",
"Z955",
"R079",
"D8982",
"R7989",
"R609",
"D631",
"M109",
"E039",
"M341",
"K219",
"G4733",
"N319"
] |
Allergies: Penicillins / Ativan / carvedilol / amlodipine Chief Complaint: abdominal pain, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] y/o female with a history of ESRD (s/p LURT [MASKED] on immunosuppression), anemia (weekly transusions and epo injections), CAD s/p [MASKED] 4 (most recently [MASKED], HFpEF (EF 55% [MASKED], IPMN ([MASKED]), HTN, T1DM, and h/o multiple MDR UTIs (Klebsiella, E.coli, Enterococcus), scleroderma/CREST who presents with diarrhea and abdominal pain. The patient was recently treated with Bactrim for a UTI about a week ago. Around that same time, the patient began having diarrhea and abdominal pain. The pain is described as [MASKED], located over the lower bilateral quadrants. It is intermittent without known triggers. Nothing makes it worse, including food or movements. She has also had profuse diarrhea, described as large volume episodes occurring almost every hour. It has been associated with fecal urgency. No hematochezia or melena. She reports decreased enteral intake over this time. No new nausea, vomiting, fever, chills, dysuria or hematuria. No history of similar symptoms or c.diff infections. No recent travel, sick contacts, new foods or medications. Patient was seen at [MASKED] on [MASKED]. She was given 1L IVF with plan to follow up at [MASKED] for repeat labs in a day. She continued to have symptoms. On [MASKED], she developed new right-sided chest pain described as [MASKED], dull/ache while sleeping. Her pain was unchanged with palpation, deep breaths, or movement and it felt similar to prior cardiac pain. She took SL nitro with resolution. She also began feeling lightheaded, particularly with bowel movements. Given her ongoing symptoms and new chest pain, she presented to the [MASKED] ED. In the ED, initial VS were: T 97.6, HR 86, BP 126/73, RR 12, SpO2 100% RA Exam notable for: Soft, NT/ ND ECG: Rate 84. NSR, Left axis deviation. ST depression in I and aVL with TWI, STE in III, ST elevation in aVR, V1- V2 (similar to prior) Labs showed: -CBC: WBC 6.7, Hgb 11.1, Plt 284 -Chem: HCO3 12, Cl 113, BUN 68, Cr 3.2 -VBG: [MASKED] -TropT 0.12->0.12, MB 8 -Lactate 1.2 Imaging showed: CT ABD & PELVIS W/O CONTRAST 1. Portal venous gas and gas within the IMV, concerning for bowel ischemia. Nondependent gas along the rectal wall is suspicious for pneumatosis in the setting of venous gas. 2. Mildly dilated, fluid-filled large colon, most consistent with given history of diarrhea. No bowel obstruction. 3. Evidence of bowel wall thickening of the distal ileum in the right lower quadrant, which may be related to enteritis of infectious or inflammatory etiology. However, given extensive vascular disease, ischemia is also on the differential. 4. Pancreatic cystic lesions, better assessed on MRI from [MASKED]. Please refer to the MRI report for follow-up recommendations. 5. Unremarkable transplant kidney. Consults: -Transplant surgery: recommended guaiac stools (trace positive yellow stool in ED), trend trops, stool culture, c. diff, CMV VL Patient received: [MASKED] 18:36 IV Promethazine 6.25 mg [MASKED] [MASKED] 20:04 IVF NS 500 mL [MASKED] 20:20 IV Dextrose 50% 25 gm [MASKED] [MASKED] 22:05 PO CycloSPORINE (Neoral) MODIFIED 25 mg [MASKED] 22:05 PO Mycophenolate Mofetil 500 mg [MASKED] 22:11 IVF LR Started 150 mL/hr [MASKED] 23:42 IV MetroNIDAZOLE (500 mg ordered) [MASKED] 23:42 IV Ciprofloxacin 400 mg [MASKED] [MASKED] 00:47 IVF NS (500 mL ordered) Transfer VS were: T 98.1, HR 95, BP 160/60, RR 16, SpO2 99% RA On arrival to the floor, patient reports persistent symptoms. Her abdominal pain is currently resolved but she continues to have diarrhea. No fever, chills, new nausea or vomiting. No recurrent chest pain, shortness of breath, or cough. She notes recent lightheadedness, particularly with diarrhea. No syncope. She describes a history of PE in [MASKED] following an angioplasty. No family history of blood clots and no personal history of atrial fibrillation. Notes her blood glucose has been running lower at home, prompting her to downtitrate her insulin. Past Medical History: -CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED] DES to LAD [MASKED] PCI of Cx and OM with [MASKED] -[MASKED] renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] -Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) -Hypertension -Dyslipidemia -Scleroderma w/ CREST syndrome -Gastroparesis/GERD/Hiatal hernia -Gout diagnosed [MASKED] years ago -OSA -Pancreatic cyst Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION PHYSICAL EXAM: VS: Temp 97.5 BP 136/72 HR 102 RR 18 96% on RA GENERAL: Ill appearing female in NAD. Lying comfortably in bed. HEENT: AT/NC, anicteric sclera, PERRL. Dry mucous membranes. Oropharynx clear. NECK: supple, no LAD CV: RRR with normal S1/S2. II/VI systolic murmur over RUSB and LUSB. No rubs or gallops. PULM: Normal respiratory effort. CTAB without wheezes, rales or rhonchi. GI: Soft, moderately distended. Moderate TTP over lower quadrants. No guarding or rebound tenderness. Normoactive BS. No masses appreciated. No significant pain over renal transplant. EXTREMITIES: Warm, well perfused. No [MASKED] edema or erythema. PULSES: 2+ radial pulses bilaterally NEURO: Alert and interactive. CN II-XII grossly intact. Moves [MASKED] extremities. DERM: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: 24 HR Data (last updated [MASKED] @ 821) Temp: 97.7 (Tm 98.9), BP: 158/82 (106-158/70-82), HR: 95 (79-95), RR: 18, O2 sat: 99% (96-99), O2 delivery: Ra, Wt: 131.2 lb/59.51 kg GENERAL: female in NAD, lying in bed HEENT: AT/NC, anicteric sclera, PERRL. Oropharynx clear. NECK: supple, no LAD CV: RRR with normal S1/S2. II/VI systolic murmur over RUSB and LUSB. No rubs or gallops. PULM: Normal respiratory effort. CTAB without wheezes, rales or rhonchi. GI: Soft, moderately distended. Non-tender. No guarding or rebound tenderness. +BS. No masses appreciated. No pain over renal graft EXTREMITIES: Warm, well perfused. 1+ pitting [MASKED] edema b/l. PULSES: 2+ radial pulses bilaterally NEURO: Alert and interactive. Moves [MASKED] extremities. DERM: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: [MASKED] 02:26PM BLOOD WBC-6.7 RBC-3.47* Hgb-11.1* Hct-34.3 MCV-99* MCH-32.0 MCHC-32.4 RDW-15.4 RDWSD-55.9* Plt [MASKED] [MASKED] 02:26PM BLOOD Neuts-80.2* Lymphs-3.6* Monos-11.4 Eos-2.6 Baso-0.2 Im [MASKED] AbsNeut-5.34 AbsLymp-0.24* AbsMono-0.76 AbsEos-0.17 AbsBaso-0.01 [MASKED] 12:40PM BLOOD [MASKED] PTT-31.5 [MASKED] [MASKED] 02:26PM BLOOD Glucose-97 UreaN-68* Creat-3.2* Na-140 K-3.7 Cl-113* HCO3-12* AnGap-15 [MASKED] 02:26PM BLOOD ALT-9 AST-9 CK(CPK)-58 AlkPhos-114* TotBili-<0.2 [MASKED] 02:26PM BLOOD CK-MB-7 cTropnT-0.12* [MASKED] 02:26PM BLOOD Albumin-2.4* [MASKED] 05:52AM BLOOD Calcium-7.6* Phos-4.9* Mg-1.0* [MASKED] 10:01PM BLOOD pO2-26* pCO2-37 pH-7.14* calTCO2-13* Base XS--17 [MASKED] 12:48PM BLOOD [MASKED] pO2-203* pCO2-15* pH-7.32* calTCO2-8* Base XS--15 Comment-GREEN TOP [MASKED] 06:05PM BLOOD Lactate-1.2 [MASKED] 12:48PM BLOOD Lactate-1.5 INTERVAL/DISCHARGE LABS & STUDIES: CT ABD & PELVIS W/O CONTRASTStudy Date of [MASKED] 7:56 [MASKED] 1. Portal venous gas and gas within the IMV, concerning for bowel ischemia. Nondependent gas along the rectal wall is suspicious for pneumatosis in the setting of venous gas. 2. Mildly dilated, fluid-filled large colon, most consistent with given history of diarrhea. No bowel obstruction. 3. Evidence of bowel wall thickening of the distal ileum in the right lower quadrant, which may be related to enteritis of infectious or inflammatory etiology. However, given extensive vascular disease, ischemia is also on the differential. 4. Pancreatic cystic lesions, better assessed on MRI from [MASKED]. Please refer to the MRI report for follow-up recommendations. 5. Unremarkable transplant kidney. DUPLEX DOPP ABD/PELStudy Date of [MASKED] 8:49 AM 1. Patent celiac axis and common hepatic arteries with appropriate waveforms. 2. SMA is patent with absent diastolic flow, likely secondary to extensive arteriosclerotic/atherosclerotic calcifications as seen on recent CT. 3. Inferior mesenteric artery is not visualized. INTERVAL/DISCHARGE LABS [MASKED] 10:01PM BLOOD pO2-26* pCO2-37 pH-7.14* calTCO2-13* Base XS--17 [MASKED] 12:48PM BLOOD [MASKED] pO2-203* pCO2-15* pH-7.32* calTCO2-8* Base XS--15 Comment-GREEN TOP [MASKED] 04:43PM BLOOD [MASKED] pO2-102 pCO2-32* pH-7.18* calTCO2-13* Base XS--15 Comment-GREEN TOP [MASKED] 08:04PM BLOOD [MASKED] pO2-40* pCO2-34* pH-7.24* calTCO2-15* Base XS--11 [MASKED] 04:11AM BLOOD [MASKED] pO2-59* pCO2-28* pH-7.33* calTCO2-15* Base XS--9 [MASKED] 05:10PM BLOOD [MASKED] pO2-27* pCO2-34* pH-7.26* calTCO2-16* Base XS--11 [MASKED] 08:35PM BLOOD [MASKED] pO2-30* pCO2-34* pH-7.26* calTCO2-16* Base XS--11 [MASKED] 04:16AM BLOOD [MASKED] pO2-61* pCO2-32* pH-7.31* calTCO2-17* Base XS--9 [MASKED] 02:26PM BLOOD Glucose-97 UreaN-68* Creat-3.2* Na-140 K-3.7 Cl-113* HCO3-12* AnGap-15 [MASKED] 05:52AM BLOOD Glucose-51* UreaN-61* Creat-3.3* Na-140 K-3.2* Cl-116* HCO3-10* AnGap-14 [MASKED] 12:40PM BLOOD Glucose-152* UreaN-60* Creat-3.3* Na-138 K-3.1* Cl-113* HCO3-8* AnGap-17 [MASKED] 07:47PM BLOOD Glucose-75 UreaN-56* Creat-3.2* Na-141 K-3.3* Cl-111* HCO3-15* AnGap-15 [MASKED] 08:50AM BLOOD Glucose-98 UreaN-50* Creat-3.2* Na-137 K-3.0* Cl-107 HCO3-14* AnGap-16 [MASKED] 08:18PM BLOOD Glucose-101* UreaN-46* Creat-3.0* Na-137 K-4.4 Cl-112* HCO3-11* AnGap-14 [MASKED] 03:55AM BLOOD Glucose-80 UreaN-43* Creat-2.8* Na-140 K-3.6 Cl-114* HCO3-12* AnGap-14 [MASKED] 06:39AM BLOOD Glucose-291* UreaN-38* Creat-2.7* Na-141 K-3.8 Cl-112* HCO3-14* AnGap-15 [MASKED] 04:32AM BLOOD Glucose-358* UreaN-42* Creat-3.0* Na-145 K-3.6 Cl-115* HCO3-18* AnGap-12 [MASKED] 04:32AM BLOOD WBC-7.8 RBC-2.69* Hgb-8.4* Hct-26.2* MCV-97 MCH-31.2 MCHC-32.1 RDW-15.9* RDWSD-56.1* Plt [MASKED] y/o female with a history of ESRD (s/p LURT [MASKED] on immunosuppression), anemia (weekly transusions and epo injections), CAD s/p [MASKED] 4 (most recently [MASKED], HFpEF (EF 55% [MASKED], IPMN ([MASKED]), HTN, T1DM, and h/o multiple MDR UTIs (Klebsiella, E.coli, Enterococcus), scleroderma/CREST who presented on [MASKED] with diarrhea and abdominal pain x7 days. CT scan on admission showed portal venous gas in the liver and pneumatosis with concern for bowel ischemia. Transplant surgery was consulted she was started on bowel rest with empiric ciprofloxacin and Flagyl. Her pH was initially very low at 7.14 with poor respiratory compensation and severe non-gap metabolic acidosis likely in the setting of continued diarrhea. She was started on oral and IV bicarb repletion. She also was given 80% of her long-acting insulin as she was n.p.o. and type I diabetic, but continued to be persistently hypoglycemic, requiring D10 drip. She continued to be acidemic with poor respiratory compensation, and she was transferred to the ICU. There she had an abdominal ultrasound which demonstrated absent diastolic flow in the SMA. Vascular surgery was consulted and felt that there was no need for procedural intervention at this time, but that she should restart a statin. [MASKED] was consulted for blood sugar management. In the ICU her respiratory status improved as did her acidemia. She was sent back to the floor and transitioned to regular diet and oral antibiotics to complete a 7 day course of ciprofloxacin and Flagyl. She was started on pravastatin 10 mg nightly after discussion with transplant pharmacy and transplant nephrology. TRANSITIONAL ISSUES ------------------- [] Patient is type I diabetes and should have close follow-up with [MASKED] with Dr. [MASKED] [] Discharge insulin regimen: Glargine 15U at breakfast. Humalog 5U with breakfast/lunch/dinner with sliding scale. [] Patient discharged on furosemide 20 mg p.o. daily. Should follow-up with PCP about titration of medication and follow-up electrolytes [] Patient started on pravastatin 10 mg nightly [] Patient currently on sodium bicarbonate 1300 twice daily for non-gap metabolic acidosis. [] Patient should have electrolytes checked in 1 week of discharge to look for resolution of metabolic acidosis. His bicarbonate has returned to normal, she should stop oral sodium bicarbonate [] Will need to clarify if she has a history of APLS (per medical records) and if she needs anticoagulation [] Discharge Cr: 3.0 [] Discharge weight: 132 lbs (reported dry weight 124 lbs) #CODE: Full (presumed) #CONTACT: [MASKED] (SISTER) [MASKED] ACTIVE ISSUES ------------- # Diarrhea # Nausea # Abdominal pain # Colitis CT on admission with evidence of colitis and concern for possible bowel ischemic. Clinical condition was stable and without any peritoneal signs on exam. She was seen by vascular surgery who recommended medical management. The patient was treated with bowel rest and started empirically on ciprofloxacin / Flagyl (day 1 = [MASKED]. CMV VL and C. Diff negative. Mesenteric duplex demonstrated normal flow velocities and waveforms in the celiac artery. SMA was patent with absent diastolic flow, likely secondary to extensive arteriosclerotic/ atherosclerotic calcifications as seen on recent CT, for which she was started on pravastatin 10 mg nightly. She was transitioned back to normal diet and completed 7 day course of ciprofloxacin and Flagyl. # [MASKED] on CKD # ESRD s/p LURT [MASKED] Most recent creatinine was around 3.0. Chronic allograft dysfunction from diabetic nephropathy and grade 2 IFTA per biopsy in [MASKED]. Current [MASKED] likely pre-renal in the setting of diarrhea. Treated with hydration with subsequent improvement back to baseline. Transplant nephrology was following. Continued cyclosporine(neoral) 25 mg bid, MMF 500 mg bid, prednisone 5 mg qd. # Metabolic acidosis # Respiratory acidosis Non-gap acidosis likely secondary to profound diarrhea. [MASKED] likely also contributing. Lactate normal. No signs of DKA. Initially treated with bicarbonate gtt, subsequently discontinued with improvement in acidosis. Patient continued on sodium bicarbonate p.o. 1300 twice daily and should continue on this as an outpatient until labs are checked in 1 week of discharge. # Hypokalemia Likley in the setting of profound diarrhea / bicarbonate administration. Repleted prn. # Peripheral edema Developed mostly in the setting of fluid resuscitation, sodium bicarbonate drip, D10 drip to treat acute metabolic derangements. Started on furosemide 20 mg p.o. daily. Will need to have electrolytes checked and follow-up titration of medication as an outpatient. Discharge creatinine 3.0, discharge weight 132 pounds with reported dry weight of 124 pounds. # DM type I # Hypoglycemia Low blood sugars likely in the setting of critical illness, npo status, [MASKED], and continuation of home lantus. [MASKED] was consulted who recommended decreasing lantus and continue to titrate her insulin accordingly. # Chest pain # Elevated Troponin # CAD s/p DES x4 Troponins stable (0.12 x2 on admission). EKG at baseline. Likely demand in the setting of CAD and hypovolemia / hypoperfusion from profound diarrhea as above. - Continued home aspirin 81 mg daily - Continued home metoprolol - Continued home ranolazine - Not on statin secondary to interaction with immunosuppression per prior notes CHRONIC ISSUES -------------- #Anemia: Iso ESRD, getting weekly Epo infusions, following w/ heme #Gout: continue allopurinol (renally dosed) #Hypothyroidism: continue levothyroxine #Scleroderma: continue home prednisone #GERD/Gastroparesis: continue pantoprazole (esomeprazole equivalent) and promethazine Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Calcitriol 0.25 mcg PO DAILY 4. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 5. FoLIC Acid 1 mg PO DAILY 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Lidocaine 5% Patch 1 PTCH TD QAM 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Mycophenolate Mofetil 500 mg PO BID 11. PredniSONE 5 mg PO DAILY 12. Promethazine 25 mg PO DAILY:PRN nausea 13. Ranolazine ER 500 mg PO BID 14. Vitamin D [MASKED] UNIT PO DAILY 15. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 16. Cilostazol 25 mg PO QPM 17. Cilostazol 50 mg PO QAM 18. melatonin 10 mg oral QHS 19. naftifine 2 % topical BID To soles of feet and between toe webs 20. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 21. trimethobenzamide 300 mg oral TID:PRN nausea 22. Calcium Carbonate 500 mg PO BID 23. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 24. Esomeprazole 40 mg Other BID 25. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 26. Glargine 20 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*10 Tablet Refills:*0 2. Pravastatin 10 mg PO QPM RX *pravastatin 10 mg 1 tablet(s) by mouth at bedtime Disp #*10 Tablet Refills:*0 3. Sodium Bicarbonate 1300 mg PO BID RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth twice a day Disp #*40 Tablet Refills:*0 4. Glargine 15 Units Breakfast Humalog 5 Units Breakfast Humalog 5 Units Lunch Humalog 5 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Allopurinol [MASKED] mg PO DAILY 6. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 7. Aspirin 81 mg PO DAILY 8. Calcitriol 0.25 mcg PO DAILY 9. Calcium Carbonate 500 mg PO BID 10. Cilostazol 25 mg PO QPM 11. Cilostazol 50 mg PO QAM 12. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 13. Esomeprazole 40 mg Other BID 14. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 15. FoLIC Acid 1 mg PO DAILY 16. Levothyroxine Sodium 125 mcg PO DAILY 17. Lidocaine 5% Patch 1 PTCH TD QAM 18. melatonin 10 mg oral QHS 19. Metoprolol Succinate XL 25 mg PO DAILY 20. Multivitamins 1 TAB PO DAILY 21. Mycophenolate Mofetil 500 mg PO BID 22. naftifine 2 % topical BID To soles of feet and between toe webs 23. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 24. PredniSONE 5 mg PO DAILY 25. Promethazine 25 mg PO DAILY:PRN nausea 26. Ranolazine ER 500 mg PO BID 27. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 28. trimethobenzamide 300 mg oral TID:PRN nausea 29. Vitamin D [MASKED] UNIT PO DAILY 30.Outpatient Physical Therapy ICD 9 557.9, ischemic colitis Outpatient physical therapy, 12 sessions 31.Outpatient Lab Work E87.2, acidosis Will need outpatient labs for: sodium, potassium, chloride, bicarbonate, BUN, creatinine, glucose Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIAMRY DIAGNOSIS ----------------- # Ischemic Colitis SECONDARY DIAGNOSES ------------------- # [MASKED] on CKD # ESRD s/p LURT [MASKED] # Metabolic acidosis # Respiratory acidosis # DM type I # Hypoglycemia # Chest pain # Elevated Troponin # CAD s/p DES x4 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [MASKED], It was a pleasure taking care of you at [MASKED]! Why was I admitted to the hospital? - You had severe diarrhea and were found to have inflammation and low blood flow to your colon for which you were started on antibiotics - You also had chest pain that resolved with the treatment of your diarrhea What should I do after discharge? - Please take [MASKED] of your medications as prescribed - Please follow up with your doctors as detailed below [MASKED] the best! Your [MASKED] care team Followup Instructions: [MASKED]
|
[] |
[
"I130",
"I5032",
"N179",
"Z794",
"Z87891",
"I2510",
"Z955",
"M109",
"E039",
"K219",
"G4733"
] |
[
"K551: Chronic vascular disorders of intestine",
"G92: Toxic encephalopathy",
"I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"I5032: Chronic diastolic (congestive) heart failure",
"N184: Chronic kidney disease, stage 4 (severe)",
"Z940: Kidney transplant status",
"N179: Acute kidney failure, unspecified",
"E874: Mixed disorder of acid-base balance",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"Z794: Long term (current) use of insulin",
"Z87891: Personal history of nicotine dependence",
"E876: Hypokalemia",
"E10649: Type 1 diabetes mellitus with hypoglycemia without coma",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified",
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"E1021: Type 1 diabetes mellitus with diabetic nephropathy",
"K3184: Gastroparesis",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z955: Presence of coronary angioplasty implant and graft",
"R079: Chest pain, unspecified",
"D8982: Autoimmune lymphoproliferative syndrome [ALPS]",
"R7989: Other specified abnormal findings of blood chemistry",
"R609: Edema, unspecified",
"D631: Anemia in chronic kidney disease",
"M109: Gout, unspecified",
"E039: Hypothyroidism, unspecified",
"M341: CR(E)ST syndrome",
"K219: Gastro-esophageal reflux disease without esophagitis",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"N319: Neuromuscular dysfunction of bladder, unspecified"
] |
10,030,753
| 27,720,208
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
___ Endoscopic Ultrasound and Biopsy of
Abdominal/Pancreatic Mass
History of Present Illness:
Ms. ___ is a ___ Female with ESRD (s/p LURT ___ on
immunosuppression), anemia (weekly transusions and epo
injections), CAD s/p ___ 4 (most recently ___, HFpEF (55%
EF ___, pancreatic mass concerning for malignancy with
planned EUS/biopsy ___, HTN, T1DM, and h/o multiple MDR UTIs
(Klebsiella, E.coli, Enterococcus), scleroderma/CREST who
presented with angina that woke her from sleep the night before
admission found to have hemoglobin of 6.8 with elevated troponin
and guaiac positive stool.
She reports the night prior to admission she was woken from
sleep by left sided substernal chest pain radiating to her back.
She took nitroglycerin which relieved the pain but states she
was woken up approximately hourly due to chest pain. States it
is similar to her typical angina pain. No associated dyspnea,
has chronic n/v. She stopped taking her ticagrelor 1 week ago
for planned EUS/biopsy of pancreatic lesion and her cardiology
notes state plan would be to not restart. She has not had angina
pain in the last several months. She denies any fevers/chills,
abdominal pain, dysuria, hematuria, melena or dark stools.
She called the ___ clinic to see if she should come for
her transfusion ___ but was referred to the ED given her
symptoms. She presented to ___ where she was found to have a
hemoglobin of 7 from 9.8 one week prior and was transferred to
___ w/ concern for unstable angina. Of note she has had
longstanding multifactorial anemia from ESRD, chronic
inflammation, B12 deficiency, and possible GI bleeding and
receives epo injections and weekly transfusions.
Past Medical History:
-CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___ DES to LAD ___
PCI of Cx and OM with ___
-___ renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
-Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
-Hypertension
-Dyslipidemia
-Scleroderma w/ CREST syndrome
-Gastroparesis/GERD/Hiatal hernia
-Gout diagnosed ___ years ago
-OSA
-Pancreatic cyst
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GENERAL: Pleasant woman, NAD
HEENT: Anicteric sclera, MMM
NECK: supple
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DISCHARGE PHYSICAL EXAM:
========================
___ 1523 Temp: 98.8 PO BP: 169/72 HR: 78 RR: 18 O2 sat: 99%
O2 delivery: RA FSBG: 265
GENERAL: NAD
HEENT: PERRLA, EOMI, MMM
NECK: supple, JVP flat. No LAD.
CV: RRR, no g/m/r
PULM: CTAB, no wheezes, no rales, no rhonchi.
GI: Soft, non-tender, non-distended. +BS.
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&O x3
Pertinent Results:
ADMISSION LAB RESULTS
=====================
___ 02:40PM BLOOD WBC-4.9 RBC-2.17* Hgb-6.8* Hct-20.4*
MCV-94 MCH-31.3 MCHC-33.3 RDW-18.5* RDWSD-63.3* Plt ___
___ 02:40PM BLOOD Plt ___
PERTINENT LABS RESULTS
====================
___ 07:20AM BLOOD Glucose-245* UreaN-49* Creat-2.0* Na-142
K-3.8 Cl-110* HCO3-19* AnGap-13
___ 06:51AM BLOOD Glucose-200* UreaN-48* Creat-2.2* Na-143
K-4.0 Cl-109* HCO3-22 AnGap-12
___ 10:20PM BLOOD cTropnT-0.18*
___ 07:20AM BLOOD cTropnT-0.16*
___ 10:20PM BLOOD CK-MB-4
___ 06:51AM BLOOD Cyclspr-42*
DISCHARGE LAB RESULTS
=====================
___ 07:25AM BLOOD WBC-5.4 RBC-3.03* Hgb-9.3* Hct-28.5*
MCV-94 MCH-30.7 MCHC-32.6 RDW-18.5* RDWSD-62.6* Plt ___
___ 07:25AM BLOOD Glucose-383* UreaN-55* Creat-2.7* Na-141
K-3.8 Cl-110* HCO3-20* AnGap-11
___ 01:19PM BLOOD Creat-2.6*
___ 07:25AM BLOOD Albumin-2.3* Calcium-8.6 Phos-4.0 Mg-2.0
___ 07:25AM BLOOD Cyclspr-35*
MICROBIOLOGY
============
None
REPORTS/STUDIES
==============
___ EGD/EUS with Biopsy
- Normal esophagus, stomach, duodenum
- Pancreatic cyst (3) - head, body, tail
- FNA performed of thick mucinous fluid
- Findings c/w multifocal side branch IPMN, no high risk
features for malignancy
- Pathology/cytology pending at time of discharge summary
Brief Hospital Course:
This is a ___ female with a past medical history significant for
ESRD (s/p LURT ___ on immunosuppression), anemia (weekly
transfusions and epo injections), CAD s/p ___ 4 (most recently
___, HFrEF (55% EF ___, pancreatic mass concerning for
malignancy with planned EUS/biopsy ___, HTN, T1DM, and h/o
multiple MDR UTIs (Klebsiella, E.coli, Enterococcus),
scleroderma/CREST who presented with chest pain in the setting
of her chronic anemia. This resolved after transfusions. She
underwent EUS/pancreatic biopsy on ___ which was uncomplicated.
ACUTE ISSUES
============
#ACUTE ON CHRONIC ANEMIA:
The patient was due for her weekly transfusion ___ but
presented to ED given her chest pain and difficulty of obtaining
matched blood outpatient due to her extensive transfusion
history. Her hemoglobin drop appears consistent with her recent
history. Given that her HgB trend was similar to her prior
trends, there was low suspicion for new acute blood loss or
other etiology contributing. She was transfused two units pRBCs
for goal hgb >8 given concern for angina given her chest pain as
below. She will follow up on ___ for her next routine
transfusion.
#CAD, ANGINA:
The patient has an extensive cardiac history including CAD s/p
multiple stents, most recently ___ and is on anti-platelet
therapy which has been held since ___ per cardiology
recommendations in advance of EUS/biopsy. She presented with
sided chest pain that woke her from sleep multiple times,
relieved by nitro, similar to past anginal pain. ECG unchanged
from prior, troponins stable x2 at baseline. Her HgB was 6.4 on
presentation. Her chest pain went away after her first
transfusion and did not return during her hospitalization. It
was thought that the patient's symptoms were due to demand in
the setting of her anemia. She was transfused 2 units for anemia
as above. She was continued on aspirin 81, ranolazine, and
Metoprolol. Her Ticagrelor was on hold since ___ per
cardiologist in preparation for EUS with biopsy with plan not to
resume after pancreatic biopsy. Per the patient, she states that
his atorvastatin was stopped, but last cardiology note ___
lists as active medication.
#PANCREATIC MASS:
The patient initially was found to have an abdominal/pancreatic
mass found on a CT A/P obtained ___ after sustaining a fall.
She previously reported full body pruritus, and has significant
ongoing early satiety, unintentional weight loss, and malaise
raising concern for malignancy. She had a planned EUS/biopsy for
___ that was rescheduled to ___ by GI. In preparation for this
procedure her home Ticagrelor had been on hold since ___. After
speaking with the Endoscopy/ GI team, they were able to perform
an uncomplicated EUS with biopsy on ___. Pathology was
pending at the time of discharge.
#HYPERTENSION:
The patient has a history of of labile, difficult to control BP,
previously on hydralazine but the patient reports this meication
was stopped since her last discharge. She did not want to start
hydralazine. Continued metoprolol inpatient. Please consider
transition to labetalol or carvidilol for better blood pressure
effect as outpatient.
#GUAIAC POSITIVE STOOL:
The patient was found to have guaiac positive stools in the ED.
She denied any symptoms of melena, hematochezia. She previously
underwent work up with an EGD, colonoscopy and capsule endoscopy
in ___ for melena that only revealed small ileal angioectasia
with no signs of active bleeding. Occult bleeding could be due
to angioectasias, pancreatic mass, or new small/large lesion.
Given the lack of hematochezia or frank melena it was thought
that the patient was unlikely to have any significant bleed and
the decision was made not pursue GI consult/ further work up
while inpatient.
#ESRD S/P TRANSPLANT W/ RECURRENT CKD:
The patient underwent a transplant in ___ now on MMF and
cyclosporine w/ recurrent CKD likely
from poorly controlled DM and labile hypertension. Recent
baseline ~2.6. She was continued on MMF and cyclosporine. She
was continued on calcitriol, calcium carbonate.
CHRONIC ISSUES:
===============
#DIASTOLIC CHF:
Per cardiology, the patient's Lasix recently stopped with plan
to resume only if weight surpasses 124 lbs. She received Lasix
following he blood transfusion, but otherwise her Lasix
continued to be held upon discharged. Management of her other
cardiac co-morbidities as above.
#T1 DM: The patient was continued on an insulin sliding scale
and a reduced dose of lantus while NPO. Discharged on her home
insulin regimen.
#SCLERODERMA: The patient was continued on her home prednisone
5mg daily.
#GOUT: The patient was continued on her home allopurinol ___
daily.
#HYPOTHYROIDISM: The patient was continued on her home
levothyroxine.
#GERD GASTROPARESIS: The patient was continued on her home
omeprazole and promethazine for nausea.
TRANSITIONAL ISSUES:
====================
[] Patient reports that her statin was discontinued at her last
admission. Continued to hold while inpatient. Should clarify at
next PCP or cardiology appointment.
[] BP management: Patient persistently HTN while inpatient to
170s on discharge. Pt. reports that her hydralazine was stopped
after last admission (was on 50mg PO BID). She did not want to
restart. Please consider transition to labetalol or carvidilol
for better blood pressure effect as outpatient.
[] Biopsy results: patient underwent EUS w/biopsies of
pancreatic mass. Results pending at time of d/c.
[] Discharge to complete 5 day course of ciprofloxacin post
biopsy ___
[] Discharge Cr was 2.6; fluctuated between 2.0 and 2.7 as
inpatient. Transplant nephrology followed as inpatient. Advised
to encourage PO on day of discharge. No changes were made to
immunosuppressives.
[] Pt was instructed to stop calcium while taking ciprofloxacin
due to binding effect but to resume after this was finished.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Calcitriol 0.25 mcg PO DAILY
4. Calcium Carbonate 500 mg PO BID
5. Cilostazol 25 mg PO QPM
6. Cilostazol 50 mg PO QAM
7. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
8. Ferrous Sulfate 325 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Levothyroxine Sodium 125 mcg PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Multivitamins 1 TAB PO DAILY
13. Mycophenolate Mofetil 500 mg PO BID
14. Omeprazole 40 mg PO BID
15. PredniSONE 5 mg PO DAILY
16. Promethazine 25 mg PO DAILY:PRN nausea
17. Ranolazine ER 500 mg PO BID
18. Vitamin D ___ UNIT PO DAILY
19. Metoprolol Succinate XL 50 mg PO DAILY
20. Toujeo SoloStar U-300 Insulin (insulin glargine) 30 units
subcutaneous QAM
21. trimethobenzamide 300 mg oral TID:PRN nausea
22. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
23. naftifine 2 % topical BID To soles of feet and between toe
webs
24. melatonin 10 mg oral QHS
25. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H Duration: 5 Doses
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
2. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
3. Allopurinol ___ mg PO DAILY
4. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
5. Aspirin 81 mg PO DAILY
6. Calcitriol 0.25 mcg PO DAILY
7. Cilostazol 25 mg PO QPM
8. Cilostazol 50 mg PO QAM
9. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
10. FoLIC Acid 1 mg PO DAILY
11. Levothyroxine Sodium 125 mcg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. melatonin 10 mg oral QHS
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Mycophenolate Mofetil 500 mg PO BID
17. naftifine 2 % topical BID To soles of feet and between toe
webs
18. Omeprazole 40 mg PO BID
19. PredniSONE 5 mg PO DAILY
20. Promethazine 25 mg PO DAILY:PRN nausea
21. Ranolazine ER 500 mg PO BID
22. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
23. Toujeo SoloStar U-300 Insulin (insulin glargine) 30 units
subcutaneous QAM
24. trimethobenzamide 300 mg oral TID:PRN nausea
25. Vitamin D ___ UNIT PO DAILY
26. HELD- Calcium Carbonate 500 mg PO BID This medication was
held. Do not restart Calcium Carbonate until you finish
ciprofloxacin.
Discharge Disposition:
Home
Discharge Diagnosis:
Discharge Worksheet-Discharge ___,
MD on ___ @ 1700
- CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___ DES to LAD ___
PCI of Cx and OM with ___
- ___ congestive heart failure
- End-stage renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
- DM Type 1 complicated by neuropathy, retinopathy, neurogenic
bladder (intermittent straight catheterization PRN)
- Hypertension
- Dyslipidemia
- Scleroderma w/ CREST syndrome
- Gastroparesis/GERD/Hiatal hernia
- OSA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you were having
chest pain and were found to have low blood counts (anemia).
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital we gave you blood transfusions
which helped improved your blood counts and chest pain.
- We checked your EKG and this was unchanged from your prior
EKGs.
- The GI doctors did ___ ultrasound and a biopsy of
the mass in your pancreas.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments. Please finish your of ciprofloxacin (500mg daily,
for next three days). Please do not take your calcium while
taking ciprofloxacin but ok to restart after this antibiotic is
finished.
- Please make sure to follow up with your kidney doctors.
- Please make sure to follow up with the GI doctors.
- You will be contacted in ___ days with the results of your
biopsy.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
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Allergies: Penicillins / Ativan / carvedilol / amlodipine Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [MASKED] Endoscopic Ultrasound and Biopsy of Abdominal/Pancreatic Mass History of Present Illness: Ms. [MASKED] is a [MASKED] Female with ESRD (s/p LURT [MASKED] on immunosuppression), anemia (weekly transusions and epo injections), CAD s/p [MASKED] 4 (most recently [MASKED], HFpEF (55% EF [MASKED], pancreatic mass concerning for malignancy with planned EUS/biopsy [MASKED], HTN, T1DM, and h/o multiple MDR UTIs (Klebsiella, E.coli, Enterococcus), scleroderma/CREST who presented with angina that woke her from sleep the night before admission found to have hemoglobin of 6.8 with elevated troponin and guaiac positive stool. She reports the night prior to admission she was woken from sleep by left sided substernal chest pain radiating to her back. She took nitroglycerin which relieved the pain but states she was woken up approximately hourly due to chest pain. States it is similar to her typical angina pain. No associated dyspnea, has chronic n/v. She stopped taking her ticagrelor 1 week ago for planned EUS/biopsy of pancreatic lesion and her cardiology notes state plan would be to not restart. She has not had angina pain in the last several months. She denies any fevers/chills, abdominal pain, dysuria, hematuria, melena or dark stools. She called the [MASKED] clinic to see if she should come for her transfusion [MASKED] but was referred to the ED given her symptoms. She presented to [MASKED] where she was found to have a hemoglobin of 7 from 9.8 one week prior and was transferred to [MASKED] w/ concern for unstable angina. Of note she has had longstanding multifactorial anemia from ESRD, chronic inflammation, B12 deficiency, and possible GI bleeding and receives epo injections and weekly transfusions. Past Medical History: -CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED] DES to LAD [MASKED] PCI of Cx and OM with [MASKED] -[MASKED] renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] -Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) -Hypertension -Dyslipidemia -Scleroderma w/ CREST syndrome -Gastroparesis/GERD/Hiatal hernia -Gout diagnosed [MASKED] years ago -OSA -Pancreatic cyst Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION PHYSICAL EXAM: ======================== GENERAL: Pleasant woman, NAD HEENT: Anicteric sclera, MMM NECK: supple CV: RRR, S1/S2, no murmurs, gallops, or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles GI: abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric DISCHARGE PHYSICAL EXAM: ======================== [MASKED] 1523 Temp: 98.8 PO BP: 169/72 HR: 78 RR: 18 O2 sat: 99% O2 delivery: RA FSBG: 265 GENERAL: NAD HEENT: PERRLA, EOMI, MMM NECK: supple, JVP flat. No LAD. CV: RRR, no g/m/r PULM: CTAB, no wheezes, no rales, no rhonchi. GI: Soft, non-tender, non-distended. +BS. EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&O x3 Pertinent Results: ADMISSION LAB RESULTS ===================== [MASKED] 02:40PM BLOOD WBC-4.9 RBC-2.17* Hgb-6.8* Hct-20.4* MCV-94 MCH-31.3 MCHC-33.3 RDW-18.5* RDWSD-63.3* Plt [MASKED] [MASKED] 02:40PM BLOOD Plt [MASKED] PERTINENT LABS RESULTS ==================== [MASKED] 07:20AM BLOOD Glucose-245* UreaN-49* Creat-2.0* Na-142 K-3.8 Cl-110* HCO3-19* AnGap-13 [MASKED] 06:51AM BLOOD Glucose-200* UreaN-48* Creat-2.2* Na-143 K-4.0 Cl-109* HCO3-22 AnGap-12 [MASKED] 10:20PM BLOOD cTropnT-0.18* [MASKED] 07:20AM BLOOD cTropnT-0.16* [MASKED] 10:20PM BLOOD CK-MB-4 [MASKED] 06:51AM BLOOD Cyclspr-42* DISCHARGE LAB RESULTS ===================== [MASKED] 07:25AM BLOOD WBC-5.4 RBC-3.03* Hgb-9.3* Hct-28.5* MCV-94 MCH-30.7 MCHC-32.6 RDW-18.5* RDWSD-62.6* Plt [MASKED] [MASKED] 07:25AM BLOOD Glucose-383* UreaN-55* Creat-2.7* Na-141 K-3.8 Cl-110* HCO3-20* AnGap-11 [MASKED] 01:19PM BLOOD Creat-2.6* [MASKED] 07:25AM BLOOD Albumin-2.3* Calcium-8.6 Phos-4.0 Mg-2.0 [MASKED] 07:25AM BLOOD Cyclspr-35* MICROBIOLOGY ============ None REPORTS/STUDIES ============== [MASKED] EGD/EUS with Biopsy - Normal esophagus, stomach, duodenum - Pancreatic cyst (3) - head, body, tail - FNA performed of thick mucinous fluid - Findings c/w multifocal side branch IPMN, no high risk features for malignancy - Pathology/cytology pending at time of discharge summary Brief Hospital Course: This is a [MASKED] female with a past medical history significant for ESRD (s/p LURT [MASKED] on immunosuppression), anemia (weekly transfusions and epo injections), CAD s/p [MASKED] 4 (most recently [MASKED], HFrEF (55% EF [MASKED], pancreatic mass concerning for malignancy with planned EUS/biopsy [MASKED], HTN, T1DM, and h/o multiple MDR UTIs (Klebsiella, E.coli, Enterococcus), scleroderma/CREST who presented with chest pain in the setting of her chronic anemia. This resolved after transfusions. She underwent EUS/pancreatic biopsy on [MASKED] which was uncomplicated. ACUTE ISSUES ============ #ACUTE ON CHRONIC ANEMIA: The patient was due for her weekly transfusion [MASKED] but presented to ED given her chest pain and difficulty of obtaining matched blood outpatient due to her extensive transfusion history. Her hemoglobin drop appears consistent with her recent history. Given that her HgB trend was similar to her prior trends, there was low suspicion for new acute blood loss or other etiology contributing. She was transfused two units pRBCs for goal hgb >8 given concern for angina given her chest pain as below. She will follow up on [MASKED] for her next routine transfusion. #CAD, ANGINA: The patient has an extensive cardiac history including CAD s/p multiple stents, most recently [MASKED] and is on anti-platelet therapy which has been held since [MASKED] per cardiology recommendations in advance of EUS/biopsy. She presented with sided chest pain that woke her from sleep multiple times, relieved by nitro, similar to past anginal pain. ECG unchanged from prior, troponins stable x2 at baseline. Her HgB was 6.4 on presentation. Her chest pain went away after her first transfusion and did not return during her hospitalization. It was thought that the patient's symptoms were due to demand in the setting of her anemia. She was transfused 2 units for anemia as above. She was continued on aspirin 81, ranolazine, and Metoprolol. Her Ticagrelor was on hold since [MASKED] per cardiologist in preparation for EUS with biopsy with plan not to resume after pancreatic biopsy. Per the patient, she states that his atorvastatin was stopped, but last cardiology note [MASKED] lists as active medication. #PANCREATIC MASS: The patient initially was found to have an abdominal/pancreatic mass found on a CT A/P obtained [MASKED] after sustaining a fall. She previously reported full body pruritus, and has significant ongoing early satiety, unintentional weight loss, and malaise raising concern for malignancy. She had a planned EUS/biopsy for [MASKED] that was rescheduled to [MASKED] by GI. In preparation for this procedure her home Ticagrelor had been on hold since [MASKED]. After speaking with the Endoscopy/ GI team, they were able to perform an uncomplicated EUS with biopsy on [MASKED]. Pathology was pending at the time of discharge. #HYPERTENSION: The patient has a history of of labile, difficult to control BP, previously on hydralazine but the patient reports this meication was stopped since her last discharge. She did not want to start hydralazine. Continued metoprolol inpatient. Please consider transition to labetalol or carvidilol for better blood pressure effect as outpatient. #GUAIAC POSITIVE STOOL: The patient was found to have guaiac positive stools in the ED. She denied any symptoms of melena, hematochezia. She previously underwent work up with an EGD, colonoscopy and capsule endoscopy in [MASKED] for melena that only revealed small ileal angioectasia with no signs of active bleeding. Occult bleeding could be due to angioectasias, pancreatic mass, or new small/large lesion. Given the lack of hematochezia or frank melena it was thought that the patient was unlikely to have any significant bleed and the decision was made not pursue GI consult/ further work up while inpatient. #ESRD S/P TRANSPLANT W/ RECURRENT CKD: The patient underwent a transplant in [MASKED] now on MMF and cyclosporine w/ recurrent CKD likely from poorly controlled DM and labile hypertension. Recent baseline ~2.6. She was continued on MMF and cyclosporine. She was continued on calcitriol, calcium carbonate. CHRONIC ISSUES: =============== #DIASTOLIC CHF: Per cardiology, the patient's Lasix recently stopped with plan to resume only if weight surpasses 124 lbs. She received Lasix following he blood transfusion, but otherwise her Lasix continued to be held upon discharged. Management of her other cardiac co-morbidities as above. #T1 DM: The patient was continued on an insulin sliding scale and a reduced dose of lantus while NPO. Discharged on her home insulin regimen. #SCLERODERMA: The patient was continued on her home prednisone 5mg daily. #GOUT: The patient was continued on her home allopurinol [MASKED] daily. #HYPOTHYROIDISM: The patient was continued on her home levothyroxine. #GERD GASTROPARESIS: The patient was continued on her home omeprazole and promethazine for nausea. TRANSITIONAL ISSUES: ==================== [] Patient reports that her statin was discontinued at her last admission. Continued to hold while inpatient. Should clarify at next PCP or cardiology appointment. [] BP management: Patient persistently HTN while inpatient to 170s on discharge. Pt. reports that her hydralazine was stopped after last admission (was on 50mg PO BID). She did not want to restart. Please consider transition to labetalol or carvidilol for better blood pressure effect as outpatient. [] Biopsy results: patient underwent EUS w/biopsies of pancreatic mass. Results pending at time of d/c. [] Discharge to complete 5 day course of ciprofloxacin post biopsy [MASKED] [] Discharge Cr was 2.6; fluctuated between 2.0 and 2.7 as inpatient. Transplant nephrology followed as inpatient. Advised to encourage PO on day of discharge. No changes were made to immunosuppressives. [] Pt was instructed to stop calcium while taking ciprofloxacin due to binding effect but to resume after this was finished. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 3. Calcitriol 0.25 mcg PO DAILY 4. Calcium Carbonate 500 mg PO BID 5. Cilostazol 25 mg PO QPM 6. Cilostazol 50 mg PO QAM 7. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 8. Ferrous Sulfate 325 mg PO DAILY 9. FoLIC Acid 1 mg PO DAILY 10. Levothyroxine Sodium 125 mcg PO DAILY 11. Lidocaine 5% Patch 1 PTCH TD QAM 12. Multivitamins 1 TAB PO DAILY 13. Mycophenolate Mofetil 500 mg PO BID 14. Omeprazole 40 mg PO BID 15. PredniSONE 5 mg PO DAILY 16. Promethazine 25 mg PO DAILY:PRN nausea 17. Ranolazine ER 500 mg PO BID 18. Vitamin D [MASKED] UNIT PO DAILY 19. Metoprolol Succinate XL 50 mg PO DAILY 20. Toujeo SoloStar U-300 Insulin (insulin glargine) 30 units subcutaneous QAM 21. trimethobenzamide 300 mg oral TID:PRN nausea 22. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 23. naftifine 2 % topical BID To soles of feet and between toe webs 24. melatonin 10 mg oral QHS 25. Aspirin 81 mg PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q24H Duration: 5 Doses RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 2. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 3. Allopurinol [MASKED] mg PO DAILY 4. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 5. Aspirin 81 mg PO DAILY 6. Calcitriol 0.25 mcg PO DAILY 7. Cilostazol 25 mg PO QPM 8. Cilostazol 50 mg PO QAM 9. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 10. FoLIC Acid 1 mg PO DAILY 11. Levothyroxine Sodium 125 mcg PO DAILY 12. Lidocaine 5% Patch 1 PTCH TD QAM 13. melatonin 10 mg oral QHS 14. Metoprolol Succinate XL 50 mg PO DAILY 15. Multivitamins 1 TAB PO DAILY 16. Mycophenolate Mofetil 500 mg PO BID 17. naftifine 2 % topical BID To soles of feet and between toe webs 18. Omeprazole 40 mg PO BID 19. PredniSONE 5 mg PO DAILY 20. Promethazine 25 mg PO DAILY:PRN nausea 21. Ranolazine ER 500 mg PO BID 22. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 23. Toujeo SoloStar U-300 Insulin (insulin glargine) 30 units subcutaneous QAM 24. trimethobenzamide 300 mg oral TID:PRN nausea 25. Vitamin D [MASKED] UNIT PO DAILY 26. HELD- Calcium Carbonate 500 mg PO BID This medication was held. Do not restart Calcium Carbonate until you finish ciprofloxacin. Discharge Disposition: Home Discharge Diagnosis: Discharge Worksheet-Discharge [MASKED], MD on [MASKED] @ 1700 - CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED] DES to LAD [MASKED] PCI of Cx and OM with [MASKED] - [MASKED] congestive heart failure - End-stage renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] - DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization PRN) - Hypertension - Dyslipidemia - Scleroderma w/ CREST syndrome - Gastroparesis/GERD/Hiatal hernia - OSA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Ms. [MASKED], It was a pleasure caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? - You were admitted to the hospital because you were having chest pain and were found to have low blood counts (anemia). WHAT HAPPENED TO ME IN THE HOSPITAL? - While you were in the hospital we gave you blood transfusions which helped improved your blood counts and chest pain. - We checked your EKG and this was unchanged from your prior EKGs. - The GI doctors did [MASKED] ultrasound and a biopsy of the mass in your pancreas. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. Please finish your of ciprofloxacin (500mg daily, for next three days). Please do not take your calcium while taking ciprofloxacin but ok to restart after this antibiotic is finished. - Please make sure to follow up with your kidney doctors. - Please make sure to follow up with the GI doctors. - You will be contacted in [MASKED] days with the results of your biopsy. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
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"D649: Anemia, 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",
"I5032: Chronic diastolic (congestive) heart failure",
"Z940: Kidney transplant status",
"I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris",
"Z955: Presence of coronary angioplasty implant and graft",
"Z87891: Personal history of nicotine dependence",
"K869: Disease of pancreas, unspecified",
"I252: Old myocardial infarction",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"E1065: Type 1 diabetes mellitus with hyperglycemia",
"N189: Chronic kidney disease, unspecified",
"Z794: Long term (current) use of insulin",
"M341: CR(E)ST syndrome",
"M109: Gout, unspecified",
"E039: Hypothyroidism, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"E785: Hyperlipidemia, unspecified"
] |
10,030,753
| 27,987,271
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan
Attending: ___.
Chief Complaint:
Lightheadedness/Nausea/Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman, with ___ s/p living kidney
transplant ___ on cyclosporine, cellcept, prednisone, CREST,
PE previously on warfarin, CAD (s/p ___ and OM ___,
labile blood pressures who presents with hypotension.
She notes that he has long-standing issues with orthostatic
hypotension. She checks her BP at home multiple times per day in
lying and standing positions, and will range from 180-200 while
lying, to 110-120 while standing, and she is sometimes
symptomatic with lightheadedness.
Although was feeling well on the morning of admission, for the
___ days prior to that she had been having multiple episodes of
vomiting. She had no fevers, abdominal pain, diarrhea. She
states that it is typical for her to have several-day bouts of
vomiting, which tend to resolve without treatment, possibly due
to gastroparesis.
The patient was at her cardiologist's office on the day of
admission, where she was getting fitted for outpatient
monitoring of her blood pressure, when she became lightheaded,
was found to be hypotensive. Initial BP was 113 systolic, which
fell to 72. She then had vomiting, and felt like she was going
to lose consciousness. She then had improvement of her symptoms
after being placed in the supine position her systolic BP
increased to 98 mmHg. Patient currently denies any symptoms.
She was admitted ___ to ___ after presenting with similar
symptoms of hypotension and dizziness after up-titration of her
home blood pressure medications. She was given IV fluids, and
nifedipine and Lasix were held, and her symptoms resolved,
although she was consistently orthostatic despite resting SBP in
the 200s, attributed to longstanding diabetes and autonomic
dysfunction. She was discharged on carvedilol, Lasix 20mg PO
daily.
Her past medical history is significant for poorly controlled
type 1 diabetes with onset around age ___, a left sided kidney
transplant in ___, coronary artery disease with prior MI. Her
most recent drug-eluting stent was placed in the LAD and
circumflex in ___. She also has a history of scleroderma
with CREST syndrome and has a questionable diagnosis of
antiphospholipid antibodies with pulmonary embolism. She has
chronic
gastroparesis and vomits frequently. There is a history of gout
and obstructive sleep apnea. She has multiple urinary tract
infections.
In the ED initial vitals were: 96.8 HR 86 BP 139/70 RR16 98RA
EKG: Sinus rhythm, 86, normal axis, normal intervals, ST
depression with T wave inversions in lead one, aVL. ST segment
depression in lateral leads
Imaging: CXR with No acute cardiopulmonary process.
Labs/studies notable for:
Hgb 9.8, Troponin 0.14 w/ CKMB 2, Creatinine 1.9 (at baseline).
Repeat troponin 0.11.
Patient was given: ASA 243 mg, PO Zofran 4mg
Vitals on transfer: 98.8 95 139/55 14 99% RA
On the floor she feels at her baseline. Overnight she received
Carvedilol 12.5mg x2 (home dose 25mg). Home Lasix was held.
Past Medical History:
1. CARDIAC RISK FACTORS
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___,
DES to LAD and Cx/OM ___
3. OTHER PAST MEDICAL HISTORY
End-stage renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
- Scleroderma w/ CREST syndrome
- Gastroparesis/GERD/Hiatal hernia
- Gout diagnosed ___ years ago
- OSA
-NOT ACCURATE: - Antiphospholipid antibody syndrome and remote
PE
history on Coumadin ___ - this diagnosis viewed unlikely per
___ hematology/oncology note; warfarin discontinued ___
Social History:
___
Family History:
Former smoker: ___ years, ___ ppd. Quit ___ years ago. Denies
etoh/drugs. Lives at home with daughter. Currently on
disabilities.
FAMILY HISTORY: Per OMR
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
==============================
VS: T 98.3, bp 158/67, hr 92, rr 20, spo2 95% on RA
GENERAL: Well developed, well nourished woman in NAD. 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 of 6-7 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2.
III/VI systolic murmur at upper sternal borders
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-distended. Mild tenderness over renal
transplant in LLQ
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAMINATION:
===============================
Vitals: T=98.2 HR=100 BP=133/65 RR=18 O2= 94% on RA
Lying 164/73
sitting 123/68
standing 112/66
I/O= ___
Weight: 60.1
Weight on admission: 60.2
Telemetry: No events
GENERAL: Well developed, well nourished woman in NAD. 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 of 6-7 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. III/VI systolic
murmur at upper sternal borders
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-distended. Mild tenderness over renal
transplant in LLQ
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:12PM BLOOD WBC-9.1 RBC-3.18* Hgb-9.8* Hct-30.2*
MCV-95 MCH-30.8 MCHC-32.5 RDW-13.7 RDWSD-47.5* Plt ___
___ 03:12PM BLOOD Neuts-85.7* Lymphs-5.2* Monos-7.4 Eos-1.1
Baso-0.2 Im ___ AbsNeut-7.81* AbsLymp-0.47* AbsMono-0.67
AbsEos-0.10 AbsBaso-0.02
___ 03:12PM BLOOD Plt ___
___ 04:48AM BLOOD ___ PTT-28.2 ___
___ 03:12PM BLOOD Glucose-83 UreaN-41* Creat-1.9* Na-143
K-4.0 Cl-106 HCO3-26 AnGap-15
___ 03:12PM BLOOD CK(CPK)-34
___ 03:12PM BLOOD CK-MB-2 cTropnT-0.14*
___ 09:40PM BLOOD cTropnT-0.11*
___ 04:48AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1
___ 09:00AM BLOOD Cyclspr-196
DISCHARGE LABS:
================
___ 06:05AM BLOOD WBC-8.4 RBC-2.95* Hgb-9.1* Hct-28.1*
MCV-95 MCH-30.8 MCHC-32.4 RDW-13.6 RDWSD-47.1* Plt ___
___ 06:05AM BLOOD Glucose-64* UreaN-48* Creat-2.0* Na-142
K-4.4 Cl-108 HCO3-22 AnGap-16
___ 06:05AM BLOOD Calcium-10.1 Phos-3.8 Mg-1.9
___ 08:45AM BLOOD Cyclspr-181
MICRO:
=======
___ 11:44 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
STUDIES/IMAGING:
================
CXR ___: No acute cardiopulmonary process.
RENAL TRANSPLANT US ___: 1. Patent renal transplant
vasculature. No hydronephrosis and no peritransplant fluid
collection identified.
2. Small amount of movable debris noted within the urinary
bladder which could represent sludge, infectious material or
blood. Correlation with urinalysis is suggested.
Brief Hospital Course:
___ with PMhx of ___ s/p living kidney transplant ___ on
cyclosporine, cellcept, prednisone, CREST, PE previously on
warfarin, CAD (s/p ___ and OM ___ who presents for
orthostatic hypotension and prescyncope.
#Orthostatic Hypotension/Syncope:
Patient became hypotensive to ___ with standing with associated
emesis at cardiology office and was referred to ___. Patient
with multiple admissions for symptomatic orthostatic hypotension
thought to be secondary to autonomic dysregulation likely with
component of vasovagal syncope. On presentation patient with
lying 160/70 and standing SBP 86/50. Carvedilol and Lasix with
discontinued and patient was started on Nifedipine 30mg CR with
improvement in orthostatics of 164/73 lying to 112/66 standing.
Patient was instructed to take Lasix 20mg if she gained more
than 3lbs in one day and if she has significant lower extremity
edema.
#Troponin elevation:
Patient with ST depression in I, TWI in AVL, slightly elevated
troponin to 0.14 (higher than prior checks) with flat MB and
baseline creatinine. Troponin trending down on recheck to 0.11.
She does have known CAD, with PI in LAD in ___, had 80%
stenosis with diagonal with stenosis as well. She denies chest
pain, likely demand ischemia in setting of labile pressures and
hypovolemia from emesis.
#Nausea/emesis:
Patient with emesis occurring with standing. Chronic issue for
patient thought to be secondary to gastroparesis. Also may have
component of vasovagal response to standing. She also had
improvement in nausea and emesis prior to discharge with change
in anti-hypertensive regimen.
# ___ on CKD
# S/p living unrelated donor kidney transplant ___:
Prior admission for ___ with renal bx showing diabetic changes
without signs of rejection. Her immunosuppressive regimen was
increased and she was discharged with a more aggressive
antidiabetic regimen and antihypertensive regimen. Had Cr
elevation to 2.6 thought to be due to hypovolemia. Improved to
2.0 (baseline 1.9) with small fluid bolus. Cyclosporine 12 hour
trough was 181 on ___, goal 45-100. Dose was reduced to
Cyclosporine (Neoral)25mg BID. Patient needs to have 12 hour
Cyclosporine trough drawn in one week (___). She was continued
on home prednisone 5mg PO daily, MMF 500mg BID. UA initially
with bacteria and WBCs, urine culture negative. Per renal may
need ace inhibitor, will determine if blood pressure can
tolerate.
# DM1: Patient with A1C 7.5% (___). Decreased ___ Lantus to 15
given low AM blood sugars. Updated insulin regimen below.
Glargine 22 Units Breakfast
Glargine 15 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
CHRONIC ISSUES
===============
# Hypothyroidism: recent TSH 0.69, Continue home levothyroxine
125 mcg QD.
# PE: Hx of provoked PE in 1990s, on warfarin until last
admission ___ at ___. Warfarin was stopped given hx of
GIB on warfarin and negative anti-cardiolipin AB on repeat
check.
# Gout: States she is no longer taking allopurinol ___ mg QD.
# HLD: Continue home atorvastatin 20 mg QD
# CREST: Omeprazole 40 mg BID while inpatient, discharged on
home PPI.
# PVD: Continue home cilostazol 100 mg QAM, 50 mg QPM
Proxy name: ___
___: SISTER Phone: ___
#Code status: Full
TRANSITIONAL ISSUES:
====================
-New Medications: Nifedipine CR 30mg daily, Lasix 20mg PRN if
she gains more than 3lbs or has significant lower extremity
edema.
-Stopped Medicaitons: Carvedilol, Lasix daily
-Changed Medications: Cyclosporine 25mg BID. Decreased ___ Lantus
to 15 given low AM blood sugars. Updated insulin regimen below.
Glargine 22 Units Breakfast
Glargine 15 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
-Discharge Cr: 2.0
- Please monitor orthostatic blood pressures. If patient
continues to have low pressures with standing can reduce dose of
Nifedipine.
- Recommend avoiding Carvedilol as this medication seemed to
exacerbate patient's orthostasis.
- Recommend follow up with autonomic neurology for evaluation of
patient's autonomic dysregulation.
--Consider outpatient stress testing given the demand troponin
seen in the setting of hypotension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Calcitriol 0.25 mcg PO DAILY
5. Calcium Carbonate 500 mg PO BID
6. Cilostazol 100 mg PO QAM
7. Cilostazol 50 mg PO QHS
8. Ferrous Sulfate 325 mg PO DAILY
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Mycophenolate Mofetil 500 mg PO BID
11. PredniSONE 5 mg PO DAILY
12. Ranolazine ER 500 mg PO BID
13. Vitamin D ___ UNIT PO DAILY
14. Esomeprazole Magnesium 40 mg oral BID
15. Carvedilol 25 mg PO QHS
16. Carvedilol 12.5 mg PO QAM
17. Furosemide 20 mg PO DAILY
18. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
19. Glargine 22 Units Breakfast
Glargine 17 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Furosemide 20 mg PO DAILY:PRN leg swelling
Please take this medication if your weight goes up by more than
3lbs in one day.
RX *furosemide 20 mg 1 tablet(s) by mouth Daily as needed Disp
#*30 Tablet Refills:*0
2. NIFEdipine CR 30 mg PO DAILY
RX *nifedipine [Afeditab CR] 30 mg 1 tablet(s) by mouth Daily
Disp #*30 Tablet Refills:*0
3. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
RX *cyclosporine modified [Neoral] 25 mg 1 capsule(s) by mouth
Twice daily Disp #*60 Capsule Refills:*0
4. Glargine 22 Units Breakfast
Glargine 15 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Ascorbic Acid ___ mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Calcitriol 0.25 mcg PO DAILY
9. Calcium Carbonate 500 mg PO BID
10. Cilostazol 100 mg PO QAM
11. Cilostazol 50 mg PO QHS
12. Esomeprazole Magnesium 40 mg oral BID
13. Ferrous Sulfate 325 mg PO DAILY
14. Levothyroxine Sodium 125 mcg PO DAILY
15. Mycophenolate Mofetil 500 mg PO BID
16. PredniSONE 5 mg PO DAILY
17. Ranolazine ER 500 mg PO BID
18. Vitamin D ___ UNIT PO DAILY
19.Outpatient Lab Work
ICD 10: Z94.0
Please draw 12 hour cyclosporine trough on ___.
Fax to: Renal ___ fax ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Orthostatic hypotension
Secondary: Kidney transplant, acute kidney failure, troponin
elevation secondary to demand ischemia
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 ___ because had low blood pressures and
felt lightheaded. We think this is due to dysregulation of your
nervous system. It may have also been related to dehydration
from vomiting. We stopped your Carvedilol and started you on a
medication called Nifedipine.
You should stop taking your Lasix everyday. Weigh yourself every
morning and take your Lasix 20mg if weight goes up more than 3
lbs or you notice significant leg swelling. If you have to take
your Lasix please call your primary care physican. You should
also wear compression stockings to prevent blood from
accumulating in your legs.
Your Cyclosporin level was high so your dose was reduced. You
should take Cyclosporine (Neoral) 25mg twice daily. You will
need to have your Cyclosporine level checked in one week (___)
and the results should be sent to the Kidney ___.
Should you experience a recurrence or worsening of the symptoms
that originally brought you to the hospital, experience any of
the warning signs listed below, or have any other symptoms that
concern you, please seek medical attention.
It was a pleasure taking care of you!
Your ___ Care Team
Followup Instructions:
___
|
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Allergies: Penicillins / Ativan Chief Complaint: Lightheadedness/Nausea/Vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old woman, with [MASKED] s/p living kidney transplant [MASKED] on cyclosporine, cellcept, prednisone, CREST, PE previously on warfarin, CAD (s/p [MASKED] and OM [MASKED], labile blood pressures who presents with hypotension. She notes that he has long-standing issues with orthostatic hypotension. She checks her BP at home multiple times per day in lying and standing positions, and will range from 180-200 while lying, to 110-120 while standing, and she is sometimes symptomatic with lightheadedness. Although was feeling well on the morning of admission, for the [MASKED] days prior to that she had been having multiple episodes of vomiting. She had no fevers, abdominal pain, diarrhea. She states that it is typical for her to have several-day bouts of vomiting, which tend to resolve without treatment, possibly due to gastroparesis. The patient was at her cardiologist's office on the day of admission, where she was getting fitted for outpatient monitoring of her blood pressure, when she became lightheaded, was found to be hypotensive. Initial BP was 113 systolic, which fell to 72. She then had vomiting, and felt like she was going to lose consciousness. She then had improvement of her symptoms after being placed in the supine position her systolic BP increased to 98 mmHg. Patient currently denies any symptoms. She was admitted [MASKED] to [MASKED] after presenting with similar symptoms of hypotension and dizziness after up-titration of her home blood pressure medications. She was given IV fluids, and nifedipine and Lasix were held, and her symptoms resolved, although she was consistently orthostatic despite resting SBP in the 200s, attributed to longstanding diabetes and autonomic dysfunction. She was discharged on carvedilol, Lasix 20mg PO daily. Her past medical history is significant for poorly controlled type 1 diabetes with onset around age [MASKED], a left sided kidney transplant in [MASKED], coronary artery disease with prior MI. Her most recent drug-eluting stent was placed in the LAD and circumflex in [MASKED]. She also has a history of scleroderma with CREST syndrome and has a questionable diagnosis of antiphospholipid antibodies with pulmonary embolism. She has chronic gastroparesis and vomits frequently. There is a history of gout and obstructive sleep apnea. She has multiple urinary tract infections. In the ED initial vitals were: 96.8 HR 86 BP 139/70 RR16 98RA EKG: Sinus rhythm, 86, normal axis, normal intervals, ST depression with T wave inversions in lead one, aVL. ST segment depression in lateral leads Imaging: CXR with No acute cardiopulmonary process. Labs/studies notable for: Hgb 9.8, Troponin 0.14 w/ CKMB 2, Creatinine 1.9 (at baseline). Repeat troponin 0.11. Patient was given: ASA 243 mg, PO Zofran 4mg Vitals on transfer: 98.8 95 139/55 14 99% RA On the floor she feels at her baseline. Overnight she received Carvedilol 12.5mg x2 (home dose 25mg). Home Lasix was held. Past Medical History: 1. CARDIAC RISK FACTORS - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA [MASKED], DES to LAD and Cx/OM [MASKED] 3. OTHER PAST MEDICAL HISTORY End-stage renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] - Scleroderma w/ CREST syndrome - Gastroparesis/GERD/Hiatal hernia - Gout diagnosed [MASKED] years ago - OSA -NOT ACCURATE: - Antiphospholipid antibody syndrome and remote PE history on Coumadin [MASKED] - this diagnosis viewed unlikely per [MASKED] hematology/oncology note; warfarin discontinued [MASKED] Social History: [MASKED] Family History: Former smoker: [MASKED] years, [MASKED] ppd. Quit [MASKED] years ago. Denies etoh/drugs. Lives at home with daughter. Currently on disabilities. FAMILY HISTORY: Per OMR Mother-Multiple myeloma Sister and [MASKED] Sister-RA Sister - Kidney cancer [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION PHYSICAL EXAMINATION: ============================== VS: T 98.3, bp 158/67, hr 92, rr 20, spo2 95% on RA GENERAL: Well developed, well nourished woman in NAD. 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 of 6-7 cm. CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. III/VI systolic murmur at upper sternal borders LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-distended. Mild tenderness over renal transplant in LLQ EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAMINATION: =============================== Vitals: T=98.2 HR=100 BP=133/65 RR=18 O2= 94% on RA Lying 164/73 sitting 123/68 standing 112/66 I/O= [MASKED] Weight: 60.1 Weight on admission: 60.2 Telemetry: No events GENERAL: Well developed, well nourished woman in NAD. 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 of 6-7 cm. CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. III/VI systolic murmur at upper sternal borders LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-distended. Mild tenderness over renal transplant in LLQ EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: ADMISSION LABS: =============== [MASKED] 03:12PM BLOOD WBC-9.1 RBC-3.18* Hgb-9.8* Hct-30.2* MCV-95 MCH-30.8 MCHC-32.5 RDW-13.7 RDWSD-47.5* Plt [MASKED] [MASKED] 03:12PM BLOOD Neuts-85.7* Lymphs-5.2* Monos-7.4 Eos-1.1 Baso-0.2 Im [MASKED] AbsNeut-7.81* AbsLymp-0.47* AbsMono-0.67 AbsEos-0.10 AbsBaso-0.02 [MASKED] 03:12PM BLOOD Plt [MASKED] [MASKED] 04:48AM BLOOD [MASKED] PTT-28.2 [MASKED] [MASKED] 03:12PM BLOOD Glucose-83 UreaN-41* Creat-1.9* Na-143 K-4.0 Cl-106 HCO3-26 AnGap-15 [MASKED] 03:12PM BLOOD CK(CPK)-34 [MASKED] 03:12PM BLOOD CK-MB-2 cTropnT-0.14* [MASKED] 09:40PM BLOOD cTropnT-0.11* [MASKED] 04:48AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1 [MASKED] 09:00AM BLOOD Cyclspr-196 DISCHARGE LABS: ================ [MASKED] 06:05AM BLOOD WBC-8.4 RBC-2.95* Hgb-9.1* Hct-28.1* MCV-95 MCH-30.8 MCHC-32.4 RDW-13.6 RDWSD-47.1* Plt [MASKED] [MASKED] 06:05AM BLOOD Glucose-64* UreaN-48* Creat-2.0* Na-142 K-4.4 Cl-108 HCO3-22 AnGap-16 [MASKED] 06:05AM BLOOD Calcium-10.1 Phos-3.8 Mg-1.9 [MASKED] 08:45AM BLOOD Cyclspr-181 MICRO: ======= [MASKED] 11:44 am URINE Source: Catheter. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. STUDIES/IMAGING: ================ CXR [MASKED]: No acute cardiopulmonary process. RENAL TRANSPLANT US [MASKED]: 1. Patent renal transplant vasculature. No hydronephrosis and no peritransplant fluid collection identified. 2. Small amount of movable debris noted within the urinary bladder which could represent sludge, infectious material or blood. Correlation with urinalysis is suggested. Brief Hospital Course: [MASKED] with PMhx of [MASKED] s/p living kidney transplant [MASKED] on cyclosporine, cellcept, prednisone, CREST, PE previously on warfarin, CAD (s/p [MASKED] and OM [MASKED] who presents for orthostatic hypotension and prescyncope. #Orthostatic Hypotension/Syncope: Patient became hypotensive to [MASKED] with standing with associated emesis at cardiology office and was referred to [MASKED]. Patient with multiple admissions for symptomatic orthostatic hypotension thought to be secondary to autonomic dysregulation likely with component of vasovagal syncope. On presentation patient with lying 160/70 and standing SBP 86/50. Carvedilol and Lasix with discontinued and patient was started on Nifedipine 30mg CR with improvement in orthostatics of 164/73 lying to 112/66 standing. Patient was instructed to take Lasix 20mg if she gained more than 3lbs in one day and if she has significant lower extremity edema. #Troponin elevation: Patient with ST depression in I, TWI in AVL, slightly elevated troponin to 0.14 (higher than prior checks) with flat MB and baseline creatinine. Troponin trending down on recheck to 0.11. She does have known CAD, with PI in LAD in [MASKED], had 80% stenosis with diagonal with stenosis as well. She denies chest pain, likely demand ischemia in setting of labile pressures and hypovolemia from emesis. #Nausea/emesis: Patient with emesis occurring with standing. Chronic issue for patient thought to be secondary to gastroparesis. Also may have component of vasovagal response to standing. She also had improvement in nausea and emesis prior to discharge with change in anti-hypertensive regimen. # [MASKED] on CKD # S/p living unrelated donor kidney transplant [MASKED]: Prior admission for [MASKED] with renal bx showing diabetic changes without signs of rejection. Her immunosuppressive regimen was increased and she was discharged with a more aggressive antidiabetic regimen and antihypertensive regimen. Had Cr elevation to 2.6 thought to be due to hypovolemia. Improved to 2.0 (baseline 1.9) with small fluid bolus. Cyclosporine 12 hour trough was 181 on [MASKED], goal 45-100. Dose was reduced to Cyclosporine (Neoral)25mg BID. Patient needs to have 12 hour Cyclosporine trough drawn in one week ([MASKED]). She was continued on home prednisone 5mg PO daily, MMF 500mg BID. UA initially with bacteria and WBCs, urine culture negative. Per renal may need ace inhibitor, will determine if blood pressure can tolerate. # DM1: Patient with A1C 7.5% ([MASKED]). Decreased [MASKED] Lantus to 15 given low AM blood sugars. Updated insulin regimen below. Glargine 22 Units Breakfast Glargine 15 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 7 Units Dinner Insulin SC Sliding Scale using HUM Insulin CHRONIC ISSUES =============== # Hypothyroidism: recent TSH 0.69, Continue home levothyroxine 125 mcg QD. # PE: Hx of provoked PE in 1990s, on warfarin until last admission [MASKED] at [MASKED]. Warfarin was stopped given hx of GIB on warfarin and negative anti-cardiolipin AB on repeat check. # Gout: States she is no longer taking allopurinol [MASKED] mg QD. # HLD: Continue home atorvastatin 20 mg QD # CREST: Omeprazole 40 mg BID while inpatient, discharged on home PPI. # PVD: Continue home cilostazol 100 mg QAM, 50 mg QPM Proxy [MASKED]: SISTER Phone: [MASKED] #Code status: Full TRANSITIONAL ISSUES: ==================== -New Medications: Nifedipine CR 30mg daily, Lasix 20mg PRN if she gains more than 3lbs or has significant lower extremity edema. -Stopped Medicaitons: Carvedilol, Lasix daily -Changed Medications: Cyclosporine 25mg BID. Decreased [MASKED] Lantus to 15 given low AM blood sugars. Updated insulin regimen below. Glargine 22 Units Breakfast Glargine 15 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 7 Units Dinner Insulin SC Sliding Scale using HUM Insulin -Discharge Cr: 2.0 - Please monitor orthostatic blood pressures. If patient continues to have low pressures with standing can reduce dose of Nifedipine. - Recommend avoiding Carvedilol as this medication seemed to exacerbate patient's orthostasis. - Recommend follow up with autonomic neurology for evaluation of patient's autonomic dysregulation. --Consider outpatient stress testing given the demand troponin seen in the setting of hypotension. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ascorbic Acid [MASKED] mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Calcitriol 0.25 mcg PO DAILY 5. Calcium Carbonate 500 mg PO BID 6. Cilostazol 100 mg PO QAM 7. Cilostazol 50 mg PO QHS 8. Ferrous Sulfate 325 mg PO DAILY 9. Levothyroxine Sodium 125 mcg PO DAILY 10. Mycophenolate Mofetil 500 mg PO BID 11. PredniSONE 5 mg PO DAILY 12. Ranolazine ER 500 mg PO BID 13. Vitamin D [MASKED] UNIT PO DAILY 14. Esomeprazole Magnesium 40 mg oral BID 15. Carvedilol 25 mg PO QHS 16. Carvedilol 12.5 mg PO QAM 17. Furosemide 20 mg PO DAILY 18. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H 19. Glargine 22 Units Breakfast Glargine 17 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 7 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Furosemide 20 mg PO DAILY:PRN leg swelling Please take this medication if your weight goes up by more than 3lbs in one day. RX *furosemide 20 mg 1 tablet(s) by mouth Daily as needed Disp #*30 Tablet Refills:*0 2. NIFEdipine CR 30 mg PO DAILY RX *nifedipine [Afeditab CR] 30 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 3. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H RX *cyclosporine modified [Neoral] 25 mg 1 capsule(s) by mouth Twice daily Disp #*60 Capsule Refills:*0 4. Glargine 22 Units Breakfast Glargine 15 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 7 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Ascorbic Acid [MASKED] mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 20 mg PO QPM 8. Calcitriol 0.25 mcg PO DAILY 9. Calcium Carbonate 500 mg PO BID 10. Cilostazol 100 mg PO QAM 11. Cilostazol 50 mg PO QHS 12. Esomeprazole Magnesium 40 mg oral BID 13. Ferrous Sulfate 325 mg PO DAILY 14. Levothyroxine Sodium 125 mcg PO DAILY 15. Mycophenolate Mofetil 500 mg PO BID 16. PredniSONE 5 mg PO DAILY 17. Ranolazine ER 500 mg PO BID 18. Vitamin D [MASKED] UNIT PO DAILY 19.Outpatient Lab Work ICD 10: Z94.0 Please draw 12 hour cyclosporine trough on [MASKED]. Fax to: Renal [MASKED] fax [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary: Orthostatic hypotension Secondary: Kidney transplant, acute kidney failure, troponin elevation secondary to demand ischemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] because had low blood pressures and felt lightheaded. We think this is due to dysregulation of your nervous system. It may have also been related to dehydration from vomiting. We stopped your Carvedilol and started you on a medication called Nifedipine. You should stop taking your Lasix everyday. Weigh yourself every morning and take your Lasix 20mg if weight goes up more than 3 lbs or you notice significant leg swelling. If you have to take your Lasix please call your primary care physican. You should also wear compression stockings to prevent blood from accumulating in your legs. Your Cyclosporin level was high so your dose was reduced. You should take Cyclosporine (Neoral) 25mg twice daily. You will need to have your Cyclosporine level checked in one week ([MASKED]) and the results should be sent to the Kidney [MASKED]. Should you experience a recurrence or worsening of the symptoms that originally brought you to the hospital, experience any of the warning signs listed below, or have any other symptoms that concern you, please seek medical attention. It was a pleasure taking care of you! Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"I2510",
"M109",
"K219",
"E785",
"E039",
"G4733",
"I252",
"N189",
"I129",
"Z955",
"Z794",
"Z87891",
"Y929"
] |
[
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"N179: Acute kidney failure, unspecified",
"T8619: Other complication of kidney transplant",
"M341: CR(E)ST syndrome",
"G903: Multi-system degeneration of the autonomic nervous system",
"I248: Other forms of acute ischemic heart disease",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"E860: Dehydration",
"K3184: Gastroparesis",
"M109: Gout, unspecified",
"E861: Hypovolemia",
"K219: Gastro-esophageal reflux disease without esophagitis",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"N319: Neuromuscular dysfunction of bladder, unspecified",
"E785: Hyperlipidemia, unspecified",
"E039: Hypothyroidism, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"I252: Old myocardial infarction",
"E1051: Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene",
"N189: Chronic kidney disease, unspecified",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"Z955: Presence of coronary angioplasty implant and graft",
"Z794: Long term (current) use of insulin",
"Z86711: Personal history of pulmonary 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",
"E1065: Type 1 diabetes mellitus with hyperglycemia",
"Z87440: Personal history of urinary (tract) infections"
] |
10,030,753
| 28,135,069
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
___ Coronary angiography with placement of two drug eluting
stents
History of Present Illness:
___ w/ HFrEF (41% EF on most recent TTE in ___, HTN, T1DM,
CAD s/p multiple stents to LAD/Cx in ___, renal transplant on
chronic immunosuppression presents with chest pain. Patient
states that for the past couple days she has had intermittent
abdominal pain lasting seconds. No change in bowel habits. No
nausea or vomiting. On the evening of ___ she had an episode of
substernal 6 out of 10 aching chest pain of unknown duration.
She took a nitro tablet which relieved her symptoms. It was
associated with shortness of breath. She woke up at 8:30 on the
morning of ___ and had another episode sudden onset chest
pain same in quality. She took another sublingual nitro and got
better. She subsequently called an ambulance brought her in
here. This is also associated with couple days of cough
congestion and subjective fevers. No swelling in her lower
extremities are dry weight is 125 her weight today was 130. She
denies increased orthopnea. She denies hemoptysis. She does
endorse a decreased urine output.
Of note, she was recently hospitalized from ___ to ___
for orthopnea and chest pressure and received PTCA and DES x1 to
distal LAD with plan for staged PCI given her CKD. She was
started on ticagrelor 90mg PO BID.
Given the patient's history, known LCx lesion, EKG changes and
positive troponin, she was started empirically on a heparin gtt
and taken to the cath lab for LHC and PCI. She underwent
successful PCI to Cx and OM with DES. On the floor, the patient
reports that she is chest pain free, and feels otherwise well.
Past Medical History:
1. CARDIAC RISK FACTORS
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA ___
DES to LAD and Cx/OM ___ DES to LAD ___ PCI of
Cx and OM with DES
3. OTHER PAST MEDICAL HISTORY. End-stage renal disease ___
diabetes s/p L-sided living kidney transplant in ___
- Scleroderma w/ CREST syndrome
- Gastroparesis/GERD/Hiatal hernia
- Gout diagnosed ___ years ago
- OSA
Social History:
___
Family History:
Maternal Grandfather: MI in ___
Mother: Multiple myeloma. Angina in ___.
Sister and Brother: ___
Sister: ___ arthritis
Sister: Kidney cancer
Nephew: ___ disease
Nephews x2: Alopecia
Daughter (adopted): ___, celiac disease, MS
Father: ___ use disorder
Physical Exam:
============================
ADMISSION PHYSICAL EXAMINATION
============================
VS: T98.4; BP:137/60; HR:87; RR 18; 99% RA
GENERAL: Well appearing woman lying in bed and speaking to me
comfortably.
HEENT: Pupils equal, no scleral icterus or injection.
NECK: JVP faint and appears to be approximately 10cm.
CARDIAC: S1/S2 regular with no murmurs, rubs, heaves or S3/S4.
LUNGS: Lungs clear to auscultation bilaterally without any
basilar crackles. No use of accessory muscles or signs of
respiratory distress.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm extremities with no lower extremity edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: DP pulses palpable and symmetric. ___ pulses not palpable
in either foot, though detected on Doppler.
============================
DISCHARGE PHYSICAL EXAMINATION
============================
T: 98.7 BP:153 / 72 HR:94 RR:18 97% RA
GENERAL: Well appearing woman lying in bed and speaking to me
comfortably.
HEENT: Pupils equal, no scleral icterus or injection.
NECK: JVP approximately 10cm.
CARDIAC: S1/S2 regular with no murmurs, rubs, heaves or S3/S4.
LUNGS: Lungs clear to auscultation bilaterally without any
basilar crackles. No use of accessory muscles or signs of
respiratory distress.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm extremities with no lower extremity edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: DP pulses palpable and symmetric. ___ pulses not palpable
in either foot, though detected on Doppler.
Groin: Dressing with minor blood and no evidence of active
bleed. No evidence of hematoma. Femoral pulse difficult to
palpate due to positioning. No bruit auscultated.
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 10:35AM WBC-11.3* RBC-2.69* HGB-8.3* HCT-25.6* MCV-95
MCH-30.9 MCHC-32.4 RDW-13.3 RDWSD-45.4
___ 10:35AM GLUCOSE-87 UREA N-44* CREAT-2.1* SODIUM-141
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-25 ANION GAP-11
___ 10:35AM CALCIUM-9.6 PHOSPHATE-2.8 MAGNESIUM-1.9
___ 10:35AM ___
___ 10:35AM cTropnT-0.13*
___ 11:30PM cTropnT-0.12*
==========================================
DISCHARGE AND PERTINENT LABORATORY STUDIES
==========================================
___ 06:15AM BLOOD WBC-9.3 RBC-2.66*# Hgb-8.2*# Hct-24.4*
MCV-92# MCH-30.8 MCHC-33.6 RDW-16.2* RDWSD-54.8* Plt ___
___ 06:15AM BLOOD Glucose-63* UreaN-52* Creat-2.6* Na-143
K-4.3 Cl-105 HCO3-25 AnGap-13
___ 11:30PM BLOOD cTropnT-0.12*
___ 10:35AM BLOOD cTropnT-0.13*
___ 06:15AM BLOOD Calcium-9.2 Phos-3.4 Mg-1.8
===========================
REPORTS AND IMAGING STUDIES
===========================
___ 2D-ECHOCARDIOGRAM
The left atrium is normal in size. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Regional left ventricular wall motion is normal.
Quantitative (3D) LVEF = 41%. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The
pulmonary artery systolic pressure could not be determined.
There is a small pericardial effusion.
IMPRESSION: Prominent symmetric LVH with mild global left
ventricular systolic dysfunction. Small pericardial effusion.
Elevated LVEDP.
Compared with the prior study (images reviewed) of ___, LV
wall are thicker. LV systolic function has declined and there is
now a pericardial effusion. Infiltrative cardiomyopathy, such as
cardiac amyloidosis should be considered.
___ CORONARY ANGIOGRAPHY
Coronary Anatomy
Dominance: Right
LM- normal
LAD- 40% proximal, minimal mid disease, recent stent widely
patent. D1 small with 70% ostial and long 70% mid lesion
LCx- 20% proximal in-stent restenosis, There is a focal 80% mid
LCx lesion just beyond OM1 where the vessel is jailed by
previous DES. OM1 stent is widely patent. OM2 is a medium sized
vessel with 70% tubular stenosis. OM3 is a small vessel with
mild luminal irregularities
RCA- Known small, dominant vessel with mild luminal
irregularities; R-PDA is medium sized with a 50% proximal
lesion. NOt ijected at this procedure. Pressure wire of serial
LAD lesions demonstrated IFR 0.83 in distal LAD and 0.95 in mid
LAD consistent with hemodynamically signfiicant distal LAD
lesion Attempted pressure wire of mid LCx unsuccessful due to
inability to pass pressure wire into distal LCX through stent
struts
Impressions:
1. Successful PCI of Cx and OM with DES.
___ CT ABDOMEN AND PELVIS WITHOUT CONTRAST
IMPRESSION:
1. No evidence of retroperitoneal hemorrhage. Mild fat
stranding in the right
groin region which can be related to the recent instrumentation.
2. Other chronic findings as above.
============
MICROBIOLOGY
============
NONE
Brief Hospital Course:
=================
SUMMARY STATEMENT
=================
Ms. ___ is a ___ year old woman with a history of heart
failure with reduce ejection fraction (41% EF), type 1 diabetes,
HTN, coronary artery disease with prior stenting, chronic kidney
disease with a prior transplant who presents with chest pain.
She was recently hospitalized from ___ - ___ after
presenting with chest pressure and was found to have an NSTEMI.
She had an LAD stent placed at that time and was discharged with
plan for a staged intervention given her renal allograft and
chronic kidney disease. However, she re-developed chest pain on
the day prior to admission was found to have a troponinemia. She
had successful and uncomplicated stents placed to LCx and an OM
on ___. She was also transfused a unit of blood and
underwent IV diuresis given her IV fluid administration.
====================
ACUTE MEDICAL ISSUES
====================
#CORONARIES: Percutaneous Coronary Interventions: LAD PTCA; s/p
PTCA ___ DES to LAD and Cx/OM ___ DES to LAD ___
___ PCI of Cx and OM with DES
#PUMP: 41%
#RHYTHM: NSR
#ACUTE ON CHRONIC ANEMIA
#TRANSFUSION REACTION
- Patient was found to have Hb drop from 8.3 to 6.1
post-procedurally
with no evidence of groin hematoma. There was no evidence of
retroperitoneal bleed on CT. She was asymptomatic from this
blood loss, including no back pain or excessive groin pain. She
was scheduled to receive 1 unit of packed red blood cells, and
developed sensation of warmth one hour into blood transfusion.
Temp found to be 100.6 (previously incorrectly documented as
100.8). Subsequent temp checks <100.4. However, discussed with
blood bank resident and stopped transfusion. After studies were
performed on the packed red cells, she was ordered another unit
of blood which was transfused without complication. She had an
appropriate rise in her hemoglobin to this transfusion. She
never had shortness of breath, hemodynamic changes, urticaria,
rash or other transfusion reaction symptoms.
#NSTEMI:
#CAD:
She was recently hospitalized from ___ - ___ after
presenting with chest pressure and was found to have an NSTEMI.
She had an LAD stent placed at that time and was discharged with
plan for a staged intervention given her renal allograft and
chronic kidney disease. She had a known 80% mid-LCx lesion.
However, she re-developed chest pain on the day prior to
admission was found to have a troponinemia. Her chest pain was
relieved with sublingual nitroglycerin. An ECG revealed <1mm ST
elevations in V1 and V2 upon presentation. She had an elevated
troponin-T to 0.13 that was lower than any of her recent
troponins. Due to her typical symptoms and ECG changes, she had
a PCI to LCx and OM with resolution of chest pain. Troponins
stabilized after this. She was continued on her home statin,
ASA, Plavix and metoprolol.
#HFrEF exacerbation (EF 41%):
Weight stable from her prior discharge, though according to the
patient's scale she has gained 5 pounds since her last
discharge.
Mildly volume overloaded on her presenting exam (JVP only), BNP
improved from prior. However, given fluids after her study and
blood on ___, she was given 40mg IV diuresis on two occasions.
#HTN
Known to have difficult to control HTN, and noted to have issues
with orthostasis on last admission. She recently saw a
neurologist for her orthostasis. She had hypertension to SBP's
of 170's that was conservatively managed given her severe
orthostatic hypotension.
#CKD
#S/p renal transplant
Pt with recent contrast induced nephropathy after LHC last
admission. Cr 2.8 on her last discharge and 2.1 on her
admission. Rose to 2.4 and then 2.6, likely in the setting of
post-contrast nephropathy. The renal consult team was consulted
during her admission. No changes were made to her home
immunosuppressive regimen (cyclosporine 25mg BID, MMF 500mg BID,
prednisone 6mg daily).
======================
CHRONIC MEDICAL ISSUES
======================
#Type 1 DM
- Insulin sliding scale + 36 unit glargine QAM
===================
TRANSITIONAL ISSUES
===================
- New Meds: None
- Stopped/Held Meds: None
- Changed Meds: None
- Incidental Findings: None
- Discharge weight: ___: 60kg (132.28 pounds)
[ ] CBC, Sodium, Potassium, Chloride, Bicarbonate, BUN,
Creatinine, Calcium, Magnesium and Phosphate on ___.
[ ] Patient will need close monitoring of renal function given
her contrast induced nephropathy
[ ] Patient needs continued monitoring of blood pressure.
Amlodipine recently stopped due to severe orthostasis, and she
was hypertensive for much of her admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Calcitriol 0.25 mcg PO DAILY
6. Calcium Carbonate 500 mg PO BID
7. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
8. Esomeprazole 40 mg Other BID
9. Ferrous Sulfate 325 mg PO DAILY
10. HydrALAZINE 50 mg PO QHS
11. Levothyroxine Sodium 125 mcg PO DAILY
12. Mycophenolate Mofetil 500 mg PO BID
13. PredniSONE 6 mg PO DAILY
14. Vitamin D ___ UNIT PO DAILY
15. Ranolazine ER 500 mg PO BID
16. Promethazine 25 mg PO DAILY PRN nausea
17. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
18. Metoprolol Succinate XL 50 mg PO DAILY
19. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
20. Furosemide 20 mg PO DAILY
21. Cilostazol 50 mg PO QPM
22. Lidocaine 5% Patch 1 PTCH TD QAM
23. melatonin 10 mg oral QHS
24. naftifine 2 % topical BID To soles of feet and between toe
webs
25. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
26. Cilostazol 100 mg PO QAM
27. Toujeo SoloStar (insulin glargine) 36 Units subcutaneous Q
Breakfast
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Calcitriol 0.25 mcg PO DAILY
7. Calcium Carbonate 500 mg PO BID
8. Cilostazol 100 mg PO QAM
9. Cilostazol 50 mg PO QPM
10. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
11. Esomeprazole 40 mg Other BID
12. Ferrous Sulfate 325 mg PO DAILY
13. Furosemide 20 mg PO DAILY
14. HydrALAZINE 50 mg PO QHS
15. Levothyroxine Sodium 125 mcg PO DAILY
16. Lidocaine 5% Patch 1 PTCH TD QAM
17. melatonin 10 mg oral QHS
18. Metoprolol Succinate XL 50 mg PO DAILY
19. Mycophenolate Mofetil 500 mg PO BID
20. naftifine 2 % topical BID To soles of feet and between toe
webs
21. PredniSONE 6 mg PO DAILY
22. Promethazine 25 mg PO DAILY PRN nausea
23. Ranolazine ER 500 mg PO BID
24. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
25. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
26. Toujeo SoloStar (insulin glargine) 36 Units subcutaneous Q
Breakfast
27. Vitamin D ___ UNIT PO DAILY
28.Outpatient Lab Work
TO BE DRAWN ___ ICD-9 = 996.81
LABS = CBC, CHEM-10
ATTN: ___, MD
FAX: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
=================
PRIMARY DIAGNOSIS
=================
NSTEMI with two stent placements
===================
SECONDARY DIAGNOSES
===================
Acute blood loss anemia requiring transfusion
Heart Failure with Reduce Ejection Fraction
Acute Kidney Injury with Chronic Kidney Disease
Renal Transplant
Type I Diabetes
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 while you were admitted to ___
___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you were having chest
pain and we were concerned you were having a heart attack.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We did a coronary angiography (catheterization) and put two
stents in your heart to clear up the blockages.
- We gave you blood through an IV because your blood counts were
low.
- We gave you diuretics though an IV to remove extra fluid from
your body.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- Make sure you weigh yourself every morning after you go to the
bathroom and before putting on your clothes. If you weight goes
up three pounds in one day or five pounds in two days, call your
doctor.
- Make sure you call your doctor or call ___ right away if you
have more chest pain.
Discharge Weight = ___: 60kg (132.28 pounds)
Sincerely,
___ Cardiology Team
Followup Instructions:
___
|
[
"I214",
"I5023",
"N179",
"D62",
"Z940",
"E109",
"D649",
"I130",
"T458X5A",
"T8089XA",
"N189",
"Y92239",
"I25119"
] |
Allergies: Penicillins / Ativan / carvedilol / amlodipine Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [MASKED] Coronary angiography with placement of two drug eluting stents History of Present Illness: [MASKED] w/ HFrEF (41% EF on most recent TTE in [MASKED], HTN, T1DM, CAD s/p multiple stents to LAD/Cx in [MASKED], renal transplant on chronic immunosuppression presents with chest pain. Patient states that for the past couple days she has had intermittent abdominal pain lasting seconds. No change in bowel habits. No nausea or vomiting. On the evening of [MASKED] she had an episode of substernal 6 out of 10 aching chest pain of unknown duration. She took a nitro tablet which relieved her symptoms. It was associated with shortness of breath. She woke up at 8:30 on the morning of [MASKED] and had another episode sudden onset chest pain same in quality. She took another sublingual nitro and got better. She subsequently called an ambulance brought her in here. This is also associated with couple days of cough congestion and subjective fevers. No swelling in her lower extremities are dry weight is 125 her weight today was 130. She denies increased orthopnea. She denies hemoptysis. She does endorse a decreased urine output. Of note, she was recently hospitalized from [MASKED] to [MASKED] for orthopnea and chest pressure and received PTCA and DES x1 to distal LAD with plan for staged PCI given her CKD. She was started on ticagrelor 90mg PO BID. Given the patient's history, known LCx lesion, EKG changes and positive troponin, she was started empirically on a heparin gtt and taken to the cath lab for LHC and PCI. She underwent successful PCI to Cx and OM with DES. On the floor, the patient reports that she is chest pain free, and feels otherwise well. Past Medical History: 1. CARDIAC RISK FACTORS - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED] DES to LAD [MASKED] PCI of Cx and OM with DES 3. OTHER PAST MEDICAL HISTORY. End-stage renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] - Scleroderma w/ CREST syndrome - Gastroparesis/GERD/Hiatal hernia - Gout diagnosed [MASKED] years ago - OSA Social History: [MASKED] Family History: Maternal Grandfather: MI in [MASKED] Mother: Multiple myeloma. Angina in [MASKED]. Sister and Brother: [MASKED] Sister: [MASKED] arthritis Sister: Kidney cancer Nephew: [MASKED] disease Nephews x2: Alopecia Daughter (adopted): [MASKED], celiac disease, MS Father: [MASKED] use disorder Physical Exam: ============================ ADMISSION PHYSICAL EXAMINATION ============================ VS: T98.4; BP:137/60; HR:87; RR 18; 99% RA GENERAL: Well appearing woman lying in bed and speaking to me comfortably. HEENT: Pupils equal, no scleral icterus or injection. NECK: JVP faint and appears to be approximately 10cm. CARDIAC: S1/S2 regular with no murmurs, rubs, heaves or S3/S4. LUNGS: Lungs clear to auscultation bilaterally without any basilar crackles. No use of accessory muscles or signs of respiratory distress. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm extremities with no lower extremity edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: DP pulses palpable and symmetric. [MASKED] pulses not palpable in either foot, though detected on Doppler. ============================ DISCHARGE PHYSICAL EXAMINATION ============================ T: 98.7 BP:153 / 72 HR:94 RR:18 97% RA GENERAL: Well appearing woman lying in bed and speaking to me comfortably. HEENT: Pupils equal, no scleral icterus or injection. NECK: JVP approximately 10cm. CARDIAC: S1/S2 regular with no murmurs, rubs, heaves or S3/S4. LUNGS: Lungs clear to auscultation bilaterally without any basilar crackles. No use of accessory muscles or signs of respiratory distress. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm extremities with no lower extremity edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: DP pulses palpable and symmetric. [MASKED] pulses not palpable in either foot, though detected on Doppler. Groin: Dressing with minor blood and no evidence of active bleed. No evidence of hematoma. Femoral pulse difficult to palpate due to positioning. No bruit auscultated. Pertinent Results: ============================ ADMISSION LABORATORY STUDIES ============================ [MASKED] 10:35AM WBC-11.3* RBC-2.69* HGB-8.3* HCT-25.6* MCV-95 MCH-30.9 MCHC-32.4 RDW-13.3 RDWSD-45.4 [MASKED] 10:35AM GLUCOSE-87 UREA N-44* CREAT-2.1* SODIUM-141 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-25 ANION GAP-11 [MASKED] 10:35AM CALCIUM-9.6 PHOSPHATE-2.8 MAGNESIUM-1.9 [MASKED] 10:35AM [MASKED] [MASKED] 10:35AM cTropnT-0.13* [MASKED] 11:30PM cTropnT-0.12* ========================================== DISCHARGE AND PERTINENT LABORATORY STUDIES ========================================== [MASKED] 06:15AM BLOOD WBC-9.3 RBC-2.66*# Hgb-8.2*# Hct-24.4* MCV-92# MCH-30.8 MCHC-33.6 RDW-16.2* RDWSD-54.8* Plt [MASKED] [MASKED] 06:15AM BLOOD Glucose-63* UreaN-52* Creat-2.6* Na-143 K-4.3 Cl-105 HCO3-25 AnGap-13 [MASKED] 11:30PM BLOOD cTropnT-0.12* [MASKED] 10:35AM BLOOD cTropnT-0.13* [MASKED] 06:15AM BLOOD Calcium-9.2 Phos-3.4 Mg-1.8 =========================== REPORTS AND IMAGING STUDIES =========================== [MASKED] 2D-ECHOCARDIOGRAM The left atrium is normal in size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Quantitative (3D) LVEF = 41%. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. IMPRESSION: Prominent symmetric LVH with mild global left ventricular systolic dysfunction. Small pericardial effusion. Elevated LVEDP. Compared with the prior study (images reviewed) of [MASKED], LV wall are thicker. LV systolic function has declined and there is now a pericardial effusion. Infiltrative cardiomyopathy, such as cardiac amyloidosis should be considered. [MASKED] CORONARY ANGIOGRAPHY Coronary Anatomy Dominance: Right LM- normal LAD- 40% proximal, minimal mid disease, recent stent widely patent. D1 small with 70% ostial and long 70% mid lesion LCx- 20% proximal in-stent restenosis, There is a focal 80% mid LCx lesion just beyond OM1 where the vessel is jailed by previous DES. OM1 stent is widely patent. OM2 is a medium sized vessel with 70% tubular stenosis. OM3 is a small vessel with mild luminal irregularities RCA- Known small, dominant vessel with mild luminal irregularities; R-PDA is medium sized with a 50% proximal lesion. NOt ijected at this procedure. Pressure wire of serial LAD lesions demonstrated IFR 0.83 in distal LAD and 0.95 in mid LAD consistent with hemodynamically signfiicant distal LAD lesion Attempted pressure wire of mid LCx unsuccessful due to inability to pass pressure wire into distal LCX through stent struts Impressions: 1. Successful PCI of Cx and OM with DES. [MASKED] CT ABDOMEN AND PELVIS WITHOUT CONTRAST IMPRESSION: 1. No evidence of retroperitoneal hemorrhage. Mild fat stranding in the right groin region which can be related to the recent instrumentation. 2. Other chronic findings as above. ============ MICROBIOLOGY ============ NONE Brief Hospital Course: ================= SUMMARY STATEMENT ================= Ms. [MASKED] is a [MASKED] year old woman with a history of heart failure with reduce ejection fraction (41% EF), type 1 diabetes, HTN, coronary artery disease with prior stenting, chronic kidney disease with a prior transplant who presents with chest pain. She was recently hospitalized from [MASKED] - [MASKED] after presenting with chest pressure and was found to have an NSTEMI. She had an LAD stent placed at that time and was discharged with plan for a staged intervention given her renal allograft and chronic kidney disease. However, she re-developed chest pain on the day prior to admission was found to have a troponinemia. She had successful and uncomplicated stents placed to LCx and an OM on [MASKED]. She was also transfused a unit of blood and underwent IV diuresis given her IV fluid administration. ==================== ACUTE MEDICAL ISSUES ==================== #CORONARIES: Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED] DES to LAD [MASKED] [MASKED] PCI of Cx and OM with DES #PUMP: 41% #RHYTHM: NSR #ACUTE ON CHRONIC ANEMIA #TRANSFUSION REACTION - Patient was found to have Hb drop from 8.3 to 6.1 post-procedurally with no evidence of groin hematoma. There was no evidence of retroperitoneal bleed on CT. She was asymptomatic from this blood loss, including no back pain or excessive groin pain. She was scheduled to receive 1 unit of packed red blood cells, and developed sensation of warmth one hour into blood transfusion. Temp found to be 100.6 (previously incorrectly documented as 100.8). Subsequent temp checks <100.4. However, discussed with blood bank resident and stopped transfusion. After studies were performed on the packed red cells, she was ordered another unit of blood which was transfused without complication. She had an appropriate rise in her hemoglobin to this transfusion. She never had shortness of breath, hemodynamic changes, urticaria, rash or other transfusion reaction symptoms. #NSTEMI: #CAD: She was recently hospitalized from [MASKED] - [MASKED] after presenting with chest pressure and was found to have an NSTEMI. She had an LAD stent placed at that time and was discharged with plan for a staged intervention given her renal allograft and chronic kidney disease. She had a known 80% mid-LCx lesion. However, she re-developed chest pain on the day prior to admission was found to have a troponinemia. Her chest pain was relieved with sublingual nitroglycerin. An ECG revealed <1mm ST elevations in V1 and V2 upon presentation. She had an elevated troponin-T to 0.13 that was lower than any of her recent troponins. Due to her typical symptoms and ECG changes, she had a PCI to LCx and OM with resolution of chest pain. Troponins stabilized after this. She was continued on her home statin, ASA, Plavix and metoprolol. #HFrEF exacerbation (EF 41%): Weight stable from her prior discharge, though according to the patient's scale she has gained 5 pounds since her last discharge. Mildly volume overloaded on her presenting exam (JVP only), BNP improved from prior. However, given fluids after her study and blood on [MASKED], she was given 40mg IV diuresis on two occasions. #HTN Known to have difficult to control HTN, and noted to have issues with orthostasis on last admission. She recently saw a neurologist for her orthostasis. She had hypertension to SBP's of 170's that was conservatively managed given her severe orthostatic hypotension. #CKD #S/p renal transplant Pt with recent contrast induced nephropathy after LHC last admission. Cr 2.8 on her last discharge and 2.1 on her admission. Rose to 2.4 and then 2.6, likely in the setting of post-contrast nephropathy. The renal consult team was consulted during her admission. No changes were made to her home immunosuppressive regimen (cyclosporine 25mg BID, MMF 500mg BID, prednisone 6mg daily). ====================== CHRONIC MEDICAL ISSUES ====================== #Type 1 DM - Insulin sliding scale + 36 unit glargine QAM =================== TRANSITIONAL ISSUES =================== - New Meds: None - Stopped/Held Meds: None - Changed Meds: None - Incidental Findings: None - Discharge weight: [MASKED]: 60kg (132.28 pounds) [ ] CBC, Sodium, Potassium, Chloride, Bicarbonate, BUN, Creatinine, Calcium, Magnesium and Phosphate on [MASKED]. [ ] Patient will need close monitoring of renal function given her contrast induced nephropathy [ ] Patient needs continued monitoring of blood pressure. Amlodipine recently stopped due to severe orthostasis, and she was hypertensive for much of her admission. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Ascorbic Acid [MASKED] mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Calcitriol 0.25 mcg PO DAILY 6. Calcium Carbonate 500 mg PO BID 7. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 8. Esomeprazole 40 mg Other BID 9. Ferrous Sulfate 325 mg PO DAILY 10. HydrALAZINE 50 mg PO QHS 11. Levothyroxine Sodium 125 mcg PO DAILY 12. Mycophenolate Mofetil 500 mg PO BID 13. PredniSONE 6 mg PO DAILY 14. Vitamin D [MASKED] UNIT PO DAILY 15. Ranolazine ER 500 mg PO BID 16. Promethazine 25 mg PO DAILY PRN nausea 17. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 18. Metoprolol Succinate XL 50 mg PO DAILY 19. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 20. Furosemide 20 mg PO DAILY 21. Cilostazol 50 mg PO QPM 22. Lidocaine 5% Patch 1 PTCH TD QAM 23. melatonin 10 mg oral QHS 24. naftifine 2 % topical BID To soles of feet and between toe webs 25. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 26. Cilostazol 100 mg PO QAM 27. Toujeo SoloStar (insulin glargine) 36 Units subcutaneous Q Breakfast Discharge Medications: 1. Allopurinol [MASKED] mg PO DAILY 2. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 3. Ascorbic Acid [MASKED] mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Calcitriol 0.25 mcg PO DAILY 7. Calcium Carbonate 500 mg PO BID 8. Cilostazol 100 mg PO QAM 9. Cilostazol 50 mg PO QPM 10. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 11. Esomeprazole 40 mg Other BID 12. Ferrous Sulfate 325 mg PO DAILY 13. Furosemide 20 mg PO DAILY 14. HydrALAZINE 50 mg PO QHS 15. Levothyroxine Sodium 125 mcg PO DAILY 16. Lidocaine 5% Patch 1 PTCH TD QAM 17. melatonin 10 mg oral QHS 18. Metoprolol Succinate XL 50 mg PO DAILY 19. Mycophenolate Mofetil 500 mg PO BID 20. naftifine 2 % topical BID To soles of feet and between toe webs 21. PredniSONE 6 mg PO DAILY 22. Promethazine 25 mg PO DAILY PRN nausea 23. Ranolazine ER 500 mg PO BID 24. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral BID:PRN constipation 25. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 26. Toujeo SoloStar (insulin glargine) 36 Units subcutaneous Q Breakfast 27. Vitamin D [MASKED] UNIT PO DAILY 28.Outpatient Lab Work TO BE DRAWN [MASKED] ICD-9 = 996.81 LABS = CBC, CHEM-10 ATTN: [MASKED], MD FAX: [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: ================= PRIMARY DIAGNOSIS ================= NSTEMI with two stent placements =================== SECONDARY DIAGNOSES =================== Acute blood loss anemia requiring transfusion Heart Failure with Reduce Ejection Fraction Acute Kidney Injury with Chronic Kidney Disease Renal Transplant Type I Diabetes 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 while you were admitted to [MASKED] [MASKED]. WHY WERE YOU ADMITTED TO THE HOSPITAL? You were admitted to the hospital because you were having chest pain and we were concerned you were having a heart attack. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - We did a coronary angiography (catheterization) and put two stents in your heart to clear up the blockages. - We gave you blood through an IV because your blood counts were low. - We gave you diuretics though an IV to remove extra fluid from your body. WHAT SHOULD YOU DO WHEN YOU GO HOME? - Make sure you weigh yourself every morning after you go to the bathroom and before putting on your clothes. If you weight goes up three pounds in one day or five pounds in two days, call your doctor. - Make sure you call your doctor or call [MASKED] right away if you have more chest pain. Discharge Weight = [MASKED]: 60kg (132.28 pounds) Sincerely, [MASKED] Cardiology Team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"D62",
"D649",
"I130",
"N189"
] |
[
"I214: Non-ST elevation (NSTEMI) myocardial infarction",
"I5023: Acute on chronic systolic (congestive) heart failure",
"N179: Acute kidney failure, unspecified",
"D62: Acute posthemorrhagic anemia",
"Z940: Kidney transplant status",
"E109: Type 1 diabetes mellitus without complications",
"D649: Anemia, 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",
"T458X5A: Adverse effect of other primarily systemic and hematological agents, initial encounter",
"T8089XA: Other complications following infusion, transfusion and therapeutic injection, initial encounter",
"N189: Chronic kidney disease, unspecified",
"Y92239: Unspecified place in hospital as the place of occurrence of the external cause",
"I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris"
] |
10,030,753
| 29,523,678
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMH HFrEF (EF 41%), ESRD ___ T1DM s/p LURT transplant ___
(on cellcept, prednisone, and cyclosporine), CAD s/p multiple
DES (most recently ___, CREST syndrome, DM1, and
dysautonomia with orthostatic hypotension who initially
presented to ___ ___ with dyspnea, now transferred to
___ for further evaluation and treatment.
Of note, patient was admitted to ___ ___ after
presenting with ___ swelling and weight gain, admitted for acute
on chronic HFrEF exacerbation requiring IV diuresis. She was
also treated for an Ecoli UTI. After discharge, patient
traveled to ___ in the middle of ___ where it was
difficult for her to control the amount of salt in her diet.
Her weight went up to 130lbs from a dry weight of 122lbs and
patient was experiencing orthopnea and dyspnea with even minimal
exertion. No chest pain. As such, her outpatient cardiologist
instructed her to increase home Lasix from 40mg daily to 40mg
BID. Her weight came back down to her dry weight, but her
symptoms of dyspnea persisted so she presented to the ___ on ___.
In the ___ her ___ were notable for BUN/Cr 65/2.7,
___ 5.4, Trop T 0.22, NT proBNP >70000. She also had a CXR
done which showed no evidence of pulmonary edema or infection.
They felt the most likely cause of her dyspnea was a CHF
exacerbation so she was given 40mg IV Lasix. They felt her trop
leak was secondary to demand in the setting of a CHF
exacerbation. She was admitted to medicine for further workup
and management.
Patient was evaluated by cardiology while inpatient at
___, and she examined euvolemic and recommendation was to
hold off on diuresis for a day. There was some concern that the
cause of her dyspnea may not be cardiac in nature.
On arrival to ___, patient recounts the history as above. She
indeed says that after increasing her lasix dose to 40mg BID,
her weight decreased and any lower extremity swelling vanished.
Her respiratory symptoms, however, have not improved. Patient
describes ongoing orthopnea, which causes her to festinate at
night. Her symptoms can be ongoing for >30min. She also
continues to experience dyspnea upon only light exertion with
her walker. Patient does say that these symptoms are consistent
with prior episodes of heart failure. No chest pain. No
diaphoresis. No palpitations. No cough. No
fevers/chills/nightsweats. ___ ROS is otherwise NEGATIVE.
Past Medical History:
-CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___ DES to LAD ___
PCI of Cx and OM with ___
-___ renal disease ___ diabetes s/p ___ living kidney
transplant in ___
-Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
-Hypertension
-Dyslipidemia
-Scleroderma w/ CREST syndrome
-Gastroparesis/GERD/Hiatal hernia
-Gout diagnosed ___ years ago
-OSA
Social History:
___
Family History:
___ myeloma
Sister and ___
___
Sister - Kidney cancer
___ disease
___
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION EXAM
==========================
VS: 98.0 182/78 96 16 99 RA
GENERAL: NAD, pleasant in conversation, speaking in full
sentences.
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM.
NECK: No JVP elevation.
HEART: RRR, S1/S2, ___ systolic murmur heard throughout the
precordium (best at the upper sternal borders), no gallops or
rubs.
LUNGS: CTABL.
ABDOMEN: Nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: No cyanosis, clubbing, or edema.
PULSES: 2+ radial pulses bilaterally.
NEURO: A&Ox3, moving all 4 extremities with purpose.
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes.
DISCHARGE EXAM
==========================
VS: Temp: 98.3 (Tm 98.4), BP: 151/73 (___), HR: 97
(___), RR: 18, O2 sat: 99% (___), O2 delivery: 2L, Wt:
125.10 lb/56.75 kg
Last 24 hours Total cumulative -280ml
IN: Total 770ml, PO Amt 420ml, IV Amt Infused 350ml
OUT: Total 1050ml, Urine Amt 1050ml
GENERAL: NAD, pleasant in conversation, speaking in full
sentences.
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM.
NECK: No JVP elevation.
HEART: RRR, S1/S2, ___ systolic murmur heard throughout the
precordium (best at the upper sternal borders), no gallops or
rubs.
LUNGS: CTABL.
ABDOMEN: Nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: No cyanosis, clubbing, or edema.
PULSES: 2+ radial pulses bilaterally.
NEURO: A&Ox3, moving all 4 extremities with purpose.
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes.
Pertinent Results:
ADMISSION ___
=================================
___ 03:53AM BLOOD ___
___ Plt ___
___ 06:05AM BLOOD ___ ___
___ 03:53AM BLOOD ___
___
___ 03:53AM BLOOD LD(LDH)-404*
___ 03:53AM BLOOD ___
___ 03:53AM BLOOD ___
DISCHARGE ___
=================================
___ 04:44AM BLOOD ___
___ Plt ___
___ 04:44AM BLOOD ___
___
___ 04:44AM BLOOD ___
___ 04:44AM BLOOD ___
IMAGING
=================================
CT Lung ___
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Imaged thyroid is
unremarkable.
There is no pathologic enlargement of lymph nodes in the
supraclavicular or
axillary stations. Atherosclerosis demonstrated in both
breasts.
CHEST CAGE: Subacute fracture in the right posterior tenth rib
(04:45). No
worrisome lytic or sclerotic osseous destructive lesions
identified in the
level of the ribs, vertebra or sternum.
UPPER ABDOMEN: Atherosclerosis in the imaged upper abdomen
arteries. Patient
status post cholecystectomy.
MEDIASTINUM: There is small hiatal hernia, remaining of the
esophagus is
mildly patulous, unchanged and could represent esophageal
dysmotility.
No pathologic enlargement of lymph nodes in the mediastinum.
Hilar contours
suggest no gross lymphadenopathy.
HEART and PERICARDIUM: Heart is mildly enlarged. Hypodensity of
cardiac
chambers suggest anemia. There are extensive and dense
calcifications of all
coronaries, particularly the LAD and LCX. Thoracic aorta is
minimally
calcified, normal in caliber. There are minimal calcifications
of the aortic
valve leaflets. Main pulmonary artery measures up to 3.5 cm,
suggesting
pulmonary hypertension unchanged.
Small pericardial effusion, mildly enlarged in comparison to ___.
PLEURA: There is trace left layering pleural effusion, new in
comparison to ___.
LUNG: Tracheobronchial tree is patent to the subsegmental level.
Minimal
smooth interstitial line thickening and faint mosaic pattern of
attenuation at
the level of the lung bases suggest minimal pulmonary edema.
There are no interstitial abnormalities, no traction
bronchiectasis, no
honeycombing or any other evidence of diffuse lung disease.
During expiration
minimal if any ___ demonstrated in the lung bases.
Small calcified granuloma in right lung base (304:118). There
are no
measurable pulmonary nodules.
IMPRESSION:
-No diffuse interstitial lung disease.
-Minimal pulmonary edema and new left trace layering pleural
effusion. Small
pericardial effusion mildly increased since ___.
TTE ___
There is moderate symmetric left ventricular hypertrophy. There
is normal regional left ventricular systolic
function. Global left ventricular systolic function is low
normal. The visually estimated left ventricular ejection
fraction is ___. There is no resting left ventricular outflow
tract gradient. Diastolic function could not be
assessed. Normal right ventricular cavity size with normal free
wall motion. There is no aortic valve stenosis.
There is no aortic regurgitation. The mitral leaflets are mildly
thickened. 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
physiologic tricuspid regurgitation. There is a small
pericardial effusion. There are no 2D or Doppler
echocardiographic evidence of tamponade.
MICRO
=================================
Urine Cutlure ___ pending on discharge
Brief Hospital Course:
====================
PATIENT SUMMARY:
====================
___ PMH HFrEF (EF 41%), ESRD ___ T1DM s/p LURT transplant ___
(on cellcept, prednisone, and cyclosporine), CAD s/p multiple
DES (most recently ___, CREST syndrome, DM1, and
dysautonomia with orthostatic hypotension who initially
presented to ___ ___ with dyspnea, now transferred to
___ for further evaluation and treatment.
# Subjective Dyspnea:
# Anemia: Presented with subjective dyspnea on exertion. O2 sats
were normal throughout hospitalization. CT scan showed no
evidence of ILD, no significant pulmonary effusions, no
infection, and a small amount of pulmonary edema. TTE showed
normal EF and no wall motion abnormalities. Her hgb was ___ on
admission, which is similar to baseline anemia of ___. Prior
work up shows iron studies consistent with anemia of chronic
disease likely from renal failure. She received one unit RBCs
with hgb bump to 7.8. Plan for her to get EPO as outpatient.
# UTI: e coli at last admission that was treated with
cefpodoxime. UA this admission c/w urinary tract infection.
Urine culture is pending. Started cefpodoxime ___ with plan
of 2 week course to finish on ___. Would recommend repeat UA as
outpatient to make sure she
clears, as unsure if this is new infection or ___
prior
infection.
# HFrEF (LVEF 41% from prior TTE, 55% this admission): continued
home lasix. Increased and fractionated home metoprolol which was
transitioned to metoprolol succinate 50 mg daily on discharge.
Continued hydralazine 50 mg BID for afterload reduction.
Discharge weight was 56.97 kg.
# ESRD s/p Transplant - From most recent admission ___,
patient's elevated Cr was felt to be due to chronic graft
rejection; however, it is actually due to poorly controlled
diabetes. She appears to be around her baseline (based on
___, and her Cr is actually better than when she was
discharged on ___. Continued home cellcept, cyclosporine,
prednisone, calcitriol, and calcium carbonate.
# Coronary artery disease s/p multiple stents (most recently
___
# Troponinemia - Cath ___ with normal LM, 40% ___ LAD w/
80% distal lesion beyond previous stent, 80% mid LCx. Patient
has persistently elevated troponin, decreased renal clearance.
EKG on admission without ischemic changes. CT does note coronary
calcifications. Continued home ASA 81mg daily, Ticagrelor 90mg
BID, Ranolazine 500mg ER BID, cilostazole 100mg qAM, 50mg qPM.
Patient says that she was taken off Atorvastatin 20mg qd several
months ago given interactions with her immunosuppression.
# Incidental pancreatic head mass - Recent ___ CT Torso at
___ was significant for a 2.1 x 1.4 cm hypodense mass in the
region of the pancreatic head and a 1 cm exophytic hypodensity
off anterior aspect of the pancreatic body, suspicious for
malignancy. On further review thought it might be an IPMN so
plan was for MRCP 6 weeks from date of CT scan to eval for
changes. She is scheduled for the MRCP in two weeks.
# Hypertension
# Dysautonomia
# Orthostatic hypotension: Per most recent discharge summary she
had difficult to control HTN given her dysautonomia iso
longstanding T1DM. Goal SBP < 160 given recent SAH. At the last
admission, her BP meds were titrated while inpatient and she was
discharged on Hydralazine 75mg TID and metoprolol succinate
125mg daily, though patient has been taking metoprolol 25mg qd
and hydralazine 50mg BID. During this admission, her heart rate
and blood pressure were well controlled with metoprolol tartate
12.5 q6h and hydralazine 50 BID. She was discharged on
metoprolol succinate 50 and hydralazine 50 BID.
# DM1: Continued home regimen in addition to HISS
# Neurogenic bladder: Patient does intermittent straight caths
at home. Continued intermittent straight cath while inpatient
# Hypothyroidism: Continued home levothyroxine 125mcg daily
# Gout: Renally dosed allopurinol ___ qd
====================
TRANSITIONAL ISSUES:
====================
[] Consider stress test given significant coronary artery
disease seen on CT scan
[] Would benefit from EPO as outpatient, she has an appointment
with hematology to discuss her anemia and the possibility of epo
injections
[] Continue cefpodoxime for UTI for 2 weeks D1 ___, to
finish on ___. Urine cultures are pending.
[] Obtain UA/Uculture at the end of treatment for UTI to ensure
bacteria was cleared.
[] Will need diuretic titration when she changes her diet as
outpatient. With low sodium diet in hospital, she was getting
lasix 20 mg and euvolemic.
[] Check Cr as outpatient on ___. It bumped from 3.0 to 3.2
during admission.
- New Meds: cefpodoxime
- Stopped/Held Meds: none
- Changed Meds: metoprolol succinate 25 to 50
- ___ appointments: transplant nephrology, PCP
- ___ Needed: chem 10
- Discharge weight: 56.97 kg
- Discharge creatinine: 3.2
# CODE: Presumed FULL
# CONTACT: ___ (SISTER) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H
2. Allopurinol ___ mg PO DAILY
3. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Calcitriol 0.25 mcg PO DAILY
7. Calcium Carbonate 500 mg PO BID
8. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
9. FoLIC Acid 1 mg PO DAILY
10. Levothyroxine Sodium 125 mcg PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Mycophenolate Mofetil 500 mg PO BID
15. Omeprazole 40 mg PO BID
16. PredniSONE 6 mg PO DAILY
17. Promethazine 25 mg PO BID:PRN nausea
18. Ranolazine ER 500 mg PO BID
19. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
20. Vitamin D ___ UNIT PO DAILY
21. Cilostazol 50 mg PO QPM
22. Cilostazol 100 mg PO QAM
23. Ferrous Sulfate 325 mg PO DAILY
24. melatonin 10 mg oral QHS
25. naftifine 2 % topical BID To soles of feet and between toe
webs
26. Senna Plus ___ sodium) ___ mg oral
BID:PRN constipation
27. Toujeo SoloStar ___ Insulin (insulin glargine) 30 U
subcutaneous QAM
28. Furosemide 20 mg PO DAILY
29. HydrALAZINE 50 mg PO Q12H
30. trimethobenzamide 300 mg oral BID:PRN nausea
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO Q24H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth once a day Disp #*13
Tablet Refills:*0
2. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
5. Acetaminophen 1000 mg PO Q6H
6. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
7. Aspirin 81 mg PO DAILY
8. Calcitriol 0.25 mcg PO DAILY
9. Calcium Carbonate 500 mg PO BID
10. Cilostazol 100 mg PO QAM
11. Cilostazol 50 mg PO QPM
12. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
13. Ferrous Sulfate 325 mg PO DAILY
14. FoLIC Acid 1 mg PO DAILY
15. HydrALAZINE 50 mg PO Q12H
16. Levothyroxine Sodium 125 mcg PO DAILY
17. Lidocaine 5% Patch 1 PTCH TD QAM
18. melatonin 10 mg oral QHS
19. Multivitamins 1 TAB PO DAILY
20. Mycophenolate Mofetil 500 mg PO BID
21. naftifine 2 % topical BID To soles of feet and between toe
webs
22. Omeprazole 40 mg PO BID
23. PredniSONE 6 mg PO DAILY
24. Promethazine 25 mg PO BID:PRN nausea
25. Ranolazine ER 500 mg PO BID
26. Senna Plus ___ sodium) ___ mg oral
BID:PRN constipation
27. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
28. Toujeo SoloStar ___ Insulin (insulin glargine) 30 U
subcutaneous QAM
29. trimethobenzamide 300 mg oral BID:PRN nausea
30. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
====================
Anemia
Heart Failure with reduced Ejection Fraction
End Stage Renal Disease s/p Renal transplant
SECONDARY DIAGNOSIS
====================
CREST
Type 1 Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to ___ because you were feeling short of breath. You
were found to have anemia and were treated with a blood
transfusion. 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!
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
- You were treated with a blood transfusion and your shortness
of breath resolved.
- You had a cat scan of your lungs and an ultrasound of your
heart which were normal.
- You improved considerably and were ready to leave the hospital
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please follow up with your primary care doctor and other
health care providers (see below)
- It is important that you go to your hematology appointment so
that you can get medications to keep your blood levels from
going too low
- Please take all of your medications as prescribed (see below).
- Seek medical attention if you have shortness of breath, bloody
or dark stools, chest pain, or other symptoms of concern.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
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Allergies: Penicillins / Ativan / carvedilol / amlodipine Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] PMH HFrEF (EF 41%), ESRD [MASKED] T1DM s/p LURT transplant [MASKED] (on cellcept, prednisone, and cyclosporine), CAD s/p multiple DES (most recently [MASKED], CREST syndrome, DM1, and dysautonomia with orthostatic hypotension who initially presented to [MASKED] [MASKED] with dyspnea, now transferred to [MASKED] for further evaluation and treatment. Of note, patient was admitted to [MASKED] [MASKED] after presenting with [MASKED] swelling and weight gain, admitted for acute on chronic HFrEF exacerbation requiring IV diuresis. She was also treated for an Ecoli UTI. After discharge, patient traveled to [MASKED] in the middle of [MASKED] where it was difficult for her to control the amount of salt in her diet. Her weight went up to 130lbs from a dry weight of 122lbs and patient was experiencing orthopnea and dyspnea with even minimal exertion. No chest pain. As such, her outpatient cardiologist instructed her to increase home Lasix from 40mg daily to 40mg BID. Her weight came back down to her dry weight, but her symptoms of dyspnea persisted so she presented to the [MASKED] on [MASKED]. In the [MASKED] her [MASKED] were notable for BUN/Cr 65/2.7, [MASKED] 5.4, Trop T 0.22, NT proBNP >70000. She also had a CXR done which showed no evidence of pulmonary edema or infection. They felt the most likely cause of her dyspnea was a CHF exacerbation so she was given 40mg IV Lasix. They felt her trop leak was secondary to demand in the setting of a CHF exacerbation. She was admitted to medicine for further workup and management. Patient was evaluated by cardiology while inpatient at [MASKED], and she examined euvolemic and recommendation was to hold off on diuresis for a day. There was some concern that the cause of her dyspnea may not be cardiac in nature. On arrival to [MASKED], patient recounts the history as above. She indeed says that after increasing her lasix dose to 40mg BID, her weight decreased and any lower extremity swelling vanished. Her respiratory symptoms, however, have not improved. Patient describes ongoing orthopnea, which causes her to festinate at night. Her symptoms can be ongoing for >30min. She also continues to experience dyspnea upon only light exertion with her walker. Patient does say that these symptoms are consistent with prior episodes of heart failure. No chest pain. No diaphoresis. No palpitations. No cough. No fevers/chills/nightsweats. [MASKED] ROS is otherwise NEGATIVE. Past Medical History: -CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA [MASKED] DES to LAD and Cx/OM [MASKED] DES to LAD [MASKED] PCI of Cx and OM with [MASKED] -[MASKED] renal disease [MASKED] diabetes s/p [MASKED] living kidney transplant in [MASKED] -Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) -Hypertension -Dyslipidemia -Scleroderma w/ CREST syndrome -Gastroparesis/GERD/Hiatal hernia -Gout diagnosed [MASKED] years ago -OSA Social History: [MASKED] Family History: [MASKED] myeloma Sister and [MASKED] [MASKED] Sister - Kidney cancer [MASKED] disease [MASKED] Daughter [MASKED], celiac disease, MS Father - alcohol use disorder Physical Exam: ADMISSION EXAM ========================== VS: 98.0 182/78 96 16 99 RA GENERAL: NAD, pleasant in conversation, speaking in full sentences. HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM. NECK: No JVP elevation. HEART: RRR, S1/S2, [MASKED] systolic murmur heard throughout the precordium (best at the upper sternal borders), no gallops or rubs. LUNGS: CTABL. ABDOMEN: Nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly. EXTREMITIES: No cyanosis, clubbing, or edema. PULSES: 2+ radial pulses bilaterally. NEURO: A&Ox3, moving all 4 extremities with purpose. SKIN: Warm and well perfused, no excoriations or lesions, no rashes. DISCHARGE EXAM ========================== VS: Temp: 98.3 (Tm 98.4), BP: 151/73 ([MASKED]), HR: 97 ([MASKED]), RR: 18, O2 sat: 99% ([MASKED]), O2 delivery: 2L, Wt: 125.10 lb/56.75 kg Last 24 hours Total cumulative -280ml IN: Total 770ml, PO Amt 420ml, IV Amt Infused 350ml OUT: Total 1050ml, Urine Amt 1050ml GENERAL: NAD, pleasant in conversation, speaking in full sentences. HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM. NECK: No JVP elevation. HEART: RRR, S1/S2, [MASKED] systolic murmur heard throughout the precordium (best at the upper sternal borders), no gallops or rubs. LUNGS: CTABL. ABDOMEN: Nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly. EXTREMITIES: No cyanosis, clubbing, or edema. PULSES: 2+ radial pulses bilaterally. NEURO: A&Ox3, moving all 4 extremities with purpose. SKIN: Warm and well perfused, no excoriations or lesions, no rashes. Pertinent Results: ADMISSION [MASKED] ================================= [MASKED] 03:53AM BLOOD [MASKED] [MASKED] Plt [MASKED] [MASKED] 06:05AM BLOOD [MASKED] [MASKED] [MASKED] 03:53AM BLOOD [MASKED] [MASKED] [MASKED] 03:53AM BLOOD LD(LDH)-404* [MASKED] 03:53AM BLOOD [MASKED] [MASKED] 03:53AM BLOOD [MASKED] DISCHARGE [MASKED] ================================= [MASKED] 04:44AM BLOOD [MASKED] [MASKED] Plt [MASKED] [MASKED] 04:44AM BLOOD [MASKED] [MASKED] [MASKED] 04:44AM BLOOD [MASKED] [MASKED] 04:44AM BLOOD [MASKED] IMAGING ================================= CT Lung [MASKED] NECK, THORACIC INLET, AXILLAE, CHEST WALL: Imaged thyroid is unremarkable. There is no pathologic enlargement of lymph nodes in the supraclavicular or axillary stations. Atherosclerosis demonstrated in both breasts. CHEST CAGE: Subacute fracture in the right posterior tenth rib (04:45). No worrisome lytic or sclerotic osseous destructive lesions identified in the level of the ribs, vertebra or sternum. UPPER ABDOMEN: Atherosclerosis in the imaged upper abdomen arteries. Patient status post cholecystectomy. MEDIASTINUM: There is small hiatal hernia, remaining of the esophagus is mildly patulous, unchanged and could represent esophageal dysmotility. No pathologic enlargement of lymph nodes in the mediastinum. Hilar contours suggest no gross lymphadenopathy. HEART and PERICARDIUM: Heart is mildly enlarged. Hypodensity of cardiac chambers suggest anemia. There are extensive and dense calcifications of all coronaries, particularly the LAD and LCX. Thoracic aorta is minimally calcified, normal in caliber. There are minimal calcifications of the aortic valve leaflets. Main pulmonary artery measures up to 3.5 cm, suggesting pulmonary hypertension unchanged. Small pericardial effusion, mildly enlarged in comparison to [MASKED]. PLEURA: There is trace left layering pleural effusion, new in comparison to [MASKED]. LUNG: Tracheobronchial tree is patent to the subsegmental level. Minimal smooth interstitial line thickening and faint mosaic pattern of attenuation at the level of the lung bases suggest minimal pulmonary edema. There are no interstitial abnormalities, no traction bronchiectasis, no honeycombing or any other evidence of diffuse lung disease. During expiration minimal if any [MASKED] demonstrated in the lung bases. Small calcified granuloma in right lung base (304:118). There are no measurable pulmonary nodules. IMPRESSION: -No diffuse interstitial lung disease. -Minimal pulmonary edema and new left trace layering pleural effusion. Small pericardial effusion mildly increased since [MASKED]. TTE [MASKED] There is moderate symmetric left ventricular hypertrophy. There is normal regional left ventricular systolic function. Global left ventricular systolic function is low normal. The visually estimated left ventricular ejection fraction is [MASKED]. There is no resting left ventricular outflow tract gradient. Diastolic function could not be assessed. Normal right ventricular cavity size with normal free wall motion. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral leaflets are mildly thickened. 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 physiologic tricuspid regurgitation. There is a small pericardial effusion. There are no 2D or Doppler echocardiographic evidence of tamponade. MICRO ================================= Urine Cutlure [MASKED] pending on discharge Brief Hospital Course: ==================== PATIENT SUMMARY: ==================== [MASKED] PMH HFrEF (EF 41%), ESRD [MASKED] T1DM s/p LURT transplant [MASKED] (on cellcept, prednisone, and cyclosporine), CAD s/p multiple DES (most recently [MASKED], CREST syndrome, DM1, and dysautonomia with orthostatic hypotension who initially presented to [MASKED] [MASKED] with dyspnea, now transferred to [MASKED] for further evaluation and treatment. # Subjective Dyspnea: # Anemia: Presented with subjective dyspnea on exertion. O2 sats were normal throughout hospitalization. CT scan showed no evidence of ILD, no significant pulmonary effusions, no infection, and a small amount of pulmonary edema. TTE showed normal EF and no wall motion abnormalities. Her hgb was [MASKED] on admission, which is similar to baseline anemia of [MASKED]. Prior work up shows iron studies consistent with anemia of chronic disease likely from renal failure. She received one unit RBCs with hgb bump to 7.8. Plan for her to get EPO as outpatient. # UTI: e coli at last admission that was treated with cefpodoxime. UA this admission c/w urinary tract infection. Urine culture is pending. Started cefpodoxime [MASKED] with plan of 2 week course to finish on [MASKED]. Would recommend repeat UA as outpatient to make sure she clears, as unsure if this is new infection or [MASKED] prior infection. # HFrEF (LVEF 41% from prior TTE, 55% this admission): continued home lasix. Increased and fractionated home metoprolol which was transitioned to metoprolol succinate 50 mg daily on discharge. Continued hydralazine 50 mg BID for afterload reduction. Discharge weight was 56.97 kg. # ESRD s/p Transplant - From most recent admission [MASKED], patient's elevated Cr was felt to be due to chronic graft rejection; however, it is actually due to poorly controlled diabetes. She appears to be around her baseline (based on [MASKED], and her Cr is actually better than when she was discharged on [MASKED]. Continued home cellcept, cyclosporine, prednisone, calcitriol, and calcium carbonate. # Coronary artery disease s/p multiple stents (most recently [MASKED] # Troponinemia - Cath [MASKED] with normal LM, 40% [MASKED] LAD w/ 80% distal lesion beyond previous stent, 80% mid LCx. Patient has persistently elevated troponin, decreased renal clearance. EKG on admission without ischemic changes. CT does note coronary calcifications. Continued home ASA 81mg daily, Ticagrelor 90mg BID, Ranolazine 500mg ER BID, cilostazole 100mg qAM, 50mg qPM. Patient says that she was taken off Atorvastatin 20mg qd several months ago given interactions with her immunosuppression. # Incidental pancreatic head mass - Recent [MASKED] CT Torso at [MASKED] was significant for a 2.1 x 1.4 cm hypodense mass in the region of the pancreatic head and a 1 cm exophytic hypodensity off anterior aspect of the pancreatic body, suspicious for malignancy. On further review thought it might be an IPMN so plan was for MRCP 6 weeks from date of CT scan to eval for changes. She is scheduled for the MRCP in two weeks. # Hypertension # Dysautonomia # Orthostatic hypotension: Per most recent discharge summary she had difficult to control HTN given her dysautonomia iso longstanding T1DM. Goal SBP < 160 given recent SAH. At the last admission, her BP meds were titrated while inpatient and she was discharged on Hydralazine 75mg TID and metoprolol succinate 125mg daily, though patient has been taking metoprolol 25mg qd and hydralazine 50mg BID. During this admission, her heart rate and blood pressure were well controlled with metoprolol tartate 12.5 q6h and hydralazine 50 BID. She was discharged on metoprolol succinate 50 and hydralazine 50 BID. # DM1: Continued home regimen in addition to HISS # Neurogenic bladder: Patient does intermittent straight caths at home. Continued intermittent straight cath while inpatient # Hypothyroidism: Continued home levothyroxine 125mcg daily # Gout: Renally dosed allopurinol [MASKED] qd ==================== TRANSITIONAL ISSUES: ==================== [] Consider stress test given significant coronary artery disease seen on CT scan [] Would benefit from EPO as outpatient, she has an appointment with hematology to discuss her anemia and the possibility of epo injections [] Continue cefpodoxime for UTI for 2 weeks D1 [MASKED], to finish on [MASKED]. Urine cultures are pending. [] Obtain UA/Uculture at the end of treatment for UTI to ensure bacteria was cleared. [] Will need diuretic titration when she changes her diet as outpatient. With low sodium diet in hospital, she was getting lasix 20 mg and euvolemic. [] Check Cr as outpatient on [MASKED]. It bumped from 3.0 to 3.2 during admission. - New Meds: cefpodoxime - Stopped/Held Meds: none - Changed Meds: metoprolol succinate 25 to 50 - [MASKED] appointments: transplant nephrology, PCP - [MASKED] Needed: chem 10 - Discharge weight: 56.97 kg - Discharge creatinine: 3.2 # CODE: Presumed FULL # CONTACT: [MASKED] (SISTER) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q6H 2. Allopurinol [MASKED] mg PO DAILY 3. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Calcitriol 0.25 mcg PO DAILY 7. Calcium Carbonate 500 mg PO BID 8. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 9. FoLIC Acid 1 mg PO DAILY 10. Levothyroxine Sodium 125 mcg PO DAILY 11. Lidocaine 5% Patch 1 PTCH TD QAM 12. Metoprolol Succinate XL 25 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Mycophenolate Mofetil 500 mg PO BID 15. Omeprazole 40 mg PO BID 16. PredniSONE 6 mg PO DAILY 17. Promethazine 25 mg PO BID:PRN nausea 18. Ranolazine ER 500 mg PO BID 19. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 20. Vitamin D [MASKED] UNIT PO DAILY 21. Cilostazol 50 mg PO QPM 22. Cilostazol 100 mg PO QAM 23. Ferrous Sulfate 325 mg PO DAILY 24. melatonin 10 mg oral QHS 25. naftifine 2 % topical BID To soles of feet and between toe webs 26. Senna Plus [MASKED] sodium) [MASKED] mg oral BID:PRN constipation 27. Toujeo SoloStar [MASKED] Insulin (insulin glargine) 30 U subcutaneous QAM 28. Furosemide 20 mg PO DAILY 29. HydrALAZINE 50 mg PO Q12H 30. trimethobenzamide 300 mg oral BID:PRN nausea Discharge Medications: 1. Cefpodoxime Proxetil 400 mg PO Q24H RX *cefpodoxime 200 mg 2 tablet(s) by mouth once a day Disp #*13 Tablet Refills:*0 2. Allopurinol [MASKED] mg PO DAILY RX *allopurinol [MASKED] mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Acetaminophen 1000 mg PO Q6H 6. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 7. Aspirin 81 mg PO DAILY 8. Calcitriol 0.25 mcg PO DAILY 9. Calcium Carbonate 500 mg PO BID 10. Cilostazol 100 mg PO QAM 11. Cilostazol 50 mg PO QPM 12. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 13. Ferrous Sulfate 325 mg PO DAILY 14. FoLIC Acid 1 mg PO DAILY 15. HydrALAZINE 50 mg PO Q12H 16. Levothyroxine Sodium 125 mcg PO DAILY 17. Lidocaine 5% Patch 1 PTCH TD QAM 18. melatonin 10 mg oral QHS 19. Multivitamins 1 TAB PO DAILY 20. Mycophenolate Mofetil 500 mg PO BID 21. naftifine 2 % topical BID To soles of feet and between toe webs 22. Omeprazole 40 mg PO BID 23. PredniSONE 6 mg PO DAILY 24. Promethazine 25 mg PO BID:PRN nausea 25. Ranolazine ER 500 mg PO BID 26. Senna Plus [MASKED] sodium) [MASKED] mg oral BID:PRN constipation 27. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 28. Toujeo SoloStar [MASKED] Insulin (insulin glargine) 30 U subcutaneous QAM 29. trimethobenzamide 300 mg oral BID:PRN nausea 30. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS ==================== Anemia Heart Failure with reduced Ejection Fraction End Stage Renal Disease s/p Renal transplant SECONDARY DIAGNOSIS ==================== CREST Type 1 Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You came to [MASKED] because you were feeling short of breath. You were found to have anemia and were treated with a blood transfusion. 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! WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL: - You were treated with a blood transfusion and your shortness of breath resolved. - You had a cat scan of your lungs and an ultrasound of your heart which were normal. - You improved considerably and were ready to leave the hospital WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL: - Please follow up with your primary care doctor and other health care providers (see below) - It is important that you go to your hematology appointment so that you can get medications to keep your blood levels from going too low - Please take all of your medications as prescribed (see below). - Seek medical attention if you have shortness of breath, bloody or dark stools, chest pain, or other symptoms of concern. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
|
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"I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"N390: Urinary tract infection, site not specified",
"Z940: Kidney transplant status",
"I5022: Chronic systolic (congestive) heart failure",
"N189: Chronic kidney disease, unspecified",
"D631: Anemia in chronic kidney disease",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z955: Presence of coronary angioplasty implant and graft",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"M341: CR(E)ST syndrome",
"E785: Hyperlipidemia, unspecified",
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"Z87891: Personal history of nicotine dependence",
"D136: Benign neoplasm of pancreas",
"E039: Hypothyroidism, unspecified",
"M1A9XX0: Chronic gout, unspecified, without tophus (tophi)",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"K3184: Gastroparesis",
"N319: Neuromuscular dysfunction of bladder, unspecified",
"Z794: Long term (current) use of insulin",
"K219: Gastro-esophageal reflux disease without esophagitis",
"R7989: Other specified abnormal findings of blood chemistry"
] |
10,030,753
| 29,738,545
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan
Attending: ___
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD ___
Colonoscopy ___
History of Present Illness:
___ year-old woman with antiphospholipid syndrome, history of PE
on warfarin, and poorly-controlled T1DM complicated by
retinopathy, neuropathy with gastroparesis and neurogenic
bladder and ESRD status post living kidney transplant in ___ on
MMF, tacrolimus, prednisone, several artery CAD s/p MI in ___
and ___ and 3 drug-eluting stents placed in ___, who
presents with several days of melena and hematemesis. She
frequently has nausea/vomiting secondary to gastroparesis, but
on ___ she began having episodes of dark brown emesis, as
well as black tarry stools. On ___ she also began having
episodes of bright red hematemesis. She went to a cardiology
appointment, and her cardiologist referred her to the ED given
this hx and her paleness on exam. She's had no fevers/chills, no
odynophagia, no abdominal pain, no chest pain, no SOB. She has
had lightheadedness upon standing. She initially presented to ___
___, where her systolics were in the 70-80's which responded
to IVF. Her INR was found to be 6.1, and she was given Kcentra
and vitamin K. She did not receive any blood prior to transfer
due to difficult crossmatch. By the time she arrived at ___
ED, she was HD stable with INR of 1 and Hgb 5.1. Her last BM was
the morning of ___, and her last episode of emesis was in the
ED prior to transfer.
In the ED:
- initial vitals: 97.2 90 119/68 16 100% RA
- exam notable for: dark brown stool mixed with bright red blood
- labs notable for Hgb 5.1, INR 1
- EKG: sinus @ 94, NA/NI, minimal ST depressions laterally
- GI was consulted, who agreed with MICU admission and NPO for
EGD
- on transfer, vitals were: 98.3 87 124/56 22 100% RA
On arrival to the MICU, she feels fatigued but otherwise has no
complaints.
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, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA ___,
DES to LAD and Cx/OM ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization) - End-stage renal disease ___ diabetes s/p
L-sided living kidney transplant in ___
- Scleroderma w/ CREST syndrome
- Antiphospholipid antibody syndrome and remote PE history on
Coumadin ___
- Gastroparesis/GERD/Hiatal hernia
- Gout diagnosed ___ years ago
- OSA
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Physical Exam:
Admission physical exam:
============================
GENERAL: appears tired and pale, NAD
HEENT: Pale anicteric sclera, dry MM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
PULM: CTAB
CV: RRR, SEM
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
NEURO: grossly intact
Discharge physical exam:
============================
T 98.5 HR 99 BP 167/81 RR 18 97 RA
General: pleasant middle-aged woman lying in bed in NAD
HEENT: NCAT, anicteric sclera, moist mucosa, no JVD appreciated
CV: RRR, + systolic murmur
Lungs: CTAB, no w/r/r
Abdomen: +BS, soft, non-distended, non-tender to palpation, no
rebound or guarding
Ext: wwp, no edema
Neuro: alert and oriented, moving all extremities
Pertinent Results:
=======================
LABS ON ADMISSION
=======================
___ 08:45PM BLOOD WBC-11.1* RBC-1.64*# Hgb-5.1*# Hct-15.8*#
MCV-96 MCH-31.1 MCHC-32.3 RDW-14.4 RDWSD-49.1* Plt ___
___ 08:45PM BLOOD Neuts-90.9* Lymphs-3.0* Monos-4.9*
Eos-0.5* Baso-0.1 Im ___ AbsNeut-10.11*# AbsLymp-0.33*
AbsMono-0.55 AbsEos-0.06 AbsBaso-0.01
___ 08:45PM BLOOD ___ PTT-31.5 ___
___ 08:45PM BLOOD Glucose-142* UreaN-51* Creat-1.5* Na-139
K-5.2* Cl-109* HCO3-24 AnGap-11
___ 05:34AM BLOOD ALT-11 AST-11 AlkPhos-67 TotBili-0.3
___ 08:45PM BLOOD Calcium-8.8 Phos-2.6* Mg-1.9
___ 07:45AM BLOOD tacroFK-8.3
___ 08:45PM BLOOD Lactate-0.9
=======================
PERTINENT INTERVAL LABS
=======================
___ 05:00PM BLOOD Lupus-NEG
___
Test Result Reference
Range/Units
CARDIOLIPIN AB (IGG) <14 GPL
Value Interpretation
----- --------------
< or = 14 Negative
15 - 20 Indeterminate
21 - 80 Low to Medium Positive
>80 High Positive
Test Result Reference
Range/Units
CARDIOLIPIN AB (IGM) <12 MPL
Value Interpretation
----- --------------
< or = 12 Negative
13 - 20 Indeterminate
21 - 80 Low to Medium Positive
>80 High Positive
___ 05:00PM BLOOD b2micro-5.3*
___ 05:18AM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA,
IGM, IGG)-PND
___ 10:27PM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:27PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 10:27PM URINE RBC-0 WBC-44* Bacteri-FEW Yeast-MANY
Epi-<1
___ 10:27PM URINE CastHy-3*
___ 10:27PM URINE Mucous-RARE
___ 10:27PM URINE Hours-RANDOM UreaN-517 Creat-75 Na-127
Cl-79
___ 10:37AM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:37AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 10:37AM URINE RBC-64* WBC-67* Bacteri-FEW Yeast-MANY
Epi-1
___ 10:37AM URINE CastHy-5*
___ 10:37AM URINE Mucous-RARE
=======================
LABS ON DISCHARGE
=======================
___ 05:05AM BLOOD WBC-6.7 RBC-2.73* Hgb-8.3* Hct-25.4*
MCV-93 MCH-30.4 MCHC-32.7 RDW-14.8 RDWSD-48.6* Plt ___
___ 05:05AM BLOOD ___ PTT-55.5* ___
___ 05:05AM BLOOD Glucose-202* UreaN-25* Creat-1.4* Na-142
K-4.2 Cl-108 HCO3-27 AnGap-11
___ 05:05AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9
___ 05:05AM BLOOD tacroFK-8.8
=======================
MICROBIOLOGY
=======================
__________________________________________________________
___ 10:37 am URINE Source: ___.
URINE CULTURE (Pending):
__________________________________________________________
___ 10:27 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
=======================
ENDOSCOPY
=======================
___ EGD
Findings:
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Recommendations: No blood or source of bleeding identified on
EGD.
Will proceed with colonoscopy +/- capsule endoscopy.
___ Colonoscopy
Findings:
Other No blood or source of bleeding seen in the colon and
examined parts of the terminal ileum.
Impression: No blood or source of bleeding seen in the colon and
examined parts of the terminal ileum.
Otherwise normal colonoscopy to terminal ileum at 10cm
Recommendations: Will proceed with capsule endoscopy.
___ Capsule study
Procedure Information and Findings
1. Small ileal angioectasia
2. No active bleeding
=======================
IMAGING
=======================
___ ECG
Sinus rhythm. Lateral ST-T wave abnormalities. Cannot rule out
myocardial
ischemia. Compared to the previous tracing of ___ wave
changes appear to be more pronounced. Clinical correlation is
suggested.
QTc (___) 418/___
___ CXR
Mild cardiomegaly and upper zone redistribution, unchanged.
Minimal bibasilar atelectasis and/or scarring unchanged.
Allowing for this, no acute pulmonary process identified. No
pneumonic
infiltrate or pleural effusion detected.
Brief Hospital Course:
___ year-old woman with APLS on Coumadin for hx of PE,
poorly-controlled T1DM complicated by ESRD status post living
kidney transplant in ___ on MMF, tacrolimus, prednisone, CAD
s/p MI x 2 and DES ___, initially admitted to the MICU with
upper GI bleed.
# GI bleed: most likely upper GI source, perhaps esophageal
given frequent vomiting, esophagitis given immunosuppression, or
gastric ulcers. No evidence of cirrhosis or portal hypertension,
and EGD in ___ was unremarkable. Patient underwent EGD on ___
which was unrevealing for source of bleed. She underwent
colonscopy which was also negative. Capusle study only revealed
small ileal angioectasia but no active bleeding. The patient
remained hemodynamically stable without further epsidodes of
acute bleeding. H/H stable at 8.3/25.4 on discharge. As
described, anticoagulation was started in setting of APLS after
discussion of risks and benefits. Discharge per GI recs on PPI
daily.
#History of PE, APLAS: Home warfarin was held given active GI
bleed. The patient carries this diagnosis in the medical record
and appears to have been diagnosed in the 1990s with unclear
criteria. Her family history is notable for a sister with a
diagnosis of APLS and strong family history of connective tissue
disease. However given concern for anticoagulation in the
setting of GI bleed of unclear source with a supratherapeutic
INR, hematology was consulted. Repeat anti cardiolipin, anti
beta 2 glycoprotein and lupus anticoagulant antibodies were
sent. However despite no clear historical data to prove this
diagnosis, the patient felt strongly that she would like to
remain on anticoagulation. She was started on hep gtt after
colonoscopy without evidence of bleeding. In depth discussion
was held with the patient regarding risks of anticoagulation in
the setting of the GI bleed, as well as the benefits to prevent
possible renal TMA and or DVT/PE from APLS. Ultimately, after
this discussion, the patient elected to be discharged on
warfarin without a bridge, with plans for close outpatient
follow up with hematology and primary care for further
management and follow up of APLS.
# ESRD s/p LRRT complicated by CKD, likely secondary to diabetic
nephropathy: Cr at baseline on admission (1.5), although likely
hypovolemic in setting of GI bleed. Continued on tacrolimus,
MMF, and prednisone for immunosuppression and home calcitriol
for prednisone ppx (home Bactrim was recently discontinued prior
to admission and may be resumed at the discretion of outpatient
providers). Tacrolimus decreased to 1 mg Q12 H from 2 mg on
admission.
#DM1 c/b gastroparesis, neuropathy: last Hgb A1C 9.3%. On home
glargine 36 u QAM/ 22 u QPM and Humalog sliding scale. She was
continued on home promethazine for gastroparesis and home
gabapentin, duloxetine, and lidocaine patches fr diabetic
neuropathy.
# Positive UA: Patient with evidence of pyuria and urinary
frequency though UCx growing urogenital flora. Antibiotics were
held pending repeat urine culture, which will be followed after
discharge by Dr. ___.
# HTN: Initially home anti hypertensives held in setting of GI
Bleed but these were restarted prior to discharge.
# CAD s/p MI with DES ___: Patient continued on home Plavix,
aspirin, atorvastatin and ranolazine.
# PAD: Patient continued on cilostazol.
# Hypothyroidism: Patient continued on home levothyroxine
# Gout: Patient continued on home allopurinol.
TRANSITIONAL ISSUES
========================
[ ] Please ensure transplant labs drawn 1 week post discharge
[ ] Patient to have UCx followed by Dr. ___ as outpatient
[ ] Ensure follow up with hematology for further evaluation and
management of APLS
[ ] Ensure follow up with nephrology as an outpatient
[ ] Continue to monitor closely for evidence of bleeding as
patient on warfarin, aspirin and Plavix
# Communication: HCP: sister ___ ___
# Code: Full confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranolazine ER 500 mg PO BID
2. Allopurinol ___ mg PO DAILY
3. amLODIPine 2.5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Calcitriol 0.25 mcg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Warfarin 2.5 mg PO DAILY16
9. TraZODone 50 mg PO QHS:PRN insomnia
10. Ranitidine 300 mg PO QHS
11. DULoxetine 60 mg PO DAILY
12. Gabapentin 100 mg PO QHS
13. HYDROcodone-Acetaminophen (5mg-325mg) 2 TAB PO Q4H:PRN pain
14. Levothyroxine Sodium 125 mcg PO DAILY
15. Lidocaine 5% Patch 1 PTCH TD QPM hand pain
16. Losartan Potassium 50 mg PO DAILY
17. Mycophenolate Mofetil 500 mg PO BID
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
19. Pramipexole 0.25 mg PO QHS
20. PredniSONE 5 mg PO DAILY
21. Promethazine 25 mg PO Q8H:PRN nausea
22. Cilostazol 100 mg PO QAM
23. Cilostazol 50 mg PO QPM
24. Metoprolol Succinate XL 25 mg PO DAILY
25. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN
eye irritation
26. melatonin 5 mg oral QHS:PRN insomnia
27. Vitamin D 400 UNIT PO DAILY
28. Tacrolimus 2 mg PO Q12H
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 2.5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Calcitriol 0.25 mcg PO DAILY
6. Cilostazol 100 mg PO QAM
7. Cilostazol 50 mg PO QPM
8. Clopidogrel 75 mg PO DAILY
9. DULoxetine 60 mg PO DAILY
10. Gabapentin 100 mg PO QHS
11. Levothyroxine Sodium 125 mcg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QPM hand pain
13. Losartan Potassium 50 mg PO DAILY
14. Metoprolol Succinate XL 25 mg PO DAILY
15. Mycophenolate Mofetil 500 mg PO BID
16. PredniSONE 5 mg PO DAILY
17. Promethazine 25 mg PO Q8H:PRN nausea
18. Ranolazine ER 500 mg PO BID
19. Tacrolimus 1 mg PO Q12H
RX *tacrolimus 1 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
20. TraZODone 50 mg PO QHS:PRN insomnia
21. Vitamin D 400 UNIT PO DAILY
22. Warfarin 2.5 mg PO DAILY16
23. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
24. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN
eye irritation
25. melatonin 5 mg oral QHS:PRN insomnia
26. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
27. Pramipexole 0.25 mg PO QHS
28. Glargine 36 Units Breakfast
Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
GI Bleed
ESRD s/p LRRG c/b CKD
DM1
History of APLS
Secondary diagnoses:
CAD s/p MI
PAD
Hypothyroidism
Gout
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your stay at ___. You
were admitted to the hospital with an upper GI bleed. A workup
including an upper endoscopy, colonoscopy, and capsule study did
not reveal the source of the bleeding. Your bleeding stopped on
its own and your blood counts remained stable.
After a discussion about the risks and benefits of restarting
warfarin, you elected to restart warfarin for your diagnosis of
APLS after you were discharged from the hospital. It is very
important that you follow up closely with a hematologist after
you leave the hospital.
You should weigh yourself every morning, and call your doctor if
your weight goes up by more than 3 pounds.
Your updated medications and outpatient appointments are
included in your discharge paperwork.
We wish you the best!
- Your ___ Care team
Followup Instructions:
___
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] |
Allergies: Penicillins / Ativan Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: EGD [MASKED] Colonoscopy [MASKED] History of Present Illness: [MASKED] year-old woman with antiphospholipid syndrome, history of PE on warfarin, and poorly-controlled T1DM complicated by retinopathy, neuropathy with gastroparesis and neurogenic bladder and ESRD status post living kidney transplant in [MASKED] on MMF, tacrolimus, prednisone, several artery CAD s/p MI in [MASKED] and [MASKED] and 3 drug-eluting stents placed in [MASKED], who presents with several days of melena and hematemesis. She frequently has nausea/vomiting secondary to gastroparesis, but on [MASKED] she began having episodes of dark brown emesis, as well as black tarry stools. On [MASKED] she also began having episodes of bright red hematemesis. She went to a cardiology appointment, and her cardiologist referred her to the ED given this hx and her paleness on exam. She's had no fevers/chills, no odynophagia, no abdominal pain, no chest pain, no SOB. She has had lightheadedness upon standing. She initially presented to [MASKED] [MASKED], where her systolics were in the 70-80's which responded to IVF. Her INR was found to be 6.1, and she was given Kcentra and vitamin K. She did not receive any blood prior to transfer due to difficult crossmatch. By the time she arrived at [MASKED] ED, she was HD stable with INR of 1 and Hgb 5.1. Her last BM was the morning of [MASKED], and her last episode of emesis was in the ED prior to transfer. In the ED: - initial vitals: 97.2 90 119/68 16 100% RA - exam notable for: dark brown stool mixed with bright red blood - labs notable for Hgb 5.1, INR 1 - EKG: sinus @ 94, NA/NI, minimal ST depressions laterally - GI was consulted, who agreed with MICU admission and NPO for EGD - on transfer, vitals were: 98.3 87 124/56 22 100% RA On arrival to the MICU, she feels fatigued but otherwise has no complaints. 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, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: LAD PTCA; s/p PTCA [MASKED], DES to LAD and Cx/OM [MASKED] - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Poorly controlled DM Type 1 complicated by neuropathy, retinopathy, neurogenic bladder (intermittent straight catheterization) - End-stage renal disease [MASKED] diabetes s/p L-sided living kidney transplant in [MASKED] - Scleroderma w/ CREST syndrome - Antiphospholipid antibody syndrome and remote PE history on Coumadin [MASKED] - Gastroparesis/GERD/Hiatal hernia - Gout diagnosed [MASKED] years ago - OSA Social History: [MASKED] Family History: Mother-Multiple myeloma Sister and [MASKED] Sister-RA [MASKED] disease Nephewsx2-Alopecia Daughter [MASKED], celiac disease, MS Physical Exam: Admission physical exam: ============================ GENERAL: appears tired and pale, NAD HEENT: Pale anicteric sclera, dry MM, oropharynx clear NECK: supple, JVP not elevated, no LAD PULM: CTAB CV: RRR, SEM 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 NEURO: grossly intact Discharge physical exam: ============================ T 98.5 HR 99 BP 167/81 RR 18 97 RA General: pleasant middle-aged woman lying in bed in NAD HEENT: NCAT, anicteric sclera, moist mucosa, no JVD appreciated CV: RRR, + systolic murmur Lungs: CTAB, no w/r/r Abdomen: +BS, soft, non-distended, non-tender to palpation, no rebound or guarding Ext: wwp, no edema Neuro: alert and oriented, moving all extremities Pertinent Results: ======================= LABS ON ADMISSION ======================= [MASKED] 08:45PM BLOOD WBC-11.1* RBC-1.64*# Hgb-5.1*# Hct-15.8*# MCV-96 MCH-31.1 MCHC-32.3 RDW-14.4 RDWSD-49.1* Plt [MASKED] [MASKED] 08:45PM BLOOD Neuts-90.9* Lymphs-3.0* Monos-4.9* Eos-0.5* Baso-0.1 Im [MASKED] AbsNeut-10.11*# AbsLymp-0.33* AbsMono-0.55 AbsEos-0.06 AbsBaso-0.01 [MASKED] 08:45PM BLOOD [MASKED] PTT-31.5 [MASKED] [MASKED] 08:45PM BLOOD Glucose-142* UreaN-51* Creat-1.5* Na-139 K-5.2* Cl-109* HCO3-24 AnGap-11 [MASKED] 05:34AM BLOOD ALT-11 AST-11 AlkPhos-67 TotBili-0.3 [MASKED] 08:45PM BLOOD Calcium-8.8 Phos-2.6* Mg-1.9 [MASKED] 07:45AM BLOOD tacroFK-8.3 [MASKED] 08:45PM BLOOD Lactate-0.9 ======================= PERTINENT INTERVAL LABS ======================= [MASKED] 05:00PM BLOOD Lupus-NEG [MASKED] Test Result Reference Range/Units CARDIOLIPIN AB (IGG) <14 GPL Value Interpretation ----- -------------- < or = 14 Negative 15 - 20 Indeterminate 21 - 80 Low to Medium Positive >80 High Positive Test Result Reference Range/Units CARDIOLIPIN AB (IGM) <12 MPL Value Interpretation ----- -------------- < or = 12 Negative 13 - 20 Indeterminate 21 - 80 Low to Medium Positive >80 High Positive [MASKED] 05:00PM BLOOD b2micro-5.3* [MASKED] 05:18AM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)-PND [MASKED] 10:27PM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 10:27PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [MASKED] 10:27PM URINE RBC-0 WBC-44* Bacteri-FEW Yeast-MANY Epi-<1 [MASKED] 10:27PM URINE CastHy-3* [MASKED] 10:27PM URINE Mucous-RARE [MASKED] 10:27PM URINE Hours-RANDOM UreaN-517 Creat-75 Na-127 Cl-79 [MASKED] 10:37AM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 10:37AM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG [MASKED] 10:37AM URINE RBC-64* WBC-67* Bacteri-FEW Yeast-MANY Epi-1 [MASKED] 10:37AM URINE CastHy-5* [MASKED] 10:37AM URINE Mucous-RARE ======================= LABS ON DISCHARGE ======================= [MASKED] 05:05AM BLOOD WBC-6.7 RBC-2.73* Hgb-8.3* Hct-25.4* MCV-93 MCH-30.4 MCHC-32.7 RDW-14.8 RDWSD-48.6* Plt [MASKED] [MASKED] 05:05AM BLOOD [MASKED] PTT-55.5* [MASKED] [MASKED] 05:05AM BLOOD Glucose-202* UreaN-25* Creat-1.4* Na-142 K-4.2 Cl-108 HCO3-27 AnGap-11 [MASKED] 05:05AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9 [MASKED] 05:05AM BLOOD tacroFK-8.8 ======================= MICROBIOLOGY ======================= [MASKED] [MASKED] 10:37 am URINE Source: [MASKED]. URINE CULTURE (Pending): [MASKED] [MASKED] 10:27 pm URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. ======================= ENDOSCOPY ======================= [MASKED] EGD Findings: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Normal duodenum. Recommendations: No blood or source of bleeding identified on EGD. Will proceed with colonoscopy +/- capsule endoscopy. [MASKED] Colonoscopy Findings: Other No blood or source of bleeding seen in the colon and examined parts of the terminal ileum. Impression: No blood or source of bleeding seen in the colon and examined parts of the terminal ileum. Otherwise normal colonoscopy to terminal ileum at 10cm Recommendations: Will proceed with capsule endoscopy. [MASKED] Capsule study Procedure Information and Findings 1. Small ileal angioectasia 2. No active bleeding ======================= IMAGING ======================= [MASKED] ECG Sinus rhythm. Lateral ST-T wave abnormalities. Cannot rule out myocardial ischemia. Compared to the previous tracing of [MASKED] wave changes appear to be more pronounced. Clinical correlation is suggested. QTc ([MASKED]) 418/[MASKED] [MASKED] CXR Mild cardiomegaly and upper zone redistribution, unchanged. Minimal bibasilar atelectasis and/or scarring unchanged. Allowing for this, no acute pulmonary process identified. No pneumonic infiltrate or pleural effusion detected. Brief Hospital Course: [MASKED] year-old woman with APLS on Coumadin for hx of PE, poorly-controlled T1DM complicated by ESRD status post living kidney transplant in [MASKED] on MMF, tacrolimus, prednisone, CAD s/p MI x 2 and DES [MASKED], initially admitted to the MICU with upper GI bleed. # GI bleed: most likely upper GI source, perhaps esophageal given frequent vomiting, esophagitis given immunosuppression, or gastric ulcers. No evidence of cirrhosis or portal hypertension, and EGD in [MASKED] was unremarkable. Patient underwent EGD on [MASKED] which was unrevealing for source of bleed. She underwent colonscopy which was also negative. Capusle study only revealed small ileal angioectasia but no active bleeding. The patient remained hemodynamically stable without further epsidodes of acute bleeding. H/H stable at 8.3/25.4 on discharge. As described, anticoagulation was started in setting of APLS after discussion of risks and benefits. Discharge per GI recs on PPI daily. #History of PE, APLAS: Home warfarin was held given active GI bleed. The patient carries this diagnosis in the medical record and appears to have been diagnosed in the 1990s with unclear criteria. Her family history is notable for a sister with a diagnosis of APLS and strong family history of connective tissue disease. However given concern for anticoagulation in the setting of GI bleed of unclear source with a supratherapeutic INR, hematology was consulted. Repeat anti cardiolipin, anti beta 2 glycoprotein and lupus anticoagulant antibodies were sent. However despite no clear historical data to prove this diagnosis, the patient felt strongly that she would like to remain on anticoagulation. She was started on hep gtt after colonoscopy without evidence of bleeding. In depth discussion was held with the patient regarding risks of anticoagulation in the setting of the GI bleed, as well as the benefits to prevent possible renal TMA and or DVT/PE from APLS. Ultimately, after this discussion, the patient elected to be discharged on warfarin without a bridge, with plans for close outpatient follow up with hematology and primary care for further management and follow up of APLS. # ESRD s/p LRRT complicated by CKD, likely secondary to diabetic nephropathy: Cr at baseline on admission (1.5), although likely hypovolemic in setting of GI bleed. Continued on tacrolimus, MMF, and prednisone for immunosuppression and home calcitriol for prednisone ppx (home Bactrim was recently discontinued prior to admission and may be resumed at the discretion of outpatient providers). Tacrolimus decreased to 1 mg Q12 H from 2 mg on admission. #DM1 c/b gastroparesis, neuropathy: last Hgb A1C 9.3%. On home glargine 36 u QAM/ 22 u QPM and Humalog sliding scale. She was continued on home promethazine for gastroparesis and home gabapentin, duloxetine, and lidocaine patches fr diabetic neuropathy. # Positive UA: Patient with evidence of pyuria and urinary frequency though UCx growing urogenital flora. Antibiotics were held pending repeat urine culture, which will be followed after discharge by Dr. [MASKED]. # HTN: Initially home anti hypertensives held in setting of GI Bleed but these were restarted prior to discharge. # CAD s/p MI with DES [MASKED]: Patient continued on home Plavix, aspirin, atorvastatin and ranolazine. # PAD: Patient continued on cilostazol. # Hypothyroidism: Patient continued on home levothyroxine # Gout: Patient continued on home allopurinol. TRANSITIONAL ISSUES ======================== [ ] Please ensure transplant labs drawn 1 week post discharge [ ] Patient to have UCx followed by Dr. [MASKED] as outpatient [ ] Ensure follow up with hematology for further evaluation and management of APLS [ ] Ensure follow up with nephrology as an outpatient [ ] Continue to monitor closely for evidence of bleeding as patient on warfarin, aspirin and Plavix # Communication: HCP: sister [MASKED] [MASKED] # Code: Full confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ranolazine ER 500 mg PO BID 2. Allopurinol [MASKED] mg PO DAILY 3. amLODIPine 2.5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Calcitriol 0.25 mcg PO DAILY 7. Clopidogrel 75 mg PO DAILY 8. Warfarin 2.5 mg PO DAILY16 9. TraZODone 50 mg PO QHS:PRN insomnia 10. Ranitidine 300 mg PO QHS 11. DULoxetine 60 mg PO DAILY 12. Gabapentin 100 mg PO QHS 13. HYDROcodone-Acetaminophen (5mg-325mg) 2 TAB PO Q4H:PRN pain 14. Levothyroxine Sodium 125 mcg PO DAILY 15. Lidocaine 5% Patch 1 PTCH TD QPM hand pain 16. Losartan Potassium 50 mg PO DAILY 17. Mycophenolate Mofetil 500 mg PO BID 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 19. Pramipexole 0.25 mg PO QHS 20. PredniSONE 5 mg PO DAILY 21. Promethazine 25 mg PO Q8H:PRN nausea 22. Cilostazol 100 mg PO QAM 23. Cilostazol 50 mg PO QPM 24. Metoprolol Succinate XL 25 mg PO DAILY 25. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN eye irritation 26. melatonin 5 mg oral QHS:PRN insomnia 27. Vitamin D 400 UNIT PO DAILY 28. Tacrolimus 2 mg PO Q12H Discharge Medications: 1. Allopurinol [MASKED] mg PO DAILY 2. amLODIPine 2.5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Calcitriol 0.25 mcg PO DAILY 6. Cilostazol 100 mg PO QAM 7. Cilostazol 50 mg PO QPM 8. Clopidogrel 75 mg PO DAILY 9. DULoxetine 60 mg PO DAILY 10. Gabapentin 100 mg PO QHS 11. Levothyroxine Sodium 125 mcg PO DAILY 12. Lidocaine 5% Patch 1 PTCH TD QPM hand pain 13. Losartan Potassium 50 mg PO DAILY 14. Metoprolol Succinate XL 25 mg PO DAILY 15. Mycophenolate Mofetil 500 mg PO BID 16. PredniSONE 5 mg PO DAILY 17. Promethazine 25 mg PO Q8H:PRN nausea 18. Ranolazine ER 500 mg PO BID 19. Tacrolimus 1 mg PO Q12H RX *tacrolimus 1 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 20. TraZODone 50 mg PO QHS:PRN insomnia 21. Vitamin D 400 UNIT PO DAILY 22. Warfarin 2.5 mg PO DAILY16 23. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 24. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN eye irritation 25. melatonin 5 mg oral QHS:PRN insomnia 26. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 27. Pramipexole 0.25 mg PO QHS 28. Glargine 36 Units Breakfast Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: GI Bleed ESRD s/p LRRG c/b CKD DM1 History of APLS Secondary diagnoses: CAD s/p MI PAD Hypothyroidism Gout HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure caring for you during your stay at [MASKED]. You were admitted to the hospital with an upper GI bleed. A workup including an upper endoscopy, colonoscopy, and capsule study did not reveal the source of the bleeding. Your bleeding stopped on its own and your blood counts remained stable. After a discussion about the risks and benefits of restarting warfarin, you elected to restart warfarin for your diagnosis of APLS after you were discharged from the hospital. It is very important that you follow up closely with a hematologist after you leave the hospital. You should weigh yourself every morning, and call your doctor if your weight goes up by more than 3 pounds. Your updated medications and outpatient appointments are included in your discharge paperwork. We wish you the best! - Your [MASKED] Care team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"D62",
"I2510",
"Z7901",
"I252",
"Z955",
"E785",
"G4733",
"M109",
"K219",
"Z87891",
"Y929",
"N189",
"I129",
"E039",
"Z7902"
] |
[
"K920: Hematemesis",
"D6861: Antiphospholipid syndrome",
"T8619: Other complication of kidney transplant",
"N179: Acute kidney failure, unspecified",
"E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified",
"K3184: Gastroparesis",
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"D62: Acute posthemorrhagic anemia",
"Z86711: Personal history of pulmonary embolism",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z7901: Long term (current) use of anticoagulants",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"N319: Neuromuscular dysfunction of bladder, unspecified",
"I252: Old myocardial infarction",
"Z955: Presence of coronary angioplasty implant and graft",
"E785: Hyperlipidemia, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"M109: Gout, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"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",
"N189: Chronic kidney disease, unspecified",
"K921: Melena",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"R8299: Other abnormal findings in urine",
"E039: Hypothyroidism, unspecified",
"I739: Peripheral vascular disease, unspecified",
"Z7902: Long term (current) use of antithrombotics/antiplatelets"
] |
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