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10,088,776	26,138,210	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Plaquenil / methotrexate Attending: ___. Chief Complaint: Persistent refilling of Left ICA aneurysm. Major Surgical or Invasive Procedure: ___ - Pipeline embolization of Left ICA aneurysm. History of Present Illness: ___ is a ___ y/o female known to the neurosurgery service who is s/p pipeline embolization of the left ICA aneurysm on ___. She tolerated the procedure well and was discharged to home. She has been followed by the Neurosurgery service and serial imaging studies revealed persistent filling of the left ICA aneurysm. It was determined she would undergo a second embolization and pipeline of the left ICA aneurysm. The risks and benefits of surgical intervention were discussed and the patient consented to the procedure. Past Medical History: Depression Arthritis Hypertension Hyperlipidemia Lumbar stenosis Social History: ___ Family History: No aneurysms in family -Mother: DM, PNA, passed at ___ -Father: passed at ___ -Brother: ___, stroke, diabetes Physical Exam: PHYSICAL EXAMINATION ON DISCHARGE: Intact AOx3, fluent speech CNII-XII intact ___ strength x4 extremities, no drift Sensation intact Groin mild ecchymosis. no hematoma. Dressing in place Pertinent Results: ___ - CAROTID/CEREBRAL COIL/STENT: IMPRESSION: Successful deployment of the second pipeline device proximal to the PCOM and into the old stent to the petrous segment of the internal carotid. Brief Hospital Course: #Left ICA Aneurysm: The patient was taken to the angio suite on the day of admission, ___ and underwent a pipeline embolization of the Left ICA aneurysm for persistent filling under general anesthesia. She tolerated the procedure well and was extubated in the angio suite. She was transferred to the PACU for recovery and later to the ___ for close monitoring. She remained neurologically intact throughout her hospital stay and at the time of discharge she was tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BuPROPion (Sustained Release) 300 mg PO QAM 2. FoLIC Acid 1 mg PO DAILY 3. leflunomide 20 mg oral QHS 4. Lisinopril 10 mg PO DAILY 5. Methotrexate 2.5 mg PO Frequency is Unknown 6. Ranitidine 150 mg PO DAILY 7. Simvastatin 20 mg PO QPM 8. TiCAGRELOR 90 mg PO BID 9. Venlafaxine XR 150 mg PO DAILY 10. Aspirin 325 mg PO DAILY 11. Calcium Carbonate 1250 mg PO BID Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain do not exceed 4grams (4000mg) of acetaminophen daily 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Senna 17.2 mg PO QHS 5. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 6. Methotrexate 17.5 mg PO 1X/WEEK (___) resume home dosing 7. BuPROPion (Sustained Release) 300 mg PO QAM 8. Calcium Carbonate 1250 mg PO BID 9. FoLIC Acid 1 mg PO DAILY 10. leflunomide 20 mg oral QHS 11. Lisinopril 10 mg PO DAILY 12. Ranitidine 150 mg PO DAILY 13. Simvastatin 20 mg PO QPM 14. TiCAGRELOR 90 mg PO BID RX ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:3 15. Venlafaxine XR 150 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Left ICA Aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Dr. ___ Embolization 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. It is very important to take the medication your doctor ___ prescribe for you to keep your blood thin and slippery. This will prevent clots from developing and sticking to the stent. 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. The medication may make you bleed or bruise easily. 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 Followup Instructions: ___	[ "I671", "I10", "F329", "F17210", "E7800", "Z7902" ]	Allergies: Plaquenil / methotrexate Chief Complaint: Persistent refilling of Left ICA aneurysm. Major Surgical or Invasive Procedure: [MASKED] - Pipeline embolization of Left ICA aneurysm. History of Present Illness: [MASKED] is a [MASKED] y/o female known to the neurosurgery service who is s/p pipeline embolization of the left ICA aneurysm on [MASKED]. She tolerated the procedure well and was discharged to home. She has been followed by the Neurosurgery service and serial imaging studies revealed persistent filling of the left ICA aneurysm. It was determined she would undergo a second embolization and pipeline of the left ICA aneurysm. The risks and benefits of surgical intervention were discussed and the patient consented to the procedure. Past Medical History: Depression Arthritis Hypertension Hyperlipidemia Lumbar stenosis Social History: [MASKED] Family History: No aneurysms in family -Mother: DM, PNA, passed at [MASKED] -Father: passed at [MASKED] -Brother: [MASKED], stroke, diabetes Physical Exam: PHYSICAL EXAMINATION ON DISCHARGE: Intact AOx3, fluent speech CNII-XII intact [MASKED] strength x4 extremities, no drift Sensation intact Groin mild ecchymosis. no hematoma. Dressing in place Pertinent Results: [MASKED] - CAROTID/CEREBRAL COIL/STENT: IMPRESSION: Successful deployment of the second pipeline device proximal to the PCOM and into the old stent to the petrous segment of the internal carotid. Brief Hospital Course: #Left ICA Aneurysm: The patient was taken to the angio suite on the day of admission, [MASKED] and underwent a pipeline embolization of the Left ICA aneurysm for persistent filling under general anesthesia. She tolerated the procedure well and was extubated in the angio suite. She was transferred to the PACU for recovery and later to the [MASKED] for close monitoring. She remained neurologically intact throughout her hospital stay and at the time of discharge she was tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BuPROPion (Sustained Release) 300 mg PO QAM 2. FoLIC Acid 1 mg PO DAILY 3. leflunomide 20 mg oral QHS 4. Lisinopril 10 mg PO DAILY 5. Methotrexate 2.5 mg PO Frequency is Unknown 6. Ranitidine 150 mg PO DAILY 7. Simvastatin 20 mg PO QPM 8. TiCAGRELOR 90 mg PO BID 9. Venlafaxine XR 150 mg PO DAILY 10. Aspirin 325 mg PO DAILY 11. Calcium Carbonate 1250 mg PO BID Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain do not exceed 4grams (4000mg) of acetaminophen daily 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Senna 17.2 mg PO QHS 5. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 6. Methotrexate 17.5 mg PO 1X/WEEK ([MASKED]) resume home dosing 7. BuPROPion (Sustained Release) 300 mg PO QAM 8. Calcium Carbonate 1250 mg PO BID 9. FoLIC Acid 1 mg PO DAILY 10. leflunomide 20 mg oral QHS 11. Lisinopril 10 mg PO DAILY 12. Ranitidine 150 mg PO DAILY 13. Simvastatin 20 mg PO QPM 14. TiCAGRELOR 90 mg PO BID RX ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:3 15. Venlafaxine XR 150 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Left ICA Aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Dr. [MASKED] Embolization 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. It is very important to take the medication your doctor [MASKED] prescribe for you to keep your blood thin and slippery. This will prevent clots from developing and sticking to the stent. 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. The medication may make you bleed or bruise easily. 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 Followup Instructions: [MASKED]	[]	[ "I10", "F329", "F17210", "Z7902" ]	[ "I671: Cerebral aneurysm, nonruptured", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "E7800: Pure hypercholesterolemia, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
10,088,776	27,242,516	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: arthritis medication / Plaquenil Attending: ___. Chief Complaint: paraclinoid internal carotid aneurysm Major Surgical or Invasive Procedure: ___: pipeline embolization of left ICA aneurysm History of Present Illness: ___ is a ___ woman found to have intracranial ICA aneurysm on work up of foot weakness. Her scan was reviewed at neurovascular conference at the ___ Brain Aneurysm Institute. The lesion on the one side is approximately 7 mm in diameter. To help delineate if it was indeed intracranial, she underwent a high-resolution three-dimensional CT angiogram. The films were reviewed, showing a 5-6 mm paraclinoid aneurysm. Dr. ___ natural history and treatment options with patient, and recommended treatment with a flow diverting device. Recently study demonstrated that these were approximately 92 to 93% efficacious at one year with the risk factor on the order of 2.5 to 3%. This was reviewed with her and decision was made to proceed with treatment. Past Medical History: Depression Arthritis HTN hyperlipidemia Lumbar stenosis Social History: ___ Family History: No aneurysms in family -Mother: DM, PNA, passed at ___ -Father: passed at ___ -Brother: ___, stroke, diabetes Physical Exam: Alert, oriented x3. Pupils equal round reactive to light. EOM intact. Face symmetric. Tongue midline. Strength ___ throughout. Sensation intact to light touch. No pronator drift. Right thigh with ecchymosis, soft, no area of firmness, +distal pulses with Doppler Pertinent Results: CAROTID/CEREBRAL COIL/STENT Study Date of ___ 7:51 AM IMPRESSION: Successful Pipeline embolization of left paraclinoid, carotid cave internal carotid artery aneurysm. No thromboembolic complications. Brief Hospital Course: Patient was electively brought to the angio suite on ___ for pipeline embolization of left paraclinoid ICA aneurysm with Dr. ___. She underwent an uncomplicated procedure. Please see operative report for further details. She was successfully angiosealed. She was changed from Aspirin325/Plavix to Aspirin 81 mg and Brilinta 90mg bid given resistant to Plavix. Postoperatively she was noted to have right thigh hematoma. Pressure was held, and hematoma remained soft, and she had intact sensation and distal pulses with doppler. Neurologic exam remained stable. SBP maintained <180. She was discharged home in stable condition on POD#1. At time of discharge, she was tolerating PO diet, ambulating, and pain was well controlled on oral medications. She will continue Aspirin indefinitely and Brilinta for 3 months. Medications on Admission: - Aspirin 325 mg PO DAILY - clopidogrel 75 mg tablet - BuPROPion (Sustained Release) 300 mg PO QAM - Calcium Carbonate 1500 mg PO BID - Chantix (varenicline) 0.5 mg oral BID - FoLIC Acid 1 mg PO DAILY - leflunomide 20 mg oral QHS - Lisinopril 10 mg PO DAILY - Ranitidine 150 mg PO QHS - Simvastatin 20 mg PO QPM - Venlafaxine XR 150 mg PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:12 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #8 Tablet Refills:0 5. Senna 17.2 mg PO QHS 6. TiCAGRELOR 90 mg PO BID RX ticagrelor [Brilinta] 90 mg 1 tablet by mouth every 12 hours Disp #60 Tablet Refills:*2 7. BuPROPion (Sustained Release) 300 mg PO QAM 8. Calcium Carbonate 1500 mg PO BID 9. Chantix (varenicline) 0.5 mg oral BID 10. FoLIC Acid 1 mg PO DAILY 11. leflunomide 20 mg oral QHS 12. Lisinopril 10 mg PO DAILY 13. Ranitidine 150 mg PO QHS 14. Simvastatin 20 mg PO QPM 15. Venlafaxine XR 150 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: left ICA 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 are instructed by your doctor to take Aspirin and Brilinta daily. Do not take any other products that have aspirin in them. If you are unsure of what products contain Aspirin, as your pharmacist or call our office. · It is very important to take the medication your doctor ___ prescribe for you to keep your blood thin and slippery. This will prevent clots from developing and sticking to the stent. · 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. · The medication may make you bleed or bruise easily. · 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 Followup Instructions: ___	[ "I671", "J449", "I10", "F329", "M1990", "E785", "M4806", "K219", "Z720", "Z7902" ]	Allergies: arthritis medication / Plaquenil Chief Complaint: paraclinoid internal carotid aneurysm Major Surgical or Invasive Procedure: [MASKED]: pipeline embolization of left ICA aneurysm History of Present Illness: [MASKED] is a [MASKED] woman found to have intracranial ICA aneurysm on work up of foot weakness. Her scan was reviewed at neurovascular conference at the [MASKED] Brain Aneurysm Institute. The lesion on the one side is approximately 7 mm in diameter. To help delineate if it was indeed intracranial, she underwent a high-resolution three-dimensional CT angiogram. The films were reviewed, showing a 5-6 mm paraclinoid aneurysm. Dr. [MASKED] natural history and treatment options with patient, and recommended treatment with a flow diverting device. Recently study demonstrated that these were approximately 92 to 93% efficacious at one year with the risk factor on the order of 2.5 to 3%. This was reviewed with her and decision was made to proceed with treatment. Past Medical History: Depression Arthritis HTN hyperlipidemia Lumbar stenosis Social History: [MASKED] Family History: No aneurysms in family -Mother: DM, PNA, passed at [MASKED] -Father: passed at [MASKED] -Brother: [MASKED], stroke, diabetes Physical Exam: Alert, oriented x3. Pupils equal round reactive to light. EOM intact. Face symmetric. Tongue midline. Strength [MASKED] throughout. Sensation intact to light touch. No pronator drift. Right thigh with ecchymosis, soft, no area of firmness, +distal pulses with Doppler Pertinent Results: CAROTID/CEREBRAL COIL/STENT Study Date of [MASKED] 7:51 AM IMPRESSION: Successful Pipeline embolization of left paraclinoid, carotid cave internal carotid artery aneurysm. No thromboembolic complications. Brief Hospital Course: Patient was electively brought to the angio suite on [MASKED] for pipeline embolization of left paraclinoid ICA aneurysm with Dr. [MASKED]. She underwent an uncomplicated procedure. Please see operative report for further details. She was successfully angiosealed. She was changed from Aspirin325/Plavix to Aspirin 81 mg and Brilinta 90mg bid given resistant to Plavix. Postoperatively she was noted to have right thigh hematoma. Pressure was held, and hematoma remained soft, and she had intact sensation and distal pulses with doppler. Neurologic exam remained stable. SBP maintained <180. She was discharged home in stable condition on POD#1. At time of discharge, she was tolerating PO diet, ambulating, and pain was well controlled on oral medications. She will continue Aspirin indefinitely and Brilinta for 3 months. Medications on Admission: - Aspirin 325 mg PO DAILY - clopidogrel 75 mg tablet - BuPROPion (Sustained Release) 300 mg PO QAM - Calcium Carbonate 1500 mg PO BID - Chantix (varenicline) 0.5 mg oral BID - FoLIC Acid 1 mg PO DAILY - leflunomide 20 mg oral QHS - Lisinopril 10 mg PO DAILY - Ranitidine 150 mg PO QHS - Simvastatin 20 mg PO QPM - Venlafaxine XR 150 mg PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:12 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #8 Tablet Refills:0 5. Senna 17.2 mg PO QHS 6. TiCAGRELOR 90 mg PO BID RX ticagrelor [Brilinta] 90 mg 1 tablet by mouth every 12 hours Disp #60 Tablet Refills:*2 7. BuPROPion (Sustained Release) 300 mg PO QAM 8. Calcium Carbonate 1500 mg PO BID 9. Chantix (varenicline) 0.5 mg oral BID 10. FoLIC Acid 1 mg PO DAILY 11. leflunomide 20 mg oral QHS 12. Lisinopril 10 mg PO DAILY 13. Ranitidine 150 mg PO QHS 14. Simvastatin 20 mg PO QPM 15. Venlafaxine XR 150 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: left ICA 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 are instructed by your doctor to take Aspirin and Brilinta daily. Do not take any other products that have aspirin in them. If you are unsure of what products contain Aspirin, as your pharmacist or call our office. · It is very important to take the medication your doctor [MASKED] prescribe for you to keep your blood thin and slippery. This will prevent clots from developing and sticking to the stent. · 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. · The medication may make you bleed or bruise easily. · 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 Followup Instructions: [MASKED]	[]	[ "J449", "I10", "F329", "E785", "K219", "Z7902" ]	[ "I671: Cerebral aneurysm, nonruptured", "J449: Chronic obstructive pulmonary disease, unspecified", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "E785: Hyperlipidemia, unspecified", "M4806: Spinal stenosis, lumbar region", "K219: Gastro-esophageal reflux disease without esophagitis", "Z720: Tobacco use", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
10,088,914	22,311,401	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain/ palpitations/ dyspnea Major Surgical or Invasive Procedure: Coronary artery bypass grafting x3, left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch and the posterior descending artery. History of Present Illness: Mr. ___ is an ___ year old man with a history of chronic obstructive pulmonary disease, chronic renal insufficiency, hyperlipidemia, and hypertension. He has noted episodes of chest pain, dyspnea on exertion, and palpitations. He was recently admitted to ___ for palpitations and was found to be in rapid atrial fibrillation that spontaneously converted. He then had some paroxysmal rapid atrial flutter. Troponins were mildly elevated. An echocardiogram revealed an ejection fraction of 45%. He was transferred to ___ for cardiac catheterization which demonstrated multivessel coronary artery disease. He was referred to Dr. ___ surgical revascularization in ___ and now presents for preadmission testing for surgery ___. Past Medical History: Past Medical History: Arthritis - right knee with limited mobility Atrial fibrillation/flutter Bullous Pemphigoid ___ year ago Cardiomyopathy Carotid Artery Stenosis Chronic Obstructive Pulmonary Disease Chronic Renal Insufficiency (baseline Cre 1.5) Glaucoma Hyperlipidemia Hypertension Legally Blind Psoriasis Past Surgical History Cholecystectomy Hernia Repair Knee replacement, left Social History: ___ Family History: Paternal uncles and aunts with strokes in their ___. Physical Exam: Vital Signs sheet entries see pat record Height: 70" Weight: 178 lbs General: Elderly gentleman, NAD Skin: Warm, dry, with multiple excoriations and erythematous patches over legs, chest, feet from prior psoriasis HEENT: NCAT, OP benign Neck: Supple, full ROM Chest: Lungs clear bilaterally Heart: Regular rate and rhythm, no murmur appreciated Abdomen: Normal BS, soft, non-tender, non-distended Extremities: Warm, well-perfused, trace bilateral edema Varicosities: None Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ ___ Right: 1+ Left: 1+ Radial Right: 1+ Left: 1+ Carotid Bruit: none Pertinent Results: ___ TEE PRE-BYPASS: The left atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated, Sinus of Valsava is 4cm in diameter.. The descending thoracic aorta is mildly dilated. There are visible simple atheroma along the descending aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. ___ was notified in person of the results on ___ prior to incision POST BYPASS: Poor image quality due to pneumomediastinum, epi gtt and phenylephrine gtt No new wall motion abnormalities EF% 55 Aorta intact post decannulation, small pericardial effusion noted, LC notified. Exam otherwise unchanged ___ 05:27AM BLOOD WBC-15.5* RBC-3.35* Hgb-10.1* Hct-32.0* MCV-96 MCH-30.1 MCHC-31.6* RDW-14.6 RDWSD-51.2* Plt ___ ___ 05:27AM BLOOD ___ PTT-30.8 ___ ___ 05:27AM BLOOD Glucose-84 UreaN-56* Creat-2.2* Na-138 K-3.7 Cl-100 HCO3-25 AnGap-17 ___ ___ M ___ ___ Radiology Report CHEST (PA & LAT) Study Date of ___ 2:36 ___ ___ FA8 ___ 2:36 ___ CHEST (PA & LAT) Clip # ___ Reason: eval for pleural effusions Final Report EXAMINATION: Chest radiograph. INDICATION: ___ year old man post CABG, evaluate for pleural effusions. TECHNIQUE: AP and lateral. COMPARISON: Chest radiograph ___. FINDINGS: Compared to prior, a small left greater than right pleural effusions have decreased. Mild cardiomegaly is unchanged. There is mild vascular congestion but no overt pulmonary edema. Mediastinal clips are present. Median sternotomy wires are intact. There is increased density involving the anterior mediastinum seen only on lateral view, new from ___, but unchanged from ___. IMPRESSION: 1. Small bilateral pleural effusions, decreased from ___. 2. Increased anterior mediastinal density seen on lateral view only, unchanged from ___, likely artifactual. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on ___ where the patient underwent CABGx3 (LIMA-LAD, SVG->OM, PDA). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. He went in and out of afibrillation and was treated with amiodorone and he was anticoagulated with Coumadin. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. He remained in the ICU because of shortness of breath and fluid overload. The patient was evaluated by the physical therapy service for assistance with strength and mobility. The pt. developed a UTI and was treated with Cipro. By the time of discharge on POD 13 the patient was ambulating with assistance, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to ___ unit in good condition with appropriate follow up instructions. Medications on Admission: Aspirin 325 mg tablet once a day Atorvastatin 40 mg tablet, 2 tablets daily Brimonidine Clobetasol Propionate powder apply to legs as needed Flomax 0.4 mg tablet once a day Hydroxyzine HCl 10 mg tablet Q8H Lopressor 50 mg tablet twice a day Xalantan 1 drop L eye Q HS Omega 3 daily Saw ___ daily Resperitol 50 mg QHS Co-Q 10 daily Vit D daily MVI daily Biotin daily Melatonin 5 mg QHS Vitamin C 400 IU daily Vit B12 1000 mg QHS Potassium Gluconate 595 mg Q week Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea 3. Amiodarone 400 mg PO TID 4. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN sore throat 5. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Doses 6. Docusate Sodium 100 mg PO BID 7. Furosemide 40 mg PO BID Duration: 10 Days 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Metoprolol Tartrate 25 mg PO BID 10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain: moderate/severe RX oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours Disp #50 Tablet Refills:0 11. Potassium Chloride 20 mEq PO BID Duration: 10 Days 12. Sarna Lotion 1 Appl TP QID:PRN itching 13. Tamsulosin 0.4 mg PO QHS 14. Aspirin EC 81 mg PO DAILY 15. Atorvastatin 80 mg PO QPM 16. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES 9AM AND 9PM 17. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES 9AM AND 9PM 18. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS 19. melatonin 5 mg oral DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Coronary Artery Disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours* Followup Instructions: ___	[ "I2510", "N179", "I429", "I4892", "N390", "D62", "I9789", "I6529", "E8770", "J449", "I129", "N189", "H409", "E785", "H548", "Z96652", "Z87891", "L409", "J029", "K5900", "R339", "I252", "Y832", "Y92230", "I480" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest pain/ palpitations/ dyspnea Major Surgical or Invasive Procedure: Coronary artery bypass grafting x3, left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch and the posterior descending artery. History of Present Illness: Mr. [MASKED] is an [MASKED] year old man with a history of chronic obstructive pulmonary disease, chronic renal insufficiency, hyperlipidemia, and hypertension. He has noted episodes of chest pain, dyspnea on exertion, and palpitations. He was recently admitted to [MASKED] for palpitations and was found to be in rapid atrial fibrillation that spontaneously converted. He then had some paroxysmal rapid atrial flutter. Troponins were mildly elevated. An echocardiogram revealed an ejection fraction of 45%. He was transferred to [MASKED] for cardiac catheterization which demonstrated multivessel coronary artery disease. He was referred to Dr. [MASKED] surgical revascularization in [MASKED] and now presents for preadmission testing for surgery [MASKED]. Past Medical History: Past Medical History: Arthritis - right knee with limited mobility Atrial fibrillation/flutter Bullous Pemphigoid [MASKED] year ago Cardiomyopathy Carotid Artery Stenosis Chronic Obstructive Pulmonary Disease Chronic Renal Insufficiency (baseline Cre 1.5) Glaucoma Hyperlipidemia Hypertension Legally Blind Psoriasis Past Surgical History Cholecystectomy Hernia Repair Knee replacement, left Social History: [MASKED] Family History: Paternal uncles and aunts with strokes in their [MASKED]. Physical Exam: Vital Signs sheet entries see pat record Height: 70" Weight: 178 lbs General: Elderly gentleman, NAD Skin: Warm, dry, with multiple excoriations and erythematous patches over legs, chest, feet from prior psoriasis HEENT: NCAT, OP benign Neck: Supple, full ROM Chest: Lungs clear bilaterally Heart: Regular rate and rhythm, no murmur appreciated Abdomen: Normal BS, soft, non-tender, non-distended Extremities: Warm, well-perfused, trace bilateral edema Varicosities: None Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ [MASKED] Right: 1+ Left: 1+ Radial Right: 1+ Left: 1+ Carotid Bruit: none Pertinent Results: [MASKED] TEE PRE-BYPASS: The left atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated, Sinus of Valsava is 4cm in diameter.. The descending thoracic aorta is mildly dilated. There are visible simple atheroma along the descending aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [MASKED] was notified in person of the results on [MASKED] prior to incision POST BYPASS: Poor image quality due to pneumomediastinum, epi gtt and phenylephrine gtt No new wall motion abnormalities EF% 55 Aorta intact post decannulation, small pericardial effusion noted, LC notified. Exam otherwise unchanged [MASKED] 05:27AM BLOOD WBC-15.5* RBC-3.35* Hgb-10.1* Hct-32.0* MCV-96 MCH-30.1 MCHC-31.6* RDW-14.6 RDWSD-51.2* Plt [MASKED] [MASKED] 05:27AM BLOOD [MASKED] PTT-30.8 [MASKED] [MASKED] 05:27AM BLOOD Glucose-84 UreaN-56* Creat-2.2* Na-138 K-3.7 Cl-100 HCO3-25 AnGap-17 [MASKED] [MASKED] M [MASKED] [MASKED] Radiology Report CHEST (PA & LAT) Study Date of [MASKED] 2:36 [MASKED] [MASKED] FA8 [MASKED] 2:36 [MASKED] CHEST (PA & LAT) Clip # [MASKED] Reason: eval for pleural effusions Final Report EXAMINATION: Chest radiograph. INDICATION: [MASKED] year old man post CABG, evaluate for pleural effusions. TECHNIQUE: AP and lateral. COMPARISON: Chest radiograph [MASKED]. FINDINGS: Compared to prior, a small left greater than right pleural effusions have decreased. Mild cardiomegaly is unchanged. There is mild vascular congestion but no overt pulmonary edema. Mediastinal clips are present. Median sternotomy wires are intact. There is increased density involving the anterior mediastinum seen only on lateral view, new from [MASKED], but unchanged from [MASKED]. IMPRESSION: 1. Small bilateral pleural effusions, decreased from [MASKED]. 2. Increased anterior mediastinal density seen on lateral view only, unchanged from [MASKED], likely artifactual. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [MASKED] where the patient underwent CABGx3 (LIMA-LAD, SVG->OM, PDA). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. He went in and out of afibrillation and was treated with amiodorone and he was anticoagulated with Coumadin. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. He remained in the ICU because of shortness of breath and fluid overload. The patient was evaluated by the physical therapy service for assistance with strength and mobility. The pt. developed a UTI and was treated with Cipro. By the time of discharge on POD 13 the patient was ambulating with assistance, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [MASKED] unit in good condition with appropriate follow up instructions. Medications on Admission: Aspirin 325 mg tablet once a day Atorvastatin 40 mg tablet, 2 tablets daily Brimonidine Clobetasol Propionate powder apply to legs as needed Flomax 0.4 mg tablet once a day Hydroxyzine HCl 10 mg tablet Q8H Lopressor 50 mg tablet twice a day Xalantan 1 drop L eye Q HS Omega 3 daily Saw [MASKED] daily Resperitol 50 mg QHS Co-Q 10 daily Vit D daily MVI daily Biotin daily Melatonin 5 mg QHS Vitamin C 400 IU daily Vit B12 1000 mg QHS Potassium Gluconate 595 mg Q week Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea 3. Amiodarone 400 mg PO TID 4. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN sore throat 5. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Doses 6. Docusate Sodium 100 mg PO BID 7. Furosemide 40 mg PO BID Duration: 10 Days 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Metoprolol Tartrate 25 mg PO BID 10. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain: moderate/severe RX oxycodone 5 mg [MASKED] tablet(s) by mouth every six (6) hours Disp #50 Tablet Refills:0 11. Potassium Chloride 20 mEq PO BID Duration: 10 Days 12. Sarna Lotion 1 Appl TP QID:PRN itching 13. Tamsulosin 0.4 mg PO QHS 14. Aspirin EC 81 mg PO DAILY 15. Atorvastatin 80 mg PO QPM 16. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES 9AM AND 9PM 17. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES 9AM AND 9PM 18. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS 19. melatonin 5 mg oral DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Coronary Artery Disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [MASKED] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours* Followup Instructions: [MASKED]	[]	[ "I2510", "N179", "N390", "D62", "J449", "I129", "N189", "E785", "Z87891", "K5900", "I252", "Y92230", "I480" ]	[ "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "N179: Acute kidney failure, unspecified", "I429: Cardiomyopathy, unspecified", "I4892: Unspecified atrial flutter", "N390: Urinary tract infection, site not specified", "D62: Acute posthemorrhagic anemia", "I9789: Other postprocedural complications and disorders of the circulatory system, not elsewhere classified", "I6529: Occlusion and stenosis of unspecified carotid artery", "E8770: Fluid overload, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "H409: Unspecified glaucoma", "E785: Hyperlipidemia, unspecified", "H548: Legal blindness, as defined in USA", "Z96652: Presence of left artificial knee joint", "Z87891: Personal history of nicotine dependence", "L409: Psoriasis, unspecified", "J029: Acute pharyngitis, unspecified", "K5900: Constipation, unspecified", "R339: Retention of urine, unspecified", "I252: Old myocardial infarction", "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", "I480: Paroxysmal atrial fibrillation" ]
10,088,966	23,861,822	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Enalapril / Diovan / morphine Attending: ___. Chief Complaint: fall Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ year old with history of mitral valve repair and CABG (LIMA to LAD, SVG to OM on ___, atrial flutter/fibrillation on warfarin, Hodgkin's and DLBCL s/p chemo currently in remission, HTN, lymphedema and GERD who presents after a fall. History is significant for a chronic gait disorder where he is cane dependent. Per oncologist, he likely has some sensory ataxia as a side effect of prior chemotherapy. He has had prior spine MRI with no evidence of myelopathy. He has had multiple falls in the last year, including one admission to ___ in ___ for orthostatic syncope. His beta blocker dose and diuretic have been on hold recently. He has been working with home ___ to improve mobility. Per ED report, he was using walker at home and went to use the restroom. When trying to go back to bed he slipped and fell and wife heard the fall. Wife reports no ___ and he denied ___ or LOC. Wife could not help him up and called ___. He denied lightheadedness, chest pain, palpitaitons, and nausea prior to the fall. Reported he does not have pain, numbness, weakness in his arms or legs. Of note, he has a hx of hyponatremia (Na 130-132) in the past, that has improved in the fluids. In the ED, initial VS were: 97.5 84 142/84 19 99% RA FAST negative On exam, bruising all over body, L upper arm, R buttock/hip, abdomen and chest Na 126 --> 125 INR 2.3 UA negative Imaging showed: CXR: Pulmonary edema. Likely left lower lobe atelectasis, though consolidation may have a similar appearance 1. No acute intra-thoracic, abdominal or intrapelvic abnormalities. 2. Evidence of prior fracture with interval healing of the left first rib, right eleventh rib. Stable compression deformity of L1 and L2 since ___. 3. Atheromatous disease of the abdominal aorta with new ulcerated plaque at the level of the ___. CT spine No acute fracture or traumatic malalignment. CT head No acute intracranial abnormalities. EKG showed: flutter with 4:1 block, RBBB, right atrial abnormality Patient was given: ___ 15:46 IVF NS ___ Started ___ 17:02 PO Acetaminophen 1000 mg ___ ___ 17:47 IH Albuterol 0.083% Neb Soln 1 NEB ___ ___ 17:47 IH Ipratropium Bromide Neb 1 NEB ___ ___ 17:47 IVF D5W ___ Started ___ 19:22 PO/NG Acyclovir 400 mg ___ ___ 19:22 PO/NG Warfarin 4 mg ___ pt not safe at home, admit for hyponatremia, weakness Transfer VS were: 98.3 73 105/58 16 97% RA When seen on the floor, he is unable to recall the events of the past 24 hours of the last 24 hours. He is oriented to self and time but not place. REVIEW OF SYSTEMS: A ten point ROS was conducted and was negative except as above in the HPI. Past Medical History: PAST ONCOLOGY HISTORY: 1. Hodgkin's disease, 8 cycles ___ MOPP, chlorambucil, vinblastine, procarbazine, predisone. - recurrent disease several months later. Treated with 2 cycles gemcitabine, navelbine, liposomal doxo. - A second complete remission after these two cycles followed by one additional cycle. Remainder of the therapy was discontinued due to excess toxicity. - Gemcitabine and Navelbine for improvement of his symptoms. - Brentuximab at ___. 2. Subsequently diffuse large B-cell lymphoma treated with six cycles of R-CHOP completed in ___. Now in remission PAST MEDICAL HISTORY: - Mitral regurgitation s/p MV repair (P2 triangular resection and 32 - mm ___ II annuloplasty ring - ___ - CAD s/p 2v CABG (LIMA to LAD, SVG to OM - ___ - A-flutter/A-fib on warfarin - HTN - GERD - s/p b/l hernia repair - Hodgkin disease - Diffuse large B cell Lymphoma - Hypogammaglobulinemia ALLERGIES: ASA, enalapril, diovan, morphine Social History: ___ Family History: Maternal aunt had some type of cancer either uterine or colon in her ___ or ___. Maternal grandfather developed prostate cancer at ___ and died at ___. Father had brain hemorrhage. Mother died at ___. Physical Exam: Admission PE Gen: NAD, A&O x1, lying in bed Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA ___. GI: soft, NT, ND, BS+ MSK: 3+ edema at ankles, baseline lymphedema Skin: Multiple bruises on upper and lower extremities. No jaundice. Neuro: AAOx1. No facial droop. Discharge PE: 97.3 151 / 92 116 18 95 Ra Gen: NAD HEENT: EOMI, PERRLA, MMM CV: irregular, nl s1s2 no m/r/g, JVP approximately 10 cm Resp: Mild bibasilar crackles Abd: Soft, NT, ND +BS Ext: chronic lymphedema changes, 1+ b/l edema Neuro: CN II-XII intact, ___ strength throughout, AAOx3, slow to answer some questions Psych: normal affect Pertinent Results: ___ 05:55PM URINE UHOLD-HOLD ___ 05:55PM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 ___ 01:15PM GLUCOSE-106* UREA N-19 CREAT-0.8 SODIUM-126* POTASSIUM-4.9 CHLORIDE-89* TOTAL CO2-22 ANION GAP-20 ___ 01:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL ___ 05:36PM NA+-125* ___ 05:55PM URINE COLOR-Yellow APPEAR-Clear SP ___ CXR ___: IMPRESSION: Pulmonary edema. Likely left lower lobe atelectasis, though consolidation may have a similar appearance. Enlarged mediastinal silhouette, likely due to positioning and technique. CT head ___: IMPRESSION: No acute intracranial abnormalities. CT C/A/P ___: IMPRESSION: 1. No acute sequelae of trauma. 2. Subacute and chronic fractures, detailed above. 3. Atheromatous disease of the abdominal aorta with new ulcerated plaque in the abdominal aorta at the level of the ___. 4. Cardiomegaly with right chamber enlargement and evidence of hepatic congestion. CT C-spine ___: IMPRESSION: No acute fracture or traumatic malalignment. Additional nonemergent findings as described above. Discharge labs: ___ 06:25AM BLOOD WBC-5.9 RBC-4.16* Hgb-12.8* Hct-37.5* MCV-90 MCH-30.8 MCHC-34.1 RDW-16.2* RDWSD-53.4* Plt ___ ___ 06:25AM BLOOD ___ ___ 06:25AM BLOOD Glucose-99 UreaN-21* Creat-0.9 Na-128* K-4.1 Cl-89* HCO3-23 AnGap-20 ___ 06:45AM BLOOD ___ Brief Hospital Course: ___ year old with history of mitral valve repair and CABG (LIMA to LAD, SVG to OM on ___, atrial flutter/fibrillation on warfarin, Hodgkin's and DLBCL s/p chemo currently in remission, HTN, lymphedema and GERD who presents after a fall. # Fall: Similar to prior presentations. Likely driven by chronic sensory ataxia as a side effect of prior chemotherapy as well as probably some proximal muscle wasting. He has had prior spine MRI with no evidence of myelopathy. He has had multiple falls in the last year, including one admission to ___ in ___ for orthostatic syncope. He continues to be off beta blocker and diuretics. Orthostatics negative after receiving IV fluids. -Discharge to rehab # Acute metabolic encephalopathy: Per wife over last week has had new onset of confusion and fatigue, possibly related to hyponatremia. No evidence of infection and not on any medications that should cause confusion. There may also be a component of underlying dementia given his age and significant volume loss on CT but wife denies significant chronic behavioral or memory issues. Slowly improving and per wife closer to baseline. -Avoid deliriogenic medications # Hyponatremia: Initially he appeared volume depleted, was given IV fluids with initial improvement of hyponatremia from 126 to 131 but then subsequent worsening to 126. He was put on a fluid restriction of 1.5 L with stabilization of hyponatremia. He appeared volume overloaded on ___ with crackles, increased edema and proBNP elevated to 13,211 and was given IV Lasix 20 and 40 mg with improvement in volume status and improvement in hyponatremia to 128. He appeared euvolemic on discharge. - Continue 1.5 L fluid restriction - Recommend checking repeat chem 7 on ___, if worsening hyponatremia consider Lasix 40 mg PO (but would avoid standing diuretics due to history of significant orthostatic hypotension). # Chronic meds - continue home vitamins (Pyridoxine, Riboflavin, Vitamin B Complex, Vitamin D 1000) Regular PIV x2 Full code (presumed) Name of health care proxy: ___ ___: wife Phone number: ___ ___: to STR Expected length to stay less than 30 days. Greater than 30 minutes were spent on discharge related activities on day of discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Docusate Sodium 100 mg PO DAILY 2. Warfarin 2 mg PO DAILY16 3. Acyclovir 400 mg PO Q8H 4. Omeprazole 20 mg PO DAILY 5. Cyanocobalamin ___ mcg PO DAILY 6. Pyridoxine 100 mg PO DAILY 7. Riboflavin (Vitamin B-2) 50 mg PO DAILY 8. Vitamin B Complex 1 CAP PO BID 9. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Cyanocobalamin ___ mcg PO DAILY 3. Docusate Sodium 100 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Pyridoxine 100 mg PO DAILY 6. Riboflavin (Vitamin B-2) 50 mg PO DAILY 7. Vitamin B Complex 1 CAP PO BID 8. Vitamin D 1000 UNIT PO DAILY 9. Warfarin 2 mg PO DAILY16 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Fall Hyponatremia Acute metabolic encephalopathy 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 Mr. ___, You were admitted with a fall and confusion. You were found to have worsening low salt levels (hyponatremia). You were put on a fluid restriction and the levels improved. Your confusion slowly improved. You are being discharged to a rehab facility to work on your strength. Followup Instructions: ___	[ "E871", "G9341", "E861", "I4892", "D801", "I4891", "M25552", "I2510", "I10", "K219", "S20219A", "E8770", "W19XXXA", "Z9181", "Y92009", "R260", "Z951", "Z7901", "Z8571", "Z8572", "T451X5A", "Y929", "Z87891" ]	Allergies: Aspirin / Enalapril / Diovan / morphine Chief Complaint: fall Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a [MASKED] year old with history of mitral valve repair and CABG (LIMA to LAD, SVG to OM on [MASKED], atrial flutter/fibrillation on warfarin, Hodgkin's and DLBCL s/p chemo currently in remission, HTN, lymphedema and GERD who presents after a fall. History is significant for a chronic gait disorder where he is cane dependent. Per oncologist, he likely has some sensory ataxia as a side effect of prior chemotherapy. He has had prior spine MRI with no evidence of myelopathy. He has had multiple falls in the last year, including one admission to [MASKED] in [MASKED] for orthostatic syncope. His beta blocker dose and diuretic have been on hold recently. He has been working with home [MASKED] to improve mobility. Per ED report, he was using walker at home and went to use the restroom. When trying to go back to bed he slipped and fell and wife heard the fall. Wife reports no [MASKED] and he denied [MASKED] or LOC. Wife could not help him up and called [MASKED]. He denied lightheadedness, chest pain, palpitaitons, and nausea prior to the fall. Reported he does not have pain, numbness, weakness in his arms or legs. Of note, he has a hx of hyponatremia (Na 130-132) in the past, that has improved in the fluids. In the ED, initial VS were: 97.5 84 142/84 19 99% RA FAST negative On exam, bruising all over body, L upper arm, R buttock/hip, abdomen and chest Na 126 --> 125 INR 2.3 UA negative Imaging showed: CXR: Pulmonary edema. Likely left lower lobe atelectasis, though consolidation may have a similar appearance 1. No acute intra-thoracic, abdominal or intrapelvic abnormalities. 2. Evidence of prior fracture with interval healing of the left first rib, right eleventh rib. Stable compression deformity of L1 and L2 since [MASKED]. 3. Atheromatous disease of the abdominal aorta with new ulcerated plaque at the level of the [MASKED]. CT spine No acute fracture or traumatic malalignment. CT head No acute intracranial abnormalities. EKG showed: flutter with 4:1 block, RBBB, right atrial abnormality Patient was given: [MASKED] 15:46 IVF NS [MASKED] Started [MASKED] 17:02 PO Acetaminophen 1000 mg [MASKED] [MASKED] 17:47 IH Albuterol 0.083% Neb Soln 1 NEB [MASKED] [MASKED] 17:47 IH Ipratropium Bromide Neb 1 NEB [MASKED] [MASKED] 17:47 IVF D5W [MASKED] Started [MASKED] 19:22 PO/NG Acyclovir 400 mg [MASKED] [MASKED] 19:22 PO/NG Warfarin 4 mg [MASKED] pt not safe at home, admit for hyponatremia, weakness Transfer VS were: 98.3 73 105/58 16 97% RA When seen on the floor, he is unable to recall the events of the past 24 hours of the last 24 hours. He is oriented to self and time but not place. REVIEW OF SYSTEMS: A ten point ROS was conducted and was negative except as above in the HPI. Past Medical History: PAST ONCOLOGY HISTORY: 1. Hodgkin's disease, 8 cycles [MASKED] MOPP, chlorambucil, vinblastine, procarbazine, predisone. - recurrent disease several months later. Treated with 2 cycles gemcitabine, navelbine, liposomal doxo. - A second complete remission after these two cycles followed by one additional cycle. Remainder of the therapy was discontinued due to excess toxicity. - Gemcitabine and Navelbine for improvement of his symptoms. - Brentuximab at [MASKED]. 2. Subsequently diffuse large B-cell lymphoma treated with six cycles of R-CHOP completed in [MASKED]. Now in remission PAST MEDICAL HISTORY: - Mitral regurgitation s/p MV repair (P2 triangular resection and 32 - mm [MASKED] II annuloplasty ring - [MASKED] - CAD s/p 2v CABG (LIMA to LAD, SVG to OM - [MASKED] - A-flutter/A-fib on warfarin - HTN - GERD - s/p b/l hernia repair - Hodgkin disease - Diffuse large B cell Lymphoma - Hypogammaglobulinemia ALLERGIES: ASA, enalapril, diovan, morphine Social History: [MASKED] Family History: Maternal aunt had some type of cancer either uterine or colon in her [MASKED] or [MASKED]. Maternal grandfather developed prostate cancer at [MASKED] and died at [MASKED]. Father had brain hemorrhage. Mother died at [MASKED]. Physical Exam: Admission PE Gen: NAD, A&O x1, lying in bed Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA [MASKED]. GI: soft, NT, ND, BS+ MSK: 3+ edema at ankles, baseline lymphedema Skin: Multiple bruises on upper and lower extremities. No jaundice. Neuro: AAOx1. No facial droop. Discharge PE: 97.3 151 / 92 116 18 95 Ra Gen: NAD HEENT: EOMI, PERRLA, MMM CV: irregular, nl s1s2 no m/r/g, JVP approximately 10 cm Resp: Mild bibasilar crackles Abd: Soft, NT, ND +BS Ext: chronic lymphedema changes, 1+ b/l edema Neuro: CN II-XII intact, [MASKED] strength throughout, AAOx3, slow to answer some questions Psych: normal affect Pertinent Results: [MASKED] 05:55PM URINE UHOLD-HOLD [MASKED] 05:55PM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [MASKED] 01:15PM GLUCOSE-106* UREA N-19 CREAT-0.8 SODIUM-126* POTASSIUM-4.9 CHLORIDE-89* TOTAL CO2-22 ANION GAP-20 [MASKED] 01:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [MASKED] 05:36PM NA+-125* [MASKED] 05:55PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] CXR [MASKED]: IMPRESSION: Pulmonary edema. Likely left lower lobe atelectasis, though consolidation may have a similar appearance. Enlarged mediastinal silhouette, likely due to positioning and technique. CT head [MASKED]: IMPRESSION: No acute intracranial abnormalities. CT C/A/P [MASKED]: IMPRESSION: 1. No acute sequelae of trauma. 2. Subacute and chronic fractures, detailed above. 3. Atheromatous disease of the abdominal aorta with new ulcerated plaque in the abdominal aorta at the level of the [MASKED]. 4. Cardiomegaly with right chamber enlargement and evidence of hepatic congestion. CT C-spine [MASKED]: IMPRESSION: No acute fracture or traumatic malalignment. Additional nonemergent findings as described above. Discharge labs: [MASKED] 06:25AM BLOOD WBC-5.9 RBC-4.16* Hgb-12.8* Hct-37.5* MCV-90 MCH-30.8 MCHC-34.1 RDW-16.2* RDWSD-53.4* Plt [MASKED] [MASKED] 06:25AM BLOOD [MASKED] [MASKED] 06:25AM BLOOD Glucose-99 UreaN-21* Creat-0.9 Na-128* K-4.1 Cl-89* HCO3-23 AnGap-20 [MASKED] 06:45AM BLOOD [MASKED] Brief Hospital Course: [MASKED] year old with history of mitral valve repair and CABG (LIMA to LAD, SVG to OM on [MASKED], atrial flutter/fibrillation on warfarin, Hodgkin's and DLBCL s/p chemo currently in remission, HTN, lymphedema and GERD who presents after a fall. # Fall: Similar to prior presentations. Likely driven by chronic sensory ataxia as a side effect of prior chemotherapy as well as probably some proximal muscle wasting. He has had prior spine MRI with no evidence of myelopathy. He has had multiple falls in the last year, including one admission to [MASKED] in [MASKED] for orthostatic syncope. He continues to be off beta blocker and diuretics. Orthostatics negative after receiving IV fluids. -Discharge to rehab # Acute metabolic encephalopathy: Per wife over last week has had new onset of confusion and fatigue, possibly related to hyponatremia. No evidence of infection and not on any medications that should cause confusion. There may also be a component of underlying dementia given his age and significant volume loss on CT but wife denies significant chronic behavioral or memory issues. Slowly improving and per wife closer to baseline. -Avoid deliriogenic medications # Hyponatremia: Initially he appeared volume depleted, was given IV fluids with initial improvement of hyponatremia from 126 to 131 but then subsequent worsening to 126. He was put on a fluid restriction of 1.5 L with stabilization of hyponatremia. He appeared volume overloaded on [MASKED] with crackles, increased edema and proBNP elevated to 13,211 and was given IV Lasix 20 and 40 mg with improvement in volume status and improvement in hyponatremia to 128. He appeared euvolemic on discharge. - Continue 1.5 L fluid restriction - Recommend checking repeat chem 7 on [MASKED], if worsening hyponatremia consider Lasix 40 mg PO (but would avoid standing diuretics due to history of significant orthostatic hypotension). # Chronic meds - continue home vitamins (Pyridoxine, Riboflavin, Vitamin B Complex, Vitamin D 1000) Regular PIV x2 Full code (presumed) Name of health care proxy: [MASKED] [MASKED]: wife Phone number: [MASKED] [MASKED]: to STR Expected length to stay less than 30 days. Greater than 30 minutes were spent on discharge related activities on day of discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Docusate Sodium 100 mg PO DAILY 2. Warfarin 2 mg PO DAILY16 3. Acyclovir 400 mg PO Q8H 4. Omeprazole 20 mg PO DAILY 5. Cyanocobalamin [MASKED] mcg PO DAILY 6. Pyridoxine 100 mg PO DAILY 7. Riboflavin (Vitamin B-2) 50 mg PO DAILY 8. Vitamin B Complex 1 CAP PO BID 9. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Cyanocobalamin [MASKED] mcg PO DAILY 3. Docusate Sodium 100 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Pyridoxine 100 mg PO DAILY 6. Riboflavin (Vitamin B-2) 50 mg PO DAILY 7. Vitamin B Complex 1 CAP PO BID 8. Vitamin D 1000 UNIT PO DAILY 9. Warfarin 2 mg PO DAILY16 Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Fall Hyponatremia Acute metabolic encephalopathy 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 Mr. [MASKED], You were admitted with a fall and confusion. You were found to have worsening low salt levels (hyponatremia). You were put on a fluid restriction and the levels improved. Your confusion slowly improved. You are being discharged to a rehab facility to work on your strength. Followup Instructions: [MASKED]	[]	[ "E871", "I4891", "I2510", "I10", "K219", "Z951", "Z7901", "Y929", "Z87891" ]	[ "E871: Hypo-osmolality and hyponatremia", "G9341: Metabolic encephalopathy", "E861: Hypovolemia", "I4892: Unspecified atrial flutter", "D801: Nonfamilial hypogammaglobulinemia", "I4891: Unspecified atrial fibrillation", "M25552: Pain in left hip", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "S20219A: Contusion of unspecified front wall of thorax, initial encounter", "E8770: Fluid overload, unspecified", "W19XXXA: Unspecified fall, initial encounter", "Z9181: History of falling", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "R260: Ataxic gait", "Z951: Presence of aortocoronary bypass graft", "Z7901: Long term (current) use of anticoagulants", "Z8571: Personal history of Hodgkin lymphoma", "Z8572: Personal history of non-Hodgkin lymphomas", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y929: Unspecified place or not applicable", "Z87891: Personal history of nicotine dependence" ]
10,088,966	24,370,348	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Enalapril / Diovan / morphine Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an ___ year old male with history of recent mitral valve repair and CABG (LIMA to LAD, SVG to OM on ___, atrial flutter/fibrillation on warfarin, Hodgkin's and DLBCL s/p chemo, HTN, and GERD who presents with 3 episodes of bilateral lower extremity weakness and one episode of syncope. Notably, the patient has unsteady gait at baseline attributed to peripheral neuropathy secondary to chemotherapy. 3 days prior to admission, the patient's wife reports that Mr. ___ appeared unsteady with his walker after standing up and walking with his walker toward their car; he "was wobbling." He had to use the car for support upon arriving at it. On the day of admission, he had another episode of weakness at 1 ___ where, upon standing, he braced his walker as he gradually brought himself to the ground without trauma. At 5 ___, he had another episode. He finished urinating, stood up, and was raising his pants when he lost consciousness. His wife heard a thud, found him on the floor bleeding around his left eyebrow, after which 911 was called and he was brought to ___. In all cases, he does not endorse prodromal symptoms. He denies headache, diaphoresis, visual symptoms, tongue bleeding, chest pain, dyspnea, nausea, vomiting, or incontinence. Past Medical History: PAST ONCOLOGY HISTORY: 1. Hodgkin's disease, 8 cycles ___ MOPP, chlorambucil, vinblastine, procarbazine, predisone. - recurrent disease several months later. Treated with 2 cycles gemcitabine, navelbine, liposomal doxo. - A second complete remission after these two cycles followed by one additional cycle. Remainder of the therapy was discontinued due to excess toxicity. - Gemcitabine and Navelbine for improvement of his symptoms. - Brentuximab at ___. 2. Subsequently diffuse large B-cell lymphoma treated with six cycles of R-CHOP completed in ___. Now in remission PAST MEDICAL HISTORY: - Mitral regurgitation s/p MV repair (P2 triangular resection and 32 - mm ___ II annuloplasty ring - ___ - CAD s/p 2v CABG (LIMA to LAD, SVG to OM - ___ - A-flutter/A-fib on warfarin - HTN - GERD - s/p b/l hernia repair - Hodgkin disease - Diffuse large B cell Lymphoma - Hypogammaglobulinemia ALLERGIES: ASA, enalapril, diovan, morphine Social History: ___ Family History: Maternal aunt had some type of cancer either uterine or colon in her ___ or ___. Maternal grandfather developed prostate cancer at ___ and died at ___. Father had brain hemorrhage. Mother died at ___. Physical Exam: ADMISSION PHYSICAL EXAM: Vital Signs: 97.8 100/74 63 19 100%ra Orthostatic signs: 120/70 lying, 82/55 sitting, 133/71 standing General: very pleasant older male alert and oriented x4, able to do days of week backwards without difficulty HEENT: superficial abrasion L brow, PERRL, EOMI, MMM Neck: JVP to mandible with bed at 45 degrees CV: Irreg irreg, S1 S2, no murmurs Lungs: Clear to bases posteriorly Abdomen: Soft, obese, non-tender, +BS GU: No foley Ext: cool distally in hands and feet, RLE > LLE circ (chronic from lymphedema), 3+ pitting edema bilaterally to knees Neuro: CNII-XII intact, ___ strength upper extremities ___ hip flexors ___ strength Remainder ___ strength ___ Sensory exam in tact to light touch in all extremities Normal FNF, no pronator drift DISCHARGE PHYSICAL EXAM: VS - Tmax 98.0 Tc 98.0 BP 113-152/63-87 HR 66-68 RR ___ 02 98%RA General: well appearing, NAD HEENT: left eyebrow abrasion partially visible underneath gauze, MMM Neck: no JVD, no LAD CV: irregularly irregular rate, S1 and S2 present, no murmurs presen Lungs: CTAB, minor inspiratory crackles, breathing comfortably, no pain with deep inspiration Abdomen: soft, nontender, nondistended, no HSM appreciated GU: deferred Ext: warm and well perfused, pulses, 1+ pitting edema in ___ b/l Neuro: alert and oriented, CN II-XII intact, motor strength ___ throughout except ___ quadriceps, sensation to light touch intact in distal extremities throughout Pertinent Results: ----------------- ADMISSION LABS ----------------- CBC w/ Diff ___ 07:40PM BLOOD WBC-5.8 RBC-4.00* Hgb-12.0* Hct-36.9* MCV-92 MCH-30.0 MCHC-32.5 RDW-16.1* RDWSD-54.1* Plt ___ ___ 07:40PM BLOOD Neuts-74.2* Lymphs-6.7* Monos-9.6 Eos-7.9* Baso-0.7 Im ___ AbsNeut-4.32 AbsLymp-0.39* AbsMono-0.56 AbsEos-0.46 AbsBaso-0.04 Electrolytes ___ 07:40PM BLOOD Glucose-103* UreaN-26* Creat-1.1 Na-135 K-4.0 Cl-94* HCO3-30 AnGap-15 ___ 07:40PM BLOOD Calcium-9.2 Mg-2.3 Anticoagulation ___ 07:40PM BLOOD ___ PTT-39.2* ___ Cardiac ___ 05:45AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 07:40PM BLOOD cTropnT-<0.01 Urinalysis ___ 12:00PM URINE Color-Straw Appear-Clear Sp ___ ___ 12:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG MICRO: none IMAGING: ___ Noncontrast head CT: No acute intracranial process. ___ervical spine: 1. No acute fracture or traumatic malalignment in the cervical spine. 2. Acute appearing left first rib fracture at the costovertebral junction. 3. Moderate degenerative changes of the cervical spine, better evaluated on prior MRI from ___. No significant interval change. ___ CXR PA and Lat: 1. No acute cardiopulmonary process. 2. Left first rib fracture better appreciated on prior CT. No other displaced rib fractures. ___ Overnight telemetry: Baseline atrial fibrillation/flutter with 3:1 conduction, no other abnormalities noted. ----------------- DISCHARGE LABS ----------------- Electrolytes ___ 05:36AM BLOOD Glucose-90 UreaN-18 Creat-0.8 Na-133 K-4.2 Cl-97 HCO3-26 AnGap-14 ___ 05:36AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.2 LFTs ___ 05:36AM BLOOD ___ PTT-37.7* ___ Brief Hospital Course: Mr. ___ is an ___ year old male with history of recent mitral valve repair and CABG (LIMA to LAD, SVG to OM on ___, atrial flutter/fibrillation on warfarin, Hodgkin's and DLBCL s/p chemo, HTN, and GERD who presented with 3 episodes of bilateral lower extremity weakness and one episode of syncope upon standing. ----------------- ACTIVE ISSUES: ----------------- #SYNCOPE: Likely orthostatic hypotensive event given orthostatic vitals signs on admission exam. Though patient appeared hypervolemic with peripheral edema and elevated JVP, we believe syncope was secondary to intravascular volume depletion, beta-blockade, and possible age-related loss of sympathetic response to postural changes. He had been taking torsemide after CABG in ___ and of note lost 5 lb the week of his presentation, the most acute drop of weight since his surgery. Low suspicion for cardiogenic cause with negative consecutive trops, benign exam, unrevealing overnight telemetry. We reduced his metoprolol tartrate dose to 6.25 mg q6h, stopped torsemide, and gave him small boluses of IV fluids which resolved his symptoms. Discharged with metoprolol succinate 25 mg daily for ease of administration. #ATRIAL FLUTTER/FIBRILLATION: Rate controlled on metoprolol and asymptomatic on admission. He was admitted on warfarin, which was held due to supratherapeutic INR. He was subtherapeutic on 2 mg daily, but supratherapeutic on 3 mg daily. Discharge INR was 2.7. We discharged him on 2.5 mg MWF and 2 mg on other days of the week. #LEFT RIB FRACTURE: Seen on CXR without pneumothorax. He was asymptomatic without pleuritic chest pain or respiratory symptoms. We observed him clinically and did not perform any medical interventions. ------------------ CHRONIC ISSUES: ------------------ #GERD: No acute issues arose during this hospitalization. We continued home omeprazole #HISTORY OF HODGKIN'S LYMPHOMA AND DLBCL: In remission, no acute issues during hospitalization. We continued home acyclovir ppx CORE MEASURES: #CODE: "I don't want to be a vegetable". Wants to discuss with wife and doctors. ___ Code in interim. #EMERGENCY CONTACT HCP: wife ___ ___ TRANSITIONAL ISSUES: - Discharge weight: 74.5 kg - Stopped torsemide on discharge - Changed metoprolol tartrate to metoprolol succinate dosage on discharge 25 mg daily - Patient instructed to change positions slowly to allow blood pressure to equilibrate - Daily weights; Restart torsemide PRN Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate 25 mg PO TID ___ MD to order daily dose PO DAILY16 3. Torsemide 40 mg PO DAILY 4. Acyclovir 400 mg PO TID 5. Omeprazole 20 mg PO DAILY 6. Calcitrate (calcium citrate) 200 mg (950 mg) oral TID 7. Magnesium Oxide 250 mg PO DAILY 8. Tamsulosin 0.4 mg PO QHS 9. Vitamin B Complex 1 CAP PO BID 10. Vitamin D 1000 UNIT PO TID Discharge Medications: 1. Metoprolol Succinate XL 25 mg PO DAILY A-fib/A-flutter RX metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:2 2. Warfarin 2 mg PO QOD Take 2 mg SUN, TUES, THURS, SAT RX warfarin 2 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:2 3. Warfarin 2.5 mg PO QOD Take 2.5 mg MON, WED, FRI RX warfarin 2.5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*2 4. Acyclovir 400 mg PO TID 5. Calcitrate (calcium citrate) 200 mg (950 mg) oral TID 6. Magnesium Oxide 250 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Tamsulosin 0.4 mg PO QHS 9. Vitamin B Complex 1 CAP PO BID 10. Vitamin D 1000 UNIT PO TID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: Syncope secondary to orthostatic hypotension SECONDARY: Atrial flutter Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because you had a fall at home and hit your head. We did a CT scan of your head and did not find any bleeding. We also did a chest x ray and EKG to look at your heart and did not find anything wrong except a slow heart beat. It appears that your fainting may have been because your body can't control your blood pressure fast enough when changing positions. In the future, the best way to prevent this is to stand or sit up slowly and to wait one minute before moving to allow your blood pressure to catch up. We have also lowered your dose of metoprolol and stopped your torsemide. We are also changing your warfarin dose to alternating doses of 2 mg and 2.5 mg daily. Take 2 mg tonight when you get home. Weight yourself every day and call your doctor if your weight goes up by 3 pounds in one day. It was a pleasure taking care of you, Your ___ Team Followup Instructions: ___	[ "I951", "I4892", "G620", "D801", "E8770", "I4891", "I2510", "I10", "S2232XA", "Z951", "Z7901", "K219", "T451X5S", "Z8572", "Z87891", "W1839XA", "Y92002" ]	Allergies: Aspirin / Enalapril / Diovan / morphine Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is an [MASKED] year old male with history of recent mitral valve repair and CABG (LIMA to LAD, SVG to OM on [MASKED], atrial flutter/fibrillation on warfarin, Hodgkin's and DLBCL s/p chemo, HTN, and GERD who presents with 3 episodes of bilateral lower extremity weakness and one episode of syncope. Notably, the patient has unsteady gait at baseline attributed to peripheral neuropathy secondary to chemotherapy. 3 days prior to admission, the patient's wife reports that Mr. [MASKED] appeared unsteady with his walker after standing up and walking with his walker toward their car; he "was wobbling." He had to use the car for support upon arriving at it. On the day of admission, he had another episode of weakness at 1 [MASKED] where, upon standing, he braced his walker as he gradually brought himself to the ground without trauma. At 5 [MASKED], he had another episode. He finished urinating, stood up, and was raising his pants when he lost consciousness. His wife heard a thud, found him on the floor bleeding around his left eyebrow, after which 911 was called and he was brought to [MASKED]. In all cases, he does not endorse prodromal symptoms. He denies headache, diaphoresis, visual symptoms, tongue bleeding, chest pain, dyspnea, nausea, vomiting, or incontinence. Past Medical History: PAST ONCOLOGY HISTORY: 1. Hodgkin's disease, 8 cycles [MASKED] MOPP, chlorambucil, vinblastine, procarbazine, predisone. - recurrent disease several months later. Treated with 2 cycles gemcitabine, navelbine, liposomal doxo. - A second complete remission after these two cycles followed by one additional cycle. Remainder of the therapy was discontinued due to excess toxicity. - Gemcitabine and Navelbine for improvement of his symptoms. - Brentuximab at [MASKED]. 2. Subsequently diffuse large B-cell lymphoma treated with six cycles of R-CHOP completed in [MASKED]. Now in remission PAST MEDICAL HISTORY: - Mitral regurgitation s/p MV repair (P2 triangular resection and 32 - mm [MASKED] II annuloplasty ring - [MASKED] - CAD s/p 2v CABG (LIMA to LAD, SVG to OM - [MASKED] - A-flutter/A-fib on warfarin - HTN - GERD - s/p b/l hernia repair - Hodgkin disease - Diffuse large B cell Lymphoma - Hypogammaglobulinemia ALLERGIES: ASA, enalapril, diovan, morphine Social History: [MASKED] Family History: Maternal aunt had some type of cancer either uterine or colon in her [MASKED] or [MASKED]. Maternal grandfather developed prostate cancer at [MASKED] and died at [MASKED]. Father had brain hemorrhage. Mother died at [MASKED]. Physical Exam: ADMISSION PHYSICAL EXAM: Vital Signs: 97.8 100/74 63 19 100%ra Orthostatic signs: 120/70 lying, 82/55 sitting, 133/71 standing General: very pleasant older male alert and oriented x4, able to do days of week backwards without difficulty HEENT: superficial abrasion L brow, PERRL, EOMI, MMM Neck: JVP to mandible with bed at 45 degrees CV: Irreg irreg, S1 S2, no murmurs Lungs: Clear to bases posteriorly Abdomen: Soft, obese, non-tender, +BS GU: No foley Ext: cool distally in hands and feet, RLE > LLE circ (chronic from lymphedema), 3+ pitting edema bilaterally to knees Neuro: CNII-XII intact, [MASKED] strength upper extremities [MASKED] hip flexors [MASKED] strength Remainder [MASKED] strength [MASKED] Sensory exam in tact to light touch in all extremities Normal FNF, no pronator drift DISCHARGE PHYSICAL EXAM: VS - Tmax 98.0 Tc 98.0 BP 113-152/63-87 HR 66-68 RR [MASKED] 02 98%RA General: well appearing, NAD HEENT: left eyebrow abrasion partially visible underneath gauze, MMM Neck: no JVD, no LAD CV: irregularly irregular rate, S1 and S2 present, no murmurs presen Lungs: CTAB, minor inspiratory crackles, breathing comfortably, no pain with deep inspiration Abdomen: soft, nontender, nondistended, no HSM appreciated GU: deferred Ext: warm and well perfused, pulses, 1+ pitting edema in [MASKED] b/l Neuro: alert and oriented, CN II-XII intact, motor strength [MASKED] throughout except [MASKED] quadriceps, sensation to light touch intact in distal extremities throughout Pertinent Results: ----------------- ADMISSION LABS ----------------- CBC w/ Diff [MASKED] 07:40PM BLOOD WBC-5.8 RBC-4.00* Hgb-12.0* Hct-36.9* MCV-92 MCH-30.0 MCHC-32.5 RDW-16.1* RDWSD-54.1* Plt [MASKED] [MASKED] 07:40PM BLOOD Neuts-74.2* Lymphs-6.7* Monos-9.6 Eos-7.9* Baso-0.7 Im [MASKED] AbsNeut-4.32 AbsLymp-0.39* AbsMono-0.56 AbsEos-0.46 AbsBaso-0.04 Electrolytes [MASKED] 07:40PM BLOOD Glucose-103* UreaN-26* Creat-1.1 Na-135 K-4.0 Cl-94* HCO3-30 AnGap-15 [MASKED] 07:40PM BLOOD Calcium-9.2 Mg-2.3 Anticoagulation [MASKED] 07:40PM BLOOD [MASKED] PTT-39.2* [MASKED] Cardiac [MASKED] 05:45AM BLOOD CK-MB-2 cTropnT-<0.01 [MASKED] 07:40PM BLOOD cTropnT-<0.01 Urinalysis [MASKED] 12:00PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 12:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG MICRO: none IMAGING: [MASKED] Noncontrast head CT: No acute intracranial process. ervical spine: 1. No acute fracture or traumatic malalignment in the cervical spine. 2. Acute appearing left first rib fracture at the costovertebral junction. 3. Moderate degenerative changes of the cervical spine, better evaluated on prior MRI from [MASKED]. No significant interval change. [MASKED] CXR PA and Lat: 1. No acute cardiopulmonary process. 2. Left first rib fracture better appreciated on prior CT. No other displaced rib fractures. [MASKED] Overnight telemetry: Baseline atrial fibrillation/flutter with 3:1 conduction, no other abnormalities noted. ----------------- DISCHARGE LABS ----------------- Electrolytes [MASKED] 05:36AM BLOOD Glucose-90 UreaN-18 Creat-0.8 Na-133 K-4.2 Cl-97 HCO3-26 AnGap-14 [MASKED] 05:36AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.2 LFTs [MASKED] 05:36AM BLOOD [MASKED] PTT-37.7* [MASKED] Brief Hospital Course: Mr. [MASKED] is an [MASKED] year old male with history of recent mitral valve repair and CABG (LIMA to LAD, SVG to OM on [MASKED], atrial flutter/fibrillation on warfarin, Hodgkin's and DLBCL s/p chemo, HTN, and GERD who presented with 3 episodes of bilateral lower extremity weakness and one episode of syncope upon standing. ----------------- ACTIVE ISSUES: ----------------- #SYNCOPE: Likely orthostatic hypotensive event given orthostatic vitals signs on admission exam. Though patient appeared hypervolemic with peripheral edema and elevated JVP, we believe syncope was secondary to intravascular volume depletion, beta-blockade, and possible age-related loss of sympathetic response to postural changes. He had been taking torsemide after CABG in [MASKED] and of note lost 5 lb the week of his presentation, the most acute drop of weight since his surgery. Low suspicion for cardiogenic cause with negative consecutive trops, benign exam, unrevealing overnight telemetry. We reduced his metoprolol tartrate dose to 6.25 mg q6h, stopped torsemide, and gave him small boluses of IV fluids which resolved his symptoms. Discharged with metoprolol succinate 25 mg daily for ease of administration. #ATRIAL FLUTTER/FIBRILLATION: Rate controlled on metoprolol and asymptomatic on admission. He was admitted on warfarin, which was held due to supratherapeutic INR. He was subtherapeutic on 2 mg daily, but supratherapeutic on 3 mg daily. Discharge INR was 2.7. We discharged him on 2.5 mg MWF and 2 mg on other days of the week. #LEFT RIB FRACTURE: Seen on CXR without pneumothorax. He was asymptomatic without pleuritic chest pain or respiratory symptoms. We observed him clinically and did not perform any medical interventions. ------------------ CHRONIC ISSUES: ------------------ #GERD: No acute issues arose during this hospitalization. We continued home omeprazole #HISTORY OF HODGKIN'S LYMPHOMA AND DLBCL: In remission, no acute issues during hospitalization. We continued home acyclovir ppx CORE MEASURES: #CODE: "I don't want to be a vegetable". Wants to discuss with wife and doctors. [MASKED] Code in interim. #EMERGENCY CONTACT HCP: wife [MASKED] [MASKED] TRANSITIONAL ISSUES: - Discharge weight: 74.5 kg - Stopped torsemide on discharge - Changed metoprolol tartrate to metoprolol succinate dosage on discharge 25 mg daily - Patient instructed to change positions slowly to allow blood pressure to equilibrate - Daily weights; Restart torsemide PRN Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate 25 mg PO TID [MASKED] MD to order daily dose PO DAILY16 3. Torsemide 40 mg PO DAILY 4. Acyclovir 400 mg PO TID 5. Omeprazole 20 mg PO DAILY 6. Calcitrate (calcium citrate) 200 mg (950 mg) oral TID 7. Magnesium Oxide 250 mg PO DAILY 8. Tamsulosin 0.4 mg PO QHS 9. Vitamin B Complex 1 CAP PO BID 10. Vitamin D 1000 UNIT PO TID Discharge Medications: 1. Metoprolol Succinate XL 25 mg PO DAILY A-fib/A-flutter RX metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:2 2. Warfarin 2 mg PO QOD Take 2 mg SUN, TUES, THURS, SAT RX warfarin 2 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:2 3. Warfarin 2.5 mg PO QOD Take 2.5 mg MON, WED, FRI RX warfarin 2.5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*2 4. Acyclovir 400 mg PO TID 5. Calcitrate (calcium citrate) 200 mg (950 mg) oral TID 6. Magnesium Oxide 250 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Tamsulosin 0.4 mg PO QHS 9. Vitamin B Complex 1 CAP PO BID 10. Vitamin D 1000 UNIT PO TID Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY: Syncope secondary to orthostatic hypotension SECONDARY: Atrial flutter Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital because you had a fall at home and hit your head. We did a CT scan of your head and did not find any bleeding. We also did a chest x ray and EKG to look at your heart and did not find anything wrong except a slow heart beat. It appears that your fainting may have been because your body can't control your blood pressure fast enough when changing positions. In the future, the best way to prevent this is to stand or sit up slowly and to wait one minute before moving to allow your blood pressure to catch up. We have also lowered your dose of metoprolol and stopped your torsemide. We are also changing your warfarin dose to alternating doses of 2 mg and 2.5 mg daily. Take 2 mg tonight when you get home. Weight yourself every day and call your doctor if your weight goes up by 3 pounds in one day. It was a pleasure taking care of you, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "I4891", "I2510", "I10", "Z951", "Z7901", "K219", "Z87891" ]	[ "I951: Orthostatic hypotension", "I4892: Unspecified atrial flutter", "G620: Drug-induced polyneuropathy", "D801: Nonfamilial hypogammaglobulinemia", "E8770: Fluid overload, unspecified", "I4891: Unspecified atrial fibrillation", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "S2232XA: Fracture of one rib, left side, initial encounter for closed fracture", "Z951: Presence of aortocoronary bypass graft", "Z7901: Long term (current) use of anticoagulants", "K219: Gastro-esophageal reflux disease without esophagitis", "T451X5S: Adverse effect of antineoplastic and immunosuppressive drugs, sequela", "Z8572: Personal history of non-Hodgkin lymphomas", "Z87891: Personal history of nicotine dependence", "W1839XA: Other fall on same level, initial encounter", "Y92002: Bathroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]
10,088,966	27,318,566	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Enalapril / Diovan / morphine Attending: ___. Chief Complaint: Lethargy Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an ___ yo man with h/o MVR, CABG in ___, afib/flutter on warfarin, Hodgkin's and DLBCL s/p chemo currently in remission, who presents with lethargy. Patient was recently admitted to ___ in ___ after a fall. This was thought to be ___ neuropathy from prior chemo with possible contribution of hyponatremia. Sodium was improving with fluid restriction on discharge and he was discharged to rehab. While there he has reportedly had worsening lethargy and weakness, notes indicate "global decline in all areas of functioning". He has been unable to participate in ___ at all due to somnolence and was reportedly oriented only to self. He was seen at ___ on ___ and found to have new patchy opacity in left base concerning for atelectasis vs consolidation. He was treated with azithromycin with last dose planned for ___. However he continued to worsen, unable to eat or take meds properly due to ongoing lethargy, and was sent to ED. In the ED, initial vitals were: 97.0 71 152/100 18 100%RA - Exam notable for: bilateral crackles, +JVD, no pitting edema - Labs notable for: Na 126, sOsms 270, ___ ___. UA with 5 WBCs, uOsms 788 uNa 81. - Imaging was notable for: CXR with mild pulmonary vascular congestion and moderate cardiomegaly, not changed in the interval. Patchy atelectasis in the lung bases. CT head without acute intracranial abnormality. - Patient was given: albuterol and ipratropium nebs - Renal was consulted given hyponatremia, and recommended 1L fluid restriction. Upon arrival to the floor, patient is feeling well without complaints. He does not feel weak or short of breath. He notes that he has been sleeping very poorly because he does to feel tired at night. He is otherwise unable to recall much about what has happened over the past few weeks and what brought him into the hospital. Past Medical History: PAST ONCOLOGY HISTORY: 1. Hodgkin's disease, 8 cycles ___ MOPP, chlorambucil, vinblastine, procarbazine, predisone. - recurrent disease several months later. Treated with 2 cycles gemcitabine, navelbine, liposomal doxo. - A second complete remission after these two cycles followed by one additional cycle. Remainder of the therapy was discontinued due to excess toxicity. - Gemcitabine and Navelbine for improvement of his symptoms. - Brentuximab at ___. 2. Subsequently diffuse large B-cell lymphoma treated with six cycles of R-CHOP completed in ___. Now in remission PAST MEDICAL HISTORY: - Mitral regurgitation s/p MV repair (P2 triangular resection and 32 - mm ___ II annuloplasty ring - ___ - CAD s/p 2v CABG (LIMA to LAD, SVG to OM - ___ - A-flutter/A-fib on warfarin - HTN - GERD - s/p b/l hernia repair - Hodgkin disease - Diffuse large B cell Lymphoma - Hypogammaglobulinemia ALLERGIES: ASA, enalapril, diovan, morphine Social History: ___ Family History: Maternal aunt had some type of cancer either uterine or colon in her ___ or ___. Maternal grandfather developed prostate cancer at ___ and died at ___. Father had brain hemorrhage. Mother died at ___. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS - 97.4 \| 142/92 \| 90 \| 20 \| 97RA GENERAL - Initially agitated, refusing gown, interview, and physical, wanted to get out of bed and call ___. Suspicious of all hospital staff. After haloperidol, somnolent and appropriate. HEENT - PERRLA, sclera anicteric, oropharynx clear, tongue midline. NECK - JVP at mandible with patient at 30 degrees. CARDIAC - Regular rate and rhythm, S4 gallop, no murmurs or rubs. LUNGS - Mild crackles at the bases. ABDOMEN - Soft, non-tender, non-distended. No guarding, tenderness, or distention. EXTREMITIES - 2+ edema at ankle. Pulses intact, no cyanosis. SKIN - Some bruising over bilateral wrists. NEUROLOGIC - Intermittently somnolent (s/p Haldol), but oriented to person, place, time, and event. PERRLA, facial muscles bilaterally strong, shoulder shrug ___ bilaterally, tongue midline. Elbow flex and extend ___. Hand grip ___. Hip flex ___ bilaterally. Knee and ankle flex/extend ___. Patellar reflexes unable to elicit. DISCHARGE PHYSICAL EXAM: PHYSICAL EXAM: VITALS - 97.4 \| 105-120/83 \| 89 \| 18 \| 98RA GENERAL - Calm, pleasant, alert. Sitting in bed comfortably. HEENT - PERRLA, sclera anicteric, mucus membranes moist. NECK - JVP at midneck with patient at 45 degrees. CARDIAC - Irregular, no murmurs rubs or gallops appreciated. LUNGS - Clear to auscultation bilaterally. ABDOMEN - Soft, non-tender, no distention, guarding, or rigidity. EXTREMITIES - Erythema, edema, and warmth in R foot resolved. No tenderness to palpation in R foot. DP 2+ bilaterally. No edema bilaterally. SKIN - Some bruising over bilateral wrists. NEUROLOGIC - Alert. Confused, but appropriate. Oriented to place, year, and month. Pupils equal and reactive, EOM intact, facial muscles symmetrically strong, shoulder shrug equal symmetrically, tongue deviates L and R equally. R shoulder flexion ___, L shoulder flexion ___. Elbow extension ___ R, flexion ___ R. Elbow flexion/extension ___ L. Hand grip ___ bilaterally. Hip flexion ___ R, ___ L. Ankle flexion/extension ___ bilaterally. Pertinent Results: ADMISSION LABS: ___ 05:38PM PH-7.34* ___ 05:38PM K+-5.3* ___ 05:38PM freeCa-1.08* ___ 03:00PM URINE HOURS-RANDOM CREAT-105 SODIUM-81 ___ 03:00PM URINE OSMOLAL-788 ___ 03:00PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 03:00PM URINE RBC-3* WBC-5 BACTERIA-NONE YEAST-NONE EPI-0 ___ 03:00PM URINE MUCOUS-OCC ___ 01:46PM ___ PO2-33* PCO2-44 PH-7.39 TOTAL CO2-28 BASE XS-0 ___ 01:46PM O2 SAT-56 ___ 01:17PM VoidSpec-SPECIMEN C ___ 01:12PM GLUCOSE-93 UREA N-23* CREAT-0.8 SODIUM-126* POTASSIUM-6.4* CHLORIDE-91* TOTAL CO2-18* ANION GAP-23* ___ 01:12PM estGFR-Using this ___ 01:12PM ALT(SGPT)-31 AST(SGOT)-96* ALK PHOS-178* TOT BILI-1.1 ___ 01:12PM cTropnT-<0.01 ___ ___ 01:12PM ALBUMIN-4.0 CALCIUM-9.6 PHOSPHATE-3.7 MAGNESIUM-2.1 ___ 01:12PM OSMOLAL-270* ___ 01:12PM WBC-6.9 RBC-4.80 HGB-14.2 HCT-43.2 MCV-90 MCH-29.6 MCHC-32.9 RDW-16.2* RDWSD-53.7* ___ 01:12PM NEUTS-70.1 LYMPHS-6.1* MONOS-13.8* EOS-7.6* BASOS-1.0 IM ___ AbsNeut-4.86 AbsLymp-0.42* AbsMono-0.96* AbsEos-0.53 AbsBaso-0.07 ___ 01:12PM PLT COUNT-274 ___ 01:12PM ___ PTT-40.7* ___ MICROBIOLOGY: None positive. PATHOLOGY: None IMAGING: CXR (PA AND LATERAL) ___: IMPRESSION: Mild pulmonary vascular congestion and moderate cardiomegaly, not changed in the interval. Patchy atelectasis in the lung bases. NON-CONTRAST HEAD CT ___: IMPRESSION: No acute intracranial abnormality. PORTABLE CXR ___: IMPRESSION: In comparison with study of ___, the patient has taken a slightly better inspiration. Continued enlargement of the cardiac silhouette, though the vascular congestion has essentially cleared and there is no evidence of pleural effusion or acute focal pneumonia. Port-A-Cath tip is unchanged in position. TTE ___: IMPRESSION: In comparison with study of ___, the patient has taken a slightly better inspiration. Continued enlargement of the cardiac silhouette, though the vascular congestion has essentially cleared and there is no evidence of pleural effusion or acute focal pneumonia. Port-A-Cath tip is unchanged in position. NCHCT ___: IMPRESSION: 1. No evidence of acute intracranial process. 2. Involutional changes and nonspecific ___ matter hypodensities likely representing the sequelae of moderate chronic small vessel ischemic disease. MRI/MRA BRAIN AND NECK ___: IMPRESSION: 1. 1.1 cm focus of slow diffusion with associated FLAIR signal abnormality within the left precentral gyrus is concerning for an acute to subacute infarct. 2. Subtle 0.2 cm focus of high signal within the right frontal lobe, series 6, image 22 without definite correlate on the ADC maps, may be artifactual versus a focal small subacute infarct. Likely 0.2 cm focus of subacute infarction is seen within the right occipital lobe, series 6, image 15. 3. Unremarkable MRA of the head, specifically with normal arborization of the distal left MCA vessels. Moderate intracranial atherosclerotic disease. 4. Limited MRA of the neck without contrast. However, based on the 2D time-of-flight images, the bilateral internal carotid arteries appear to be unremarkable without evidence of significant stenosis by NASCET criteria. 5. Diffuse foci of low signal on the susceptibility weighted sequences within the cortical and subcortical regions may be secondary to hypertensive encephalopathy versus amyloid angiopathy. 6. Severe chronic microangiopathy. DISCHARGE LABS: ___ 05:08AM BLOOD WBC-5.4 RBC-3.75* Hgb-11.3* Hct-35.1* MCV-94 MCH-30.1 MCHC-32.2 RDW-16.1* RDWSD-55.0* Plt ___ ___ 06:30AM BLOOD ___ PTT-34.0 ___ ___ 05:08AM BLOOD Glucose-116* UreaN-32* Creat-0.9 Na-134 K-4.1 Cl-93* HCO3-33* AnGap-12 ___ 05:08AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.1 Brief Hospital Course: SUMMARY: Mr. ___ is an ___ with h/o MVR and CABG in ___, afib/flutter on warfarin, Hodgkin's and DLBCL s/p chemo in remission, who presents with lethargy, fluid overload, atrial fibrillation with RVR, and hyponatremia, course complicated by CVA. ACTIVE ISSUES: #Lethargy and #Delirium: We considered multiple causes for the patients change in mental status and believe it was multifactorial, with contribution from hyponatremia, fluid overload, and perhaps underlying dementia. Hyponatremia and fluid overload were treated as below. He was given haloperidol and olanzapine for agitation once. We attempted to normalize his sleep/wake cycle with trazadone and ramelteon at night. #CVA: Patient developed acute onset Right shoulder extension palsy on ___. NCHCT was WNL, but MRI on ___ showed 1.1cm left precentral gyrus FLAIR hypodensity concerning for stroke. Neurology was consulted, who felt that patient's CVA may have been related to being briefly subtherapeutic on warfarin, although it was not entirely clear. Patient was briefly transitioned from metoprolol to digoxin for permissive hypertension. His Right shoulder extension improved over the course of the hospitalization, although he continued to have difficulty fully extending Right arm at discharge. As below, he was transitioned to apixaban. #Acute on chronic CHF: Patient was volume overloaded on exam, with a ___ of 20000 and signs of overload on chest x-ray. Of note, TTE showed an EF on 30% (from 50% last ___), with multiple wall motion abnormalities. He notably was not on a statin, and we started him on high-dose statin. Of note, his metoprolol was changed to metoprolol succinate 62.5mg BID. He was diuresed with IV Lasix and then PO torsemide to a weight of 160 lbs. His dry weight is likely 155-160lb. He was discharged with a plan to follow up with his cardiologist. # Atrial fibrillation/flutter with RVR: The patient intermittently had RVR up to 140s on his home metoprolol. It was increased and converted to metoprolol succinate BID dosing. His HR stabilized on this dose of metoprolol in the ___s-90___s with some breakthrough tachycardia particularly in the morning, but uptitration was limited by blood pressure. He was briefly on digoxin immediately after his stroke in an effort to maintain both normal heart rate and sufficient BP. He was then transitioned back to metoprolol. With regards to his anticoagulation, a decision was made to transition patient from warfarin to apixaban in the setting of stroke and for comfort reasons. His INR on the day of discharge was 1.8, and he was started on apixaban 2.5mg BID. #Urinary retention: Patient notably retained urine during this hospitalization. He failed two voiding trials and required a Foley. Foley was removed prior to discharge, and patient was able to successfully void. He was discharged with a plan to follow up with urology. #Hyponatremia: Initially to 126, then improved with fluid restriction and diuresis, thought to be due to SIADH and heart failure. CHRONIC ISSUES: # CAD s/p CABG: home metoprolol was continued and atorvastatin 10mg was started. # GERD: continued omeprazole NEW MEDICATIONS: Metoprolol succinate 62.5mg BID Torsemide 20mg PO QDay Atorvastatin 10mg PO QHS Apixaban 2.5mg PO BID STOPPED MEDICATIONS: -Metoprolol tartrate TRANSITIONAL ISSUES: -f/u with cardiology -f/u with neurology -Please check daily weights in AM. If >3lb weight gain in one day or >5lb weight gain in 1 week, please notify MD -f/u with urology for urinary retention during this hospitalization -Would benefit from outpatient comprehensive geriatric evaluation with cognitive evaluation including MOCA +/- cognitive neurology vs. memory clinic appointment with Dr. ___. -Would benefit from formal hearing assessment outpatient for ?hearing aids. -If patient needs additional blood pressure medication, consider losartan (given HFrEF, ACE-I allergy) # CODE: DNR/DNI # CONTACT: HCP is wife ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Ipratropium-Albuterol Neb 1 NEB NEB Q8H 3. Azithromycin 250 mg PO Q24H 4. Vitamin D 1000 UNIT PO DAILY 5. Cyanocobalamin ___ mcg PO DAILY 6. Docusate Sodium 100 mg PO DAILY 7. Metoprolol Tartrate 12.5 mg PO TID 8. Miconazole Powder 2% 1 Appl TP BID 9. Omeprazole 20 mg PO DAILY 10. Pyridoxine 100 mg PO DAILY 11. Vitamin B Complex 1 CAP PO BID 12. Warfarin 3 mg PO DAILY16 13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN sob or wheezing 14. GuaiFENesin Dose is Unknown PO Q6H:PRN cough Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. Metoprolol Succinate XL 62.5 mg PO BID 3. Torsemide 20 mg PO DAILY 4. GuaiFENesin ___ mL PO Q6H:PRN cough 5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath or wheeze 6. Acyclovir 400 mg PO Q8H 7. Cyanocobalamin ___ mcg PO DAILY 8. Docusate Sodium 100 mg PO DAILY 9. Miconazole Powder 2% 1 Appl TP BID 10. Omeprazole 20 mg PO DAILY 11. Pyridoxine 100 mg PO DAILY 12. Vitamin B Complex 1 CAP PO BID 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: ACUTE DECOMPENSATED SYSTOLIC HEART FAILURE, HYPONATREMIA, ATRIAL FLUTTER WITH RAPID VENTRICULAR RESPONSE SECONDARY DIAGNOSES: URINARY RETENTION, CORONARY ARTERY DISEASE, GASTROESOPHAGEAL REFLUX DISEASE, HYPERTENSION 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 Mr. ___, You were seen in the hospital for confusion and sleepiness. Your symptoms were due to low sodium and fluid overload. We believe your low sodium is partially caused by an inappropriately high level of anti-diuretic hormone (called SIADH), so we treated you by restricting your fluid intake. We gave you a diuretic to treat your fluid overload and got an echocardiogram to assess any changes in your heart, which showed worsening heart failure. You had a fast heart rate, which we treated by increasing your metoprolol. You were additionally found to have a small stroke, which we treated by increasing your anticoagulation and changing your medications to allow for a higher blood pressure. When you go home, you should make sure to take your medicines and follow up with your doctors at your ___ appointments. It is important to drink less than 1.5 liters of water a day and to limit your salt intake, ideally to less than 2 grams a day. It was our pleasure to take care of you. We wish you the very best! --Your care team at the ___ Followup Instructions: ___	[ "I110", "I63422", "I63412", "E222", "C8330", "D801", "I4892", "I4891", "F05", "F0390", "G4723", "G8191", "Z951", "I25110", "K219", "Z7901", "Z87891", "I255", "R339", "Z66", "I5023", "R269", "Z9181", "E876" ]	Allergies: Aspirin / Enalapril / Diovan / morphine Chief Complaint: Lethargy Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is an [MASKED] yo man with h/o MVR, CABG in [MASKED], afib/flutter on warfarin, Hodgkin's and DLBCL s/p chemo currently in remission, who presents with lethargy. Patient was recently admitted to [MASKED] in [MASKED] after a fall. This was thought to be [MASKED] neuropathy from prior chemo with possible contribution of hyponatremia. Sodium was improving with fluid restriction on discharge and he was discharged to rehab. While there he has reportedly had worsening lethargy and weakness, notes indicate "global decline in all areas of functioning". He has been unable to participate in [MASKED] at all due to somnolence and was reportedly oriented only to self. He was seen at [MASKED] on [MASKED] and found to have new patchy opacity in left base concerning for atelectasis vs consolidation. He was treated with azithromycin with last dose planned for [MASKED]. However he continued to worsen, unable to eat or take meds properly due to ongoing lethargy, and was sent to ED. In the ED, initial vitals were: 97.0 71 152/100 18 100%RA - Exam notable for: bilateral crackles, +JVD, no pitting edema - Labs notable for: Na 126, sOsms 270, [MASKED] [MASKED]. UA with 5 WBCs, uOsms 788 uNa 81. - Imaging was notable for: CXR with mild pulmonary vascular congestion and moderate cardiomegaly, not changed in the interval. Patchy atelectasis in the lung bases. CT head without acute intracranial abnormality. - Patient was given: albuterol and ipratropium nebs - Renal was consulted given hyponatremia, and recommended 1L fluid restriction. Upon arrival to the floor, patient is feeling well without complaints. He does not feel weak or short of breath. He notes that he has been sleeping very poorly because he does to feel tired at night. He is otherwise unable to recall much about what has happened over the past few weeks and what brought him into the hospital. Past Medical History: PAST ONCOLOGY HISTORY: 1. Hodgkin's disease, 8 cycles [MASKED] MOPP, chlorambucil, vinblastine, procarbazine, predisone. - recurrent disease several months later. Treated with 2 cycles gemcitabine, navelbine, liposomal doxo. - A second complete remission after these two cycles followed by one additional cycle. Remainder of the therapy was discontinued due to excess toxicity. - Gemcitabine and Navelbine for improvement of his symptoms. - Brentuximab at [MASKED]. 2. Subsequently diffuse large B-cell lymphoma treated with six cycles of R-CHOP completed in [MASKED]. Now in remission PAST MEDICAL HISTORY: - Mitral regurgitation s/p MV repair (P2 triangular resection and 32 - mm [MASKED] II annuloplasty ring - [MASKED] - CAD s/p 2v CABG (LIMA to LAD, SVG to OM - [MASKED] - A-flutter/A-fib on warfarin - HTN - GERD - s/p b/l hernia repair - Hodgkin disease - Diffuse large B cell Lymphoma - Hypogammaglobulinemia ALLERGIES: ASA, enalapril, diovan, morphine Social History: [MASKED] Family History: Maternal aunt had some type of cancer either uterine or colon in her [MASKED] or [MASKED]. Maternal grandfather developed prostate cancer at [MASKED] and died at [MASKED]. Father had brain hemorrhage. Mother died at [MASKED]. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS - 97.4 \| 142/92 \| 90 \| 20 \| 97RA GENERAL - Initially agitated, refusing gown, interview, and physical, wanted to get out of bed and call [MASKED]. Suspicious of all hospital staff. After haloperidol, somnolent and appropriate. HEENT - PERRLA, sclera anicteric, oropharynx clear, tongue midline. NECK - JVP at mandible with patient at 30 degrees. CARDIAC - Regular rate and rhythm, S4 gallop, no murmurs or rubs. LUNGS - Mild crackles at the bases. ABDOMEN - Soft, non-tender, non-distended. No guarding, tenderness, or distention. EXTREMITIES - 2+ edema at ankle. Pulses intact, no cyanosis. SKIN - Some bruising over bilateral wrists. NEUROLOGIC - Intermittently somnolent (s/p Haldol), but oriented to person, place, time, and event. PERRLA, facial muscles bilaterally strong, shoulder shrug [MASKED] bilaterally, tongue midline. Elbow flex and extend [MASKED]. Hand grip [MASKED]. Hip flex [MASKED] bilaterally. Knee and ankle flex/extend [MASKED]. Patellar reflexes unable to elicit. DISCHARGE PHYSICAL EXAM: PHYSICAL EXAM: VITALS - 97.4 \| 105-120/83 \| 89 \| 18 \| 98RA GENERAL - Calm, pleasant, alert. Sitting in bed comfortably. HEENT - PERRLA, sclera anicteric, mucus membranes moist. NECK - JVP at midneck with patient at 45 degrees. CARDIAC - Irregular, no murmurs rubs or gallops appreciated. LUNGS - Clear to auscultation bilaterally. ABDOMEN - Soft, non-tender, no distention, guarding, or rigidity. EXTREMITIES - Erythema, edema, and warmth in R foot resolved. No tenderness to palpation in R foot. DP 2+ bilaterally. No edema bilaterally. SKIN - Some bruising over bilateral wrists. NEUROLOGIC - Alert. Confused, but appropriate. Oriented to place, year, and month. Pupils equal and reactive, EOM intact, facial muscles symmetrically strong, shoulder shrug equal symmetrically, tongue deviates L and R equally. R shoulder flexion [MASKED], L shoulder flexion [MASKED]. Elbow extension [MASKED] R, flexion [MASKED] R. Elbow flexion/extension [MASKED] L. Hand grip [MASKED] bilaterally. Hip flexion [MASKED] R, [MASKED] L. Ankle flexion/extension [MASKED] bilaterally. Pertinent Results: ADMISSION LABS: [MASKED] 05:38PM PH-7.34* [MASKED] 05:38PM K+-5.3* [MASKED] 05:38PM freeCa-1.08* [MASKED] 03:00PM URINE HOURS-RANDOM CREAT-105 SODIUM-81 [MASKED] 03:00PM URINE OSMOLAL-788 [MASKED] 03:00PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [MASKED] 03:00PM URINE RBC-3* WBC-5 BACTERIA-NONE YEAST-NONE EPI-0 [MASKED] 03:00PM URINE MUCOUS-OCC [MASKED] 01:46PM [MASKED] PO2-33* PCO2-44 PH-7.39 TOTAL CO2-28 BASE XS-0 [MASKED] 01:46PM O2 SAT-56 [MASKED] 01:17PM VoidSpec-SPECIMEN C [MASKED] 01:12PM GLUCOSE-93 UREA N-23* CREAT-0.8 SODIUM-126* POTASSIUM-6.4* CHLORIDE-91* TOTAL CO2-18* ANION GAP-23* [MASKED] 01:12PM estGFR-Using this [MASKED] 01:12PM ALT(SGPT)-31 AST(SGOT)-96* ALK PHOS-178* TOT BILI-1.1 [MASKED] 01:12PM cTropnT-<0.01 [MASKED] [MASKED] 01:12PM ALBUMIN-4.0 CALCIUM-9.6 PHOSPHATE-3.7 MAGNESIUM-2.1 [MASKED] 01:12PM OSMOLAL-270* [MASKED] 01:12PM WBC-6.9 RBC-4.80 HGB-14.2 HCT-43.2 MCV-90 MCH-29.6 MCHC-32.9 RDW-16.2* RDWSD-53.7* [MASKED] 01:12PM NEUTS-70.1 LYMPHS-6.1* MONOS-13.8* EOS-7.6* BASOS-1.0 IM [MASKED] AbsNeut-4.86 AbsLymp-0.42* AbsMono-0.96* AbsEos-0.53 AbsBaso-0.07 [MASKED] 01:12PM PLT COUNT-274 [MASKED] 01:12PM [MASKED] PTT-40.7* [MASKED] MICROBIOLOGY: None positive. PATHOLOGY: None IMAGING: CXR (PA AND LATERAL) [MASKED]: IMPRESSION: Mild pulmonary vascular congestion and moderate cardiomegaly, not changed in the interval. Patchy atelectasis in the lung bases. NON-CONTRAST HEAD CT [MASKED]: IMPRESSION: No acute intracranial abnormality. PORTABLE CXR [MASKED]: IMPRESSION: In comparison with study of [MASKED], the patient has taken a slightly better inspiration. Continued enlargement of the cardiac silhouette, though the vascular congestion has essentially cleared and there is no evidence of pleural effusion or acute focal pneumonia. Port-A-Cath tip is unchanged in position. TTE [MASKED]: IMPRESSION: In comparison with study of [MASKED], the patient has taken a slightly better inspiration. Continued enlargement of the cardiac silhouette, though the vascular congestion has essentially cleared and there is no evidence of pleural effusion or acute focal pneumonia. Port-A-Cath tip is unchanged in position. NCHCT [MASKED]: IMPRESSION: 1. No evidence of acute intracranial process. 2. Involutional changes and nonspecific [MASKED] matter hypodensities likely representing the sequelae of moderate chronic small vessel ischemic disease. MRI/MRA BRAIN AND NECK [MASKED]: IMPRESSION: 1. 1.1 cm focus of slow diffusion with associated FLAIR signal abnormality within the left precentral gyrus is concerning for an acute to subacute infarct. 2. Subtle 0.2 cm focus of high signal within the right frontal lobe, series 6, image 22 without definite correlate on the ADC maps, may be artifactual versus a focal small subacute infarct. Likely 0.2 cm focus of subacute infarction is seen within the right occipital lobe, series 6, image 15. 3. Unremarkable MRA of the head, specifically with normal arborization of the distal left MCA vessels. Moderate intracranial atherosclerotic disease. 4. Limited MRA of the neck without contrast. However, based on the 2D time-of-flight images, the bilateral internal carotid arteries appear to be unremarkable without evidence of significant stenosis by NASCET criteria. 5. Diffuse foci of low signal on the susceptibility weighted sequences within the cortical and subcortical regions may be secondary to hypertensive encephalopathy versus amyloid angiopathy. 6. Severe chronic microangiopathy. DISCHARGE LABS: [MASKED] 05:08AM BLOOD WBC-5.4 RBC-3.75* Hgb-11.3* Hct-35.1* MCV-94 MCH-30.1 MCHC-32.2 RDW-16.1* RDWSD-55.0* Plt [MASKED] [MASKED] 06:30AM BLOOD [MASKED] PTT-34.0 [MASKED] [MASKED] 05:08AM BLOOD Glucose-116* UreaN-32* Creat-0.9 Na-134 K-4.1 Cl-93* HCO3-33* AnGap-12 [MASKED] 05:08AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.1 Brief Hospital Course: SUMMARY: Mr. [MASKED] is an [MASKED] with h/o MVR and CABG in [MASKED], afib/flutter on warfarin, Hodgkin's and DLBCL s/p chemo in remission, who presents with lethargy, fluid overload, atrial fibrillation with RVR, and hyponatremia, course complicated by CVA. ACTIVE ISSUES: #Lethargy and #Delirium: We considered multiple causes for the patients change in mental status and believe it was multifactorial, with contribution from hyponatremia, fluid overload, and perhaps underlying dementia. Hyponatremia and fluid overload were treated as below. He was given haloperidol and olanzapine for agitation once. We attempted to normalize his sleep/wake cycle with trazadone and ramelteon at night. #CVA: Patient developed acute onset Right shoulder extension palsy on [MASKED]. NCHCT was WNL, but MRI on [MASKED] showed 1.1cm left precentral gyrus FLAIR hypodensity concerning for stroke. Neurology was consulted, who felt that patient's CVA may have been related to being briefly subtherapeutic on warfarin, although it was not entirely clear. Patient was briefly transitioned from metoprolol to digoxin for permissive hypertension. His Right shoulder extension improved over the course of the hospitalization, although he continued to have difficulty fully extending Right arm at discharge. As below, he was transitioned to apixaban. #Acute on chronic CHF: Patient was volume overloaded on exam, with a [MASKED] of 20000 and signs of overload on chest x-ray. Of note, TTE showed an EF on 30% (from 50% last [MASKED]), with multiple wall motion abnormalities. He notably was not on a statin, and we started him on high-dose statin. Of note, his metoprolol was changed to metoprolol succinate 62.5mg BID. He was diuresed with IV Lasix and then PO torsemide to a weight of 160 lbs. His dry weight is likely 155-160lb. He was discharged with a plan to follow up with his cardiologist. # Atrial fibrillation/flutter with RVR: The patient intermittently had RVR up to 140s on his home metoprolol. It was increased and converted to metoprolol succinate BID dosing. His HR stabilized on this dose of metoprolol in the s-90 s with some breakthrough tachycardia particularly in the morning, but uptitration was limited by blood pressure. He was briefly on digoxin immediately after his stroke in an effort to maintain both normal heart rate and sufficient BP. He was then transitioned back to metoprolol. With regards to his anticoagulation, a decision was made to transition patient from warfarin to apixaban in the setting of stroke and for comfort reasons. His INR on the day of discharge was 1.8, and he was started on apixaban 2.5mg BID. #Urinary retention: Patient notably retained urine during this hospitalization. He failed two voiding trials and required a Foley. Foley was removed prior to discharge, and patient was able to successfully void. He was discharged with a plan to follow up with urology. #Hyponatremia: Initially to 126, then improved with fluid restriction and diuresis, thought to be due to SIADH and heart failure. CHRONIC ISSUES: # CAD s/p CABG: home metoprolol was continued and atorvastatin 10mg was started. # GERD: continued omeprazole NEW MEDICATIONS: Metoprolol succinate 62.5mg BID Torsemide 20mg PO QDay Atorvastatin 10mg PO QHS Apixaban 2.5mg PO BID STOPPED MEDICATIONS: -Metoprolol tartrate TRANSITIONAL ISSUES: -f/u with cardiology -f/u with neurology -Please check daily weights in AM. If >3lb weight gain in one day or >5lb weight gain in 1 week, please notify MD -f/u with urology for urinary retention during this hospitalization -Would benefit from outpatient comprehensive geriatric evaluation with cognitive evaluation including MOCA +/- cognitive neurology vs. memory clinic appointment with Dr. [MASKED]. -Would benefit from formal hearing assessment outpatient for ?hearing aids. -If patient needs additional blood pressure medication, consider losartan (given HFrEF, ACE-I allergy) # CODE: DNR/DNI # CONTACT: HCP is wife [MASKED] [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Ipratropium-Albuterol Neb 1 NEB NEB Q8H 3. Azithromycin 250 mg PO Q24H 4. Vitamin D 1000 UNIT PO DAILY 5. Cyanocobalamin [MASKED] mcg PO DAILY 6. Docusate Sodium 100 mg PO DAILY 7. Metoprolol Tartrate 12.5 mg PO TID 8. Miconazole Powder 2% 1 Appl TP BID 9. Omeprazole 20 mg PO DAILY 10. Pyridoxine 100 mg PO DAILY 11. Vitamin B Complex 1 CAP PO BID 12. Warfarin 3 mg PO DAILY16 13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN sob or wheezing 14. GuaiFENesin Dose is Unknown PO Q6H:PRN cough Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. Metoprolol Succinate XL 62.5 mg PO BID 3. Torsemide 20 mg PO DAILY 4. GuaiFENesin [MASKED] mL PO Q6H:PRN cough 5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath or wheeze 6. Acyclovir 400 mg PO Q8H 7. Cyanocobalamin [MASKED] mcg PO DAILY 8. Docusate Sodium 100 mg PO DAILY 9. Miconazole Powder 2% 1 Appl TP BID 10. Omeprazole 20 mg PO DAILY 11. Pyridoxine 100 mg PO DAILY 12. Vitamin B Complex 1 CAP PO BID 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSES: ACUTE DECOMPENSATED SYSTOLIC HEART FAILURE, HYPONATREMIA, ATRIAL FLUTTER WITH RAPID VENTRICULAR RESPONSE SECONDARY DIAGNOSES: URINARY RETENTION, CORONARY ARTERY DISEASE, GASTROESOPHAGEAL REFLUX DISEASE, HYPERTENSION 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 Mr. [MASKED], You were seen in the hospital for confusion and sleepiness. Your symptoms were due to low sodium and fluid overload. We believe your low sodium is partially caused by an inappropriately high level of anti-diuretic hormone (called SIADH), so we treated you by restricting your fluid intake. We gave you a diuretic to treat your fluid overload and got an echocardiogram to assess any changes in your heart, which showed worsening heart failure. You had a fast heart rate, which we treated by increasing your metoprolol. You were additionally found to have a small stroke, which we treated by increasing your anticoagulation and changing your medications to allow for a higher blood pressure. When you go home, you should make sure to take your medicines and follow up with your doctors at your [MASKED] appointments. It is important to drink less than 1.5 liters of water a day and to limit your salt intake, ideally to less than 2 grams a day. It was our pleasure to take care of you. We wish you the very best! --Your care team at the [MASKED] Followup Instructions: [MASKED]	[]	[ "I110", "I4891", "Z951", "K219", "Z7901", "Z87891", "Z66" ]	[ "I110: Hypertensive heart disease with heart failure", "I63422: Cerebral infarction due to embolism of left anterior cerebral artery", "I63412: Cerebral infarction due to embolism of left middle cerebral artery", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "C8330: Diffuse large B-cell lymphoma, unspecified site", "D801: Nonfamilial hypogammaglobulinemia", "I4892: Unspecified atrial flutter", "I4891: Unspecified atrial fibrillation", "F05: Delirium due to known physiological condition", "F0390: Unspecified dementia without behavioral disturbance", "G4723: Circadian rhythm sleep disorder, irregular sleep wake type", "G8191: Hemiplegia, unspecified affecting right dominant side", "Z951: Presence of aortocoronary bypass graft", "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "K219: Gastro-esophageal reflux disease without esophagitis", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence", "I255: Ischemic cardiomyopathy", "R339: Retention of urine, unspecified", "Z66: Do not resuscitate", "I5023: Acute on chronic systolic (congestive) heart failure", "R269: Unspecified abnormalities of gait and mobility", "Z9181: History of falling", "E876: Hypokalemia" ]
10,088,966	27,696,952	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: Aspirin / Enalapril / Diovan / morphine Attending: ___. Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: Mitral valve repair (P2 triangular resection, 32mm annuloplasty ring )coronary artery bypass times two (LIMA to LAD and SVG to OM) ___ Take-back for bleeding ___ History of Present Illness: Professor ___ is a delightful ___ man with significant a history of hypertension, Hodgkin's and Non-Hodgkin's Lymphoma (in remission for ___ years), and mitral regurgitation. He was originally evaluated by the structural heart service in ___ for consideration of MitraClip. At that time, he was deemed intermediate risk for mitral valve repair and was not a candidate for MitraClip. He was relatively asymptomatic at that time and surgery was not pursued. His most recent echocardiogram demonstrated moderate/severe posterior leaflet mitral valve prolapse. There was eccentric, anteriorly-directed jet of severe (4+) mitral regurgitation. Since his last visit, he has noted worsening fatigue, occasional lightheadedness, rare palpitations, and intermittent lower extremity edema. He has gait instability at baseline. He denied syncope, dizziness, shortness of breath, dyspnea on exertion, orthopnea, or paroxysmal nocturnal dyspnea. Given the progression of his symptoms, he was referred back to Dr. ___ consideration of mitral valve repair vs. replacement. Past Medical History: 1. Eight cycles of ___ MOPP, chlorambucil, vinblastine, procarbazine, and prednisone. 2. Recurrent disease several months later. 3. Two cycles of gemcitabine, Navelbine, and liposomal doxo. 4. A second complete remission after these two cycles followed by one additional cycle. Remainder of the therapy was discontinued ___ to excess toxicity. 5. Mild hypercalcemia and right hip pain. 6. Gemcitabine and Navelbine for improvement of his symptoms. 7. Brentuximab at ___. PAST MEDICAL/SURGICAL HISTORY: # Hodgkin's lymphoma: - diagnosed in ___ after CT of the abdomen and pelvis revealed external iliac and retrocaval lymphadenopathy. Biopsy of pelvic node revealed classical Hodgkin's # Hypertension # GERD # s/p bilateral inguinal hernia repair Social History: ___ Family History: Maternal aunt had some type of cancer either uterine or colon in her ___ or ___. Maternal grandfather developed prostate cancer at ___ and died at ___. Father had brain hemorrhage. Mother died at ___. Physical Exam: BP: 134/84 (LA). Heart Rate: 92. O2 Saturation%: 99 (RA). Pain Score: 0. Height: 66.5" Weight: 157 lbs General: Pleasant elderly man, NAD Skin: Warm, dry, intact HEENT: NCAT, sclerae anicteric, OP benign Neck: Supple, full ROM Chest: Lungs clear bilaterally Heart: Regular rate and rhythm, IV/VI holosystolic murmur radiating to apex Abdomen: Normal BS, soft, non-distended, tender to palpation RUQ. No rebound or guarding. Extremities: No obvious deformity, trace ___, gait unsteady at times, furniture walks. Using cane in hall. Varicosities: none appreciated Neuro: Alert and oriented, asking questions appropriately Pulses: 2+ pedal pulses Carotid Bruit: bruit vs. transmitted murmur bilaterally Pertinent Results: ___ ECHOCARDIOGRAPHY REPORT ___ ___ MRN: ___ TEE (Complete) Done ___ at 9:05:31 AM FINAL Referring Physician ___ ___ of Cardiothoracic Surg ___ Status: Inpatient DOB: ___ Age (years): ___ M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Hypertension. Mitral valve disease. Diagnosis: I34.0 Test Information Date/Time: ___ at 09:05 ___ MD: ___, MD Test Type: TEE (Complete) Sonographer: ___, MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: Machine: philips Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Ascending: 3.5 cm <= 3.4 cm Aortic Valve - Peak Gradient: 5 mm Hg < 20 mm Hg Aortic Valve - LVOT diam: 2.2 cm Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the ___. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. No VSD. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. Simple atheroma in descending aorta. Mildly dilated abdominal aorta. No thoracic aortic dissection. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Partial mitral leaflet flail. Severe (4+) MR. ___ to the eccentric MR ___, its severity may be underestimated (Coanda effect). TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Written informed consent was obtained from the ___. A TEE was performed in the location listed above. I certify I was present in compliance with ___ regulations. The ___ was under general anesthesia throughout the procedure. No TEE related complications. Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is no ventricular septal defect. There is mild global free wall hypokinesis. The ascending aorta is mildly dilated. The transverse and descending thoracic aorta are normal in diameter. There are simple atheroma in the descending thoracic aorta. The abdominal aorta is mildly dilated. No thoracic aortic dissection is seen. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is partial posterior mitral leaflet flail. Severe (4+) mitral regurgitation is seen. ___ to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is no pericardial effusion. Post-CPB: The ___ is paced, on an infusion of epinephrine. There is a mitral ring annuloplasty with no leak and no MR. ___ residual mean gradient. LV is mildy hypokinetic with HK of the inferior and infero-septal walls. RV is mildly HK. Aorta intact. . ___ 06:03AM BLOOD WBC-6.9 RBC-3.13 Hgb-9.4* Hct-28.2* MCV-90 MCH-30.0 MCHC-33.3 RDW-17.2* RDWSD-55.3* Plt ___ ___ 05:51AM BLOOD WBC-5.2 RBC-2.89* Hgb-8.7* Hct-25.7* MCV-89 MCH-30.1 MCHC-33.9 RDW-16.6* RDWSD-54.1* Plt ___ ___ 05:58AM BLOOD WBC-6.8 RBC-3.89* Hgb-11.9* Hct-34.4* MCV-88 MCH-30.6 MCHC-34.6 RDW-16.7* RDWSD-53.0* Plt ___ ___ 06:03AM BLOOD ___ ___ 09:00AM BLOOD ___ ___ 03:03AM BLOOD ___ PTT-29.5 ___ ___ 06:03AM BLOOD Glucose-121* UreaN-37* Creat-1.0 Na-131* K-3.9 Cl-94* HCO3-22 AnGap-19 ___ 06:40AM BLOOD Glucose-108* UreaN-32* Creat-0.8 Na-129* K-3.7 Cl-89* HCO3-27 AnGap-17 ___ 06:03AM BLOOD ALT-26 AST-49* LD(LDH)-306* AlkPhos-221* Amylase-63 TotBili-3.2* ___ 05:51AM BLOOD ALT-24 AST-43* LD(LDH)-185 AlkPhos-192* TotBili-3.9* DirBili-1.9* IndBili-2.0 ___ 06:40AM BLOOD ALT-24 AST-63* LD(LDH)-303* AlkPhos-209* Amylase-47 TotBili-5.1* ___ 05:25PM BLOOD ALT-10 AST-18 LD(___)-141 AlkPhos-79 Amylase-41 TotBili-0.6 ___ 06:03AM BLOOD Mg-1.8 Brief Hospital Course: Mr. ___ underwent a cardiac catheterization on ___ in preparation for a mitral valve repair the following day. His cardiac catheterization revealed single vessel coronary artery disease. On ___ he underwent a coronary artery bypass grafting times one and a mitral valve repair. Please see the operative note for details. He tolerated the procedure well and was transferred to the surgical intensive care unit. He had high chest tube output and hemodynamic instability so he returned to the operating room for bleeding. He again returned to the surgical intensive care unit and extubated without incident. The following day his pressors were weaned and his Swan was removed. His chest tubes were removed the following day and he transferred to the step down floor. He appeared jaundiced- LFTs were slightly elevated- but trended toward normal prior to discharge. Jaundice appearance improved. Statin is held. AFib developed and he converted to SR. He will be anti-coagulated with Warfarin. Foley was re-placed for urinary retention. Flomax was started and Foley was subsequently successfully discontinued. He developed swelling of bilateral upper extremities. Ultrasound revealed superficial thrombophlebitis- without DVT. The ___ was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 7 the ___ was ambulating, yet deconditioned, the wound was healing and pain was controlled with oral analgesics. The ___ was discharged to Care One in ___ in good condition with appropriate follow up instructions. Medications on Admission: Acyclovir 400 mg tablet three times per day Calcium Citrate 250 mg tablet three times a day Cialis 5 mg tablet once a day as needed Losartan 25 mg tablet once a day Magnesium 250 mg tablet daily Omeprazole 20 mg capsule once a day as needed Triamcinolone Acetonide 0.1 % \cream up to twice a day as directed Vitamin B Complex ___ mg tablet twice a day Vitamin B2 50 mg tablet, 5 tablets once a day Vitamin B6 100 mg tablet once a day Vitamin B-12 1,000 mcg tablet, two tablets once a day Vitamin D3 1,000 unit capsule three times a day(OTC) Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 2. Amiodarone 200 mg PO BID 3. Aspirin EC 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Furosemide 40 mg PO BID Duration: 7 Days 6. Metoprolol Tartrate 50 mg PO TID 7. Omeprazole 20 mg PO DAILY 8. Potassium Chloride 20 mEq PO BID Duration: 7 Days 9. Tamsulosin 0.4 mg PO QHS 10. TraMADol 50 mg PO Q4H:PRN Pain - Moderate RX tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #40 Tablet Refills:0 11. Vitamin B Complex 1 CAP PO DAILY 12. Warfarin 2 mg PO DAILY16 afib dose to change for goal INR ___, dx: AFib 13. Acyclovir 400 mg PO Q8H 14. HELD- Losartan Potassium 25 mg PO DAILY This medication was held. Do not restart Losartan Potassium until resumed by PCP ___: Extended Care Facility: ___ Discharge Diagnosis: coronary artery disease mitral regurgitation B Cell Lymphoma Back Pain Cataracts Cervical Spondylosis Fall History/Risk Gait Disorder Gastroesophageal Reflux Disease Gynecomastia Hodgkin's Lymphoma Hyperparathyroidism Hypertension Hypogammaglobulinema Mitral Regurgitation Mitral Valve Prolapse Neuropathy Non-hodkin's Lymphoma Osteoarthritis Osteoporosis Pons Lesion (telangiectasias or cavernoma) Primary Hypogonadism Pulmonary Hypertension Schwannoma Squamous Cell Carcinoma Vitamin Deficiency Past Surgical History: Cataract surgery, bilateral Inguinal hernia repair, bilateral MOHS face Discharge Condition: Alert and oriented x3 non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours* Followup Instructions: ___	[ "I340", "J942", "I272", "I4891", "R17", "I808", "D62", "I2510", "I2584", "Z8572", "Z8571", "I10", "E569", "K219", "Z87891", "R339", "Z859" ]	Allergies: Aspirin / Enalapril / Diovan / morphine Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: Mitral valve repair (P2 triangular resection, 32mm annuloplasty ring )coronary artery bypass times two (LIMA to LAD and SVG to OM) [MASKED] Take-back for bleeding [MASKED] History of Present Illness: Professor [MASKED] is a delightful [MASKED] man with significant a history of hypertension, Hodgkin's and Non-Hodgkin's Lymphoma (in remission for [MASKED] years), and mitral regurgitation. He was originally evaluated by the structural heart service in [MASKED] for consideration of MitraClip. At that time, he was deemed intermediate risk for mitral valve repair and was not a candidate for MitraClip. He was relatively asymptomatic at that time and surgery was not pursued. His most recent echocardiogram demonstrated moderate/severe posterior leaflet mitral valve prolapse. There was eccentric, anteriorly-directed jet of severe (4+) mitral regurgitation. Since his last visit, he has noted worsening fatigue, occasional lightheadedness, rare palpitations, and intermittent lower extremity edema. He has gait instability at baseline. He denied syncope, dizziness, shortness of breath, dyspnea on exertion, orthopnea, or paroxysmal nocturnal dyspnea. Given the progression of his symptoms, he was referred back to Dr. [MASKED] consideration of mitral valve repair vs. replacement. Past Medical History: 1. Eight cycles of [MASKED] MOPP, chlorambucil, vinblastine, procarbazine, and prednisone. 2. Recurrent disease several months later. 3. Two cycles of gemcitabine, Navelbine, and liposomal doxo. 4. A second complete remission after these two cycles followed by one additional cycle. Remainder of the therapy was discontinued [MASKED] to excess toxicity. 5. Mild hypercalcemia and right hip pain. 6. Gemcitabine and Navelbine for improvement of his symptoms. 7. Brentuximab at [MASKED]. PAST MEDICAL/SURGICAL HISTORY: # Hodgkin's lymphoma: - diagnosed in [MASKED] after CT of the abdomen and pelvis revealed external iliac and retrocaval lymphadenopathy. Biopsy of pelvic node revealed classical Hodgkin's # Hypertension # GERD # s/p bilateral inguinal hernia repair Social History: [MASKED] Family History: Maternal aunt had some type of cancer either uterine or colon in her [MASKED] or [MASKED]. Maternal grandfather developed prostate cancer at [MASKED] and died at [MASKED]. Father had brain hemorrhage. Mother died at [MASKED]. Physical Exam: BP: 134/84 (LA). Heart Rate: 92. O2 Saturation%: 99 (RA). Pain Score: 0. Height: 66.5" Weight: 157 lbs General: Pleasant elderly man, NAD Skin: Warm, dry, intact HEENT: NCAT, sclerae anicteric, OP benign Neck: Supple, full ROM Chest: Lungs clear bilaterally Heart: Regular rate and rhythm, IV/VI holosystolic murmur radiating to apex Abdomen: Normal BS, soft, non-distended, tender to palpation RUQ. No rebound or guarding. Extremities: No obvious deformity, trace [MASKED], gait unsteady at times, furniture walks. Using cane in hall. Varicosities: none appreciated Neuro: Alert and oriented, asking questions appropriately Pulses: 2+ pedal pulses Carotid Bruit: bruit vs. transmitted murmur bilaterally Pertinent Results: [MASKED] ECHOCARDIOGRAPHY REPORT [MASKED] [MASKED] MRN: [MASKED] TEE (Complete) Done [MASKED] at 9:05:31 AM FINAL Referring Physician [MASKED] [MASKED] of Cardiothoracic Surg [MASKED] Status: Inpatient DOB: [MASKED] Age (years): [MASKED] M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Hypertension. Mitral valve disease. Diagnosis: I34.0 Test Information Date/Time: [MASKED] at 09:05 [MASKED] MD: [MASKED], MD Test Type: TEE (Complete) Sonographer: [MASKED], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: Machine: philips Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Ascending: 3.5 cm <= 3.4 cm Aortic Valve - Peak Gradient: 5 mm Hg < 20 mm Hg Aortic Valve - LVOT diam: 2.2 cm Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the [MASKED]. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. No VSD. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. Simple atheroma in descending aorta. Mildly dilated abdominal aorta. No thoracic aortic dissection. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Partial mitral leaflet flail. Severe (4+) MR. [MASKED] to the eccentric MR [MASKED], its severity may be underestimated (Coanda effect). TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Written informed consent was obtained from the [MASKED]. A TEE was performed in the location listed above. I certify I was present in compliance with [MASKED] regulations. The [MASKED] was under general anesthesia throughout the procedure. No TEE related complications. Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is no ventricular septal defect. There is mild global free wall hypokinesis. The ascending aorta is mildly dilated. The transverse and descending thoracic aorta are normal in diameter. There are simple atheroma in the descending thoracic aorta. The abdominal aorta is mildly dilated. No thoracic aortic dissection is seen. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is partial posterior mitral leaflet flail. Severe (4+) mitral regurgitation is seen. [MASKED] to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is no pericardial effusion. Post-CPB: The [MASKED] is paced, on an infusion of epinephrine. There is a mitral ring annuloplasty with no leak and no MR. [MASKED] residual mean gradient. LV is mildy hypokinetic with HK of the inferior and infero-septal walls. RV is mildly HK. Aorta intact. . [MASKED] 06:03AM BLOOD WBC-6.9 RBC-3.13 Hgb-9.4* Hct-28.2* MCV-90 MCH-30.0 MCHC-33.3 RDW-17.2* RDWSD-55.3* Plt [MASKED] [MASKED] 05:51AM BLOOD WBC-5.2 RBC-2.89* Hgb-8.7* Hct-25.7* MCV-89 MCH-30.1 MCHC-33.9 RDW-16.6* RDWSD-54.1* Plt [MASKED] [MASKED] 05:58AM BLOOD WBC-6.8 RBC-3.89* Hgb-11.9* Hct-34.4* MCV-88 MCH-30.6 MCHC-34.6 RDW-16.7* RDWSD-53.0* Plt [MASKED] [MASKED] 06:03AM BLOOD [MASKED] [MASKED] 09:00AM BLOOD [MASKED] [MASKED] 03:03AM BLOOD [MASKED] PTT-29.5 [MASKED] [MASKED] 06:03AM BLOOD Glucose-121* UreaN-37* Creat-1.0 Na-131* K-3.9 Cl-94* HCO3-22 AnGap-19 [MASKED] 06:40AM BLOOD Glucose-108* UreaN-32* Creat-0.8 Na-129* K-3.7 Cl-89* HCO3-27 AnGap-17 [MASKED] 06:03AM BLOOD ALT-26 AST-49* LD(LDH)-306* AlkPhos-221* Amylase-63 TotBili-3.2* [MASKED] 05:51AM BLOOD ALT-24 AST-43* LD(LDH)-185 AlkPhos-192* TotBili-3.9* DirBili-1.9* IndBili-2.0 [MASKED] 06:40AM BLOOD ALT-24 AST-63* LD(LDH)-303* AlkPhos-209* Amylase-47 TotBili-5.1* [MASKED] 05:25PM BLOOD ALT-10 AST-18 LD([MASKED])-141 AlkPhos-79 Amylase-41 TotBili-0.6 [MASKED] 06:03AM BLOOD Mg-1.8 Brief Hospital Course: Mr. [MASKED] underwent a cardiac catheterization on [MASKED] in preparation for a mitral valve repair the following day. His cardiac catheterization revealed single vessel coronary artery disease. On [MASKED] he underwent a coronary artery bypass grafting times one and a mitral valve repair. Please see the operative note for details. He tolerated the procedure well and was transferred to the surgical intensive care unit. He had high chest tube output and hemodynamic instability so he returned to the operating room for bleeding. He again returned to the surgical intensive care unit and extubated without incident. The following day his pressors were weaned and his Swan was removed. His chest tubes were removed the following day and he transferred to the step down floor. He appeared jaundiced- LFTs were slightly elevated- but trended toward normal prior to discharge. Jaundice appearance improved. Statin is held. AFib developed and he converted to SR. He will be anti-coagulated with Warfarin. Foley was re-placed for urinary retention. Flomax was started and Foley was subsequently successfully discontinued. He developed swelling of bilateral upper extremities. Ultrasound revealed superficial thrombophlebitis- without DVT. The [MASKED] was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 7 the [MASKED] was ambulating, yet deconditioned, the wound was healing and pain was controlled with oral analgesics. The [MASKED] was discharged to Care One in [MASKED] in good condition with appropriate follow up instructions. Medications on Admission: Acyclovir 400 mg tablet three times per day Calcium Citrate 250 mg tablet three times a day Cialis 5 mg tablet once a day as needed Losartan 25 mg tablet once a day Magnesium 250 mg tablet daily Omeprazole 20 mg capsule once a day as needed Triamcinolone Acetonide 0.1 % \cream up to twice a day as directed Vitamin B Complex [MASKED] mg tablet twice a day Vitamin B2 50 mg tablet, 5 tablets once a day Vitamin B6 100 mg tablet once a day Vitamin B-12 1,000 mcg tablet, two tablets once a day Vitamin D3 1,000 unit capsule three times a day(OTC) Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 2. Amiodarone 200 mg PO BID 3. Aspirin EC 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Furosemide 40 mg PO BID Duration: 7 Days 6. Metoprolol Tartrate 50 mg PO TID 7. Omeprazole 20 mg PO DAILY 8. Potassium Chloride 20 mEq PO BID Duration: 7 Days 9. Tamsulosin 0.4 mg PO QHS 10. TraMADol 50 mg PO Q4H:PRN Pain - Moderate RX tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #40 Tablet Refills:0 11. Vitamin B Complex 1 CAP PO DAILY 12. Warfarin 2 mg PO DAILY16 afib dose to change for goal INR [MASKED], dx: AFib 13. Acyclovir 400 mg PO Q8H 14. HELD- Losartan Potassium 25 mg PO DAILY This medication was held. Do not restart Losartan Potassium until resumed by PCP [MASKED]: Extended Care Facility: [MASKED] Discharge Diagnosis: coronary artery disease mitral regurgitation B Cell Lymphoma Back Pain Cataracts Cervical Spondylosis Fall History/Risk Gait Disorder Gastroesophageal Reflux Disease Gynecomastia Hodgkin's Lymphoma Hyperparathyroidism Hypertension Hypogammaglobulinema Mitral Regurgitation Mitral Valve Prolapse Neuropathy Non-hodkin's Lymphoma Osteoarthritis Osteoporosis Pons Lesion (telangiectasias or cavernoma) Primary Hypogonadism Pulmonary Hypertension Schwannoma Squamous Cell Carcinoma Vitamin Deficiency Past Surgical History: Cataract surgery, bilateral Inguinal hernia repair, bilateral MOHS face Discharge Condition: Alert and oriented x3 non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [MASKED] Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours* Followup Instructions: [MASKED]	[]	[ "I4891", "D62", "I2510", "I10", "K219", "Z87891" ]	[ "I340: Nonrheumatic mitral (valve) insufficiency", "J942: Hemothorax", "I272: Other secondary pulmonary hypertension", "I4891: Unspecified atrial fibrillation", "R17: Unspecified jaundice", "I808: Phlebitis and thrombophlebitis of other sites", "D62: Acute posthemorrhagic anemia", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I2584: Coronary atherosclerosis due to calcified coronary lesion", "Z8572: Personal history of non-Hodgkin lymphomas", "Z8571: Personal history of Hodgkin lymphoma", "I10: Essential (primary) hypertension", "E569: Vitamin deficiency, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "R339: Retention of urine, unspecified", "Z859: Personal history of malignant neoplasm, unspecified" ]
10,089,076	27,132,872	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right femoral neck fracture, Right femoral shaft fracture, and Left scapula fracture, now s/p Right DHS and retrograde femur IMN on ___. Major Surgical or Invasive Procedure: Right DHS and retrograde femur IMN on ___ History of Present Illness: ___ F pedestrian struck, transferred from ___ with L femoral neck and shaft fractures, and R scapula fracture. She was hit around 7pm last night (___) and is uncertain of exactly how she fell. CT head/face notable only for nasal bone and dental fractures, and remaining imaging including CT neck and torso were unremarkable. She denies any numbness or tingling in the arms or legs. Past Medical History: None Social History: Works in a ___. Occasional alcohol, denies tobacco or illicit drug use. Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have Right femoral shaft fracture, and Left scapula fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for Right DHS and retrograde femur IMN, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. During the course of her admission, the patient required transfusion with 2 units of pRBC and repletion of Mg/K which was successful. Patient remained hemodynamically stable. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is NVI distally in all extremities, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Calcium Carbonate 1250 mg PO TID 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QPM Start: Today - ___, First Dose: Next Routine Administration Time RX enoxaparin 40 mg/0.4 mL 40 MG SC QPM Disp #28 Syringe Refills:0 5. Multivitamins 1 TAB PO DAILY 6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth Q4H; PRN Disp #60 Tablet Refills:0 7. Senna 8.6 mg PO DAILY 8. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right femoral neck fracture, Right femoral shaft fracture, and Left scapula fracture, now s/p Right DHS and retrograde femur IMN on ___. Discharge Condition: AOX3, ambulating with assistance of ___, overall stable Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - TDWB RLE, WBAT LUE MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Lovenox 40mg daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. Physical Therapy: Activity: Activity: Out of bed w/ assist Right lower extremity: Touchdown weight bearing Left lower extremity: Full weight bearing Left upper extremity: Full weight bearing Encourage turning, deep breathing and coughing qhour when awake. Treatments Frequency: Dressing changes daily. Elevation as tolerated. Staples/sutures will be removed at follow-up. Followup Instructions: ___	[ "S72091A", "D62", "S022XXA", "S42102A", "S025XXA", "V892XXA", "Y929" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Right femoral neck fracture, Right femoral shaft fracture, and Left scapula fracture, now s/p Right DHS and retrograde femur IMN on [MASKED]. Major Surgical or Invasive Procedure: Right DHS and retrograde femur IMN on [MASKED] History of Present Illness: [MASKED] F pedestrian struck, transferred from [MASKED] with L femoral neck and shaft fractures, and R scapula fracture. She was hit around 7pm last night ([MASKED]) and is uncertain of exactly how she fell. CT head/face notable only for nasal bone and dental fractures, and remaining imaging including CT neck and torso were unremarkable. She denies any numbness or tingling in the arms or legs. Past Medical History: None Social History: Works in a [MASKED]. Occasional alcohol, denies tobacco or illicit drug use. Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have Right femoral shaft fracture, and Left scapula fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [MASKED] for Right DHS and retrograde femur IMN, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to rehab was appropriate. During the course of her admission, the patient required transfusion with 2 units of pRBC and repletion of Mg/K which was successful. Patient remained hemodynamically stable. The [MASKED] hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is NVI distally in all extremities, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up with Dr. [MASKED] routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Calcium Carbonate 1250 mg PO TID 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QPM Start: Today - [MASKED], First Dose: Next Routine Administration Time RX enoxaparin 40 mg/0.4 mL 40 MG SC QPM Disp #28 Syringe Refills:0 5. Multivitamins 1 TAB PO DAILY 6. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX oxycodone 5 mg [MASKED] tablet(s) by mouth Q4H; PRN Disp #60 Tablet Refills:0 7. Senna 8.6 mg PO DAILY 8. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Right femoral neck fracture, Right femoral shaft fracture, and Left scapula fracture, now s/p Right DHS and retrograde femur IMN on [MASKED]. Discharge Condition: AOX3, ambulating with assistance of [MASKED], overall stable Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - TDWB RLE, WBAT LUE MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Lovenox 40mg daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. Physical Therapy: Activity: Activity: Out of bed w/ assist Right lower extremity: Touchdown weight bearing Left lower extremity: Full weight bearing Left upper extremity: Full weight bearing Encourage turning, deep breathing and coughing qhour when awake. Treatments Frequency: Dressing changes daily. Elevation as tolerated. Staples/sutures will be removed at follow-up. Followup Instructions: [MASKED]	[]	[ "D62", "Y929" ]	[ "S72091A: Other fracture of head and neck of right femur, initial encounter for closed fracture", "D62: Acute posthemorrhagic anemia", "S022XXA: Fracture of nasal bones, initial encounter for closed fracture", "S42102A: Fracture of unspecified part of scapula, left shoulder, initial encounter for closed fracture", "S025XXA: Fracture of tooth (traumatic), initial encounter for closed fracture", "V892XXA: Person injured in unspecified motor-vehicle accident, traffic, initial encounter", "Y929: Unspecified place or not applicable" ]
10,089,119	22,582,998	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: polydipsia, polyuria, nausea, weight loss, fatigue Major Surgical or Invasive Procedure: None History of Present Illness: ___ pmhx IDDMI presenting with cc fatigue. Patient reports 1 week polyuria, polydipsia, insulin pump with notification that there is an occlusion for last week. Called PCP, found to have positive ketones, and was sent to ED. In ED initial VS: 97.9, HR 114, BP 117/94, RR 16, 100% RA Glucose 326 Labs significant for: hgb 16.7, Na 131, Cl 89, Bicarb 10, BS 392, pH 7.2, pCO2 33, U/A +ketones Patient was given: 2L NS, started on insulin drip Imaging notable for: clean CXR On arrival to the MICU, she confirms the above history. Past Medical History: ADHD Anxiety Social History: ___ Family History: She has a second cousin with Type 1 diabetes. No other family member with Type 1. Physical Exam: ADMISSION PHYSICAL EXAM: ======================= VITALS: Reviewed in metavision GEN: well appearing, NAD HEENT: MM tacky CV: RRR, nl s1/s2, no mrg PULM: CTA b/l no wrc GI: S/ND/NT, no HSM, BS normoactive EXT: WWP DISCHARGE PHYSICAL EXAM: ========================= VITALS: 24 HR Data (last updated ___ @ 817) Temp: 98.0 (Tm 98.2), BP: 116/74 (103-116/70-74), HR: 81 (66-96), RR: 18, O2 sat: 99% (97-100), O2 delivery: Ra GENERAL: Alert and interactive. In no acute distress. HEENT: NCAT. PERRL. Sclera anicteric and without injection. Moist mucous membranes. CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. Breathing comfortably in ra. ABDOMEN: Soft, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Distal pulses 2+ SKIN: Warm and well perfused. No rash. NEUROLOGIC: CN2-12 intact. Strength and sensation intact throughout. Gait deferred. AOx3. Pertinent Results: ADMISSION LABS ============== ___ 01:53PM PLT COUNT-255 ___ 01:53PM NEUTS-61.4 ___ MONOS-3.8* EOS-1.3 BASOS-0.8 IM ___ AbsNeut-4.85 AbsLymp-2.56 AbsMono-0.30 AbsEos-0.10 AbsBaso-0.06 ___ 01:53PM WBC-7.9 RBC-5.29* HGB-16.7* HCT-47.3* MCV-89 MCH-31.6 MCHC-35.3 RDW-12.5 RDWSD-41.1 ___ 01:53PM %HbA1c-10.7* eAG-260* ___ 01:53PM GLUCOSE-392* UREA N-20 CREAT-1.1 SODIUM-131* POTASSIUM-4.7 CHLORIDE-89* TOTAL CO2-10* ANION GAP-32* ___ 02:02PM O2 SAT-53 ___ 02:02PM PO2-33* PCO2-33* PH-7.20* TOTAL CO2-13* BASE XS--14 ___ 03:55PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE EPI-1 ___ 03:55PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30* GLUCOSE-1000* KETONE-150* BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 03:55PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 03:55PM URINE UCG-NEGATIVE ___ 06:40PM GLUCOSE-226* UREA N-15 CREAT-0.9 SODIUM-133* POTASSIUM-5.2 CHLORIDE-106 TOTAL CO2-12* ANION GAP-15 ___ 06:54PM O2 SAT-62 ___ 06:54PM GLUCOSE-207* NA+-133 K+-4.4 CL--107 TCO2-14* ___ 06:54PM ___ PH-7.23* ___ 09:57PM GLUCOSE-211* UREA N-11 CREAT-0.8 SODIUM-140 POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-15* ANION GAP-17 ___ 10:12PM ___ TEMP-36.1 PO2-28* PCO2-39 PH-7.26* TOTAL CO2-18* BASE XS--9 IMAGING: ========= +CHEST (PA & LAT) ___ IMPRESSION: No acute cardiopulmonary process. DISCHARGE LABS =============== ___ 05:02AM BLOOD WBC-4.8 RBC-4.47 Hgb-13.8 Hct-39.3 MCV-88 MCH-30.9 MCHC-35.1 RDW-12.7 RDWSD-40.7 Plt ___ ___ 05:02AM BLOOD Glucose-225* UreaN-15 Creat-0.8 Na-139 K-3.5 Cl-105 HCO3-24 AnGap-10 ___ 05:02AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.8 Brief Hospital Course: Ms. ___ a ___ year old female with a past medical history of Type 1 DM diagnosed in ___, who presented with nausea, polyuria, polydipsia, weight loss, and fatigue, who was found to be in DKA ___ malfunctioning insulin pump, insufficient subcutaneous insulin, and overall poor compliance to diabetes management. She was initially admitted to the ICU, started on an insulin drip and transitioned to SC insulin based on ___ recommendations. ACUTE ISSUES: ============= # Diabetic Ketoacidosis # T1DM: The patient presented with DKA in setting of occlusion in pump tubing and insufficient supplemental subcutaneous insulin. Of note, her A1c was 10.7, suggesting poor control overall. Her anion gap closed and FSBG ranging from 100 to low 200s on discharge. The patient requested to be switched from an insulin pump to injections. Per ___ recommendation, she will be on Glargine 13U BID (AM and ___, Humalog 8U with all meals, and ISS. She was seen by diabetes educator for education with blood sugar checks and insulin injections. She will be seen by ___ shortly after discharge. CHRONIC ISSUES: =============== # ADHD: The patient has not been on Ritalin for 1 month due to losing her home prescription. She states she was diagnosed with ADHD ___ years ago and has been doing well with Ritalin overall. She did not receive Ritalin while inpatient, but should follow up with her PCP to refill her prescription and continue monitoring her symptoms. She is motivated to taper off this medication eventually. # Anxiety: The patient has not been on Lexapro for >1 week due to not filling her home prescription. She did not require Lexapro during this hospitalization and denied any symptoms of anxiety. She was able to refill her prescription at discharge. TRANSITIONAL ISSUES: ==================== []Please continue to monitor for symptoms of DKA, including nausea, vomiting, diaphoresis. []Please encourage carb counting and close monitoring of her BG []The patient will be following up for further management of her T1DM with ___ []At discharge, her insulin regimen is: Glargine 13U BID (AM and ___, Humalog 8U with all meals, and ISS []FYI: the patient requested to be switched from an insulin pump to SC injections []Please continue to monitor ADHD symptoms and prescribe Ritalin as clinically indicated []her UA on admission showed 30 protein. Would monitor proteinurea for evidence of diabetic nephropathy iso uncontrolled DM. [] make sure she also has a annual fundus exam and neuropathy check Pt was seen and examined w residents on am rounds on ___. Pt with reasonable blood sugar control and no longer with increased anion gap. Pt wants to leave and I agree she can be safely discharged to home w close f/u in ___ and w her pcp. Okay to DC. >30 min spent on DC related activities. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Escitalopram Oxalate 10 mg PO DAILY 2. Methylphenidate SR 30 mg PO QAM 3. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Basal rate minimum: 1 units/hr Target glucose: 80-180 Discharge Medications: 1. Glargine 13 Units Breakfast Glargine 13 Units Bedtime Humalog 8 Units Breakfast Humalog 8 Units Lunch Humalog 8 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL (3 mL) AS DIR 13 Units before BKFT; 13 Units before BED; Disp #7 Syringe Refills:0 RX insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR Up to 10 Units QID per sliding scale 8 Units before LNCH; Units QID per sliding scale 8 Units before DINR; Units QID per sliding scal Disp #9 Syringe Refills:0 2. Escitalopram Oxalate 10 mg PO DAILY 3. Methylphenidate SR 30 mg PO QAM 4.test strips one touch verio Sig: check BG 8 times daily Disp# 100 (one hundred) strips Refills: 2 (zero) 5.Insulin pen needles 32G, ___ (4 mm nano) Sig: use to inject 5 times daily Disp# 100 (one hundred) needles Refills: 2 (zero) Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: =================== 1. Diabetic ketoacidosis 2. Type 1 DM SECONDARY DIAGNOSES: ================== 1. Generalized Anxiety Disorder 2. ADHD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___! WHY DID I COME TO THE HOSPITAL? You were feeling nauseous and weak at home. You were found to have diabetic ketoacidosis (DKA), which is when your blood glucose becomes very high due to a lack of insulin. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? We gave you insulin and other medications to treat the DKA. At the time of discharge, your sugars and electrolytes were back in the normal range. WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL? -You should follow up with your primary care doctor and outpatient endocrinologist. -Please continue to take all of your medications and follow up with all of your doctors. -___ continue to monitor your symptoms, and seek medical attention if you experience any nausea, vomiting, sweating, lightheadedness, or any other symptom that concerns you. -Please continue to monitor your sugars, and take your insulin as prescribed. We wish you the best! Sincerely, Your ___ Care Team Followup Instructions: ___	[ "T85614A", "E1010", "Z794", "Z9641", "F909", "F411", "T43636A", "Y92009", "T383X6A", "T43226A", "Z91128" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: polydipsia, polyuria, nausea, weight loss, fatigue Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] pmhx IDDMI presenting with cc fatigue. Patient reports 1 week polyuria, polydipsia, insulin pump with notification that there is an occlusion for last week. Called PCP, found to have positive ketones, and was sent to ED. In ED initial VS: 97.9, HR 114, BP 117/94, RR 16, 100% RA Glucose 326 Labs significant for: hgb 16.7, Na 131, Cl 89, Bicarb 10, BS 392, pH 7.2, pCO2 33, U/A +ketones Patient was given: 2L NS, started on insulin drip Imaging notable for: clean CXR On arrival to the MICU, she confirms the above history. Past Medical History: ADHD Anxiety Social History: [MASKED] Family History: She has a second cousin with Type 1 diabetes. No other family member with Type 1. Physical Exam: ADMISSION PHYSICAL EXAM: ======================= VITALS: Reviewed in metavision GEN: well appearing, NAD HEENT: MM tacky CV: RRR, nl s1/s2, no mrg PULM: CTA b/l no wrc GI: S/ND/NT, no HSM, BS normoactive EXT: WWP DISCHARGE PHYSICAL EXAM: ========================= VITALS: 24 HR Data (last updated [MASKED] @ 817) Temp: 98.0 (Tm 98.2), BP: 116/74 (103-116/70-74), HR: 81 (66-96), RR: 18, O2 sat: 99% (97-100), O2 delivery: Ra GENERAL: Alert and interactive. In no acute distress. HEENT: NCAT. PERRL. Sclera anicteric and without injection. Moist mucous membranes. CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. Breathing comfortably in ra. ABDOMEN: Soft, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Distal pulses 2+ SKIN: Warm and well perfused. No rash. NEUROLOGIC: CN2-12 intact. Strength and sensation intact throughout. Gait deferred. AOx3. Pertinent Results: ADMISSION LABS ============== [MASKED] 01:53PM PLT COUNT-255 [MASKED] 01:53PM NEUTS-61.4 [MASKED] MONOS-3.8* EOS-1.3 BASOS-0.8 IM [MASKED] AbsNeut-4.85 AbsLymp-2.56 AbsMono-0.30 AbsEos-0.10 AbsBaso-0.06 [MASKED] 01:53PM WBC-7.9 RBC-5.29* HGB-16.7* HCT-47.3* MCV-89 MCH-31.6 MCHC-35.3 RDW-12.5 RDWSD-41.1 [MASKED] 01:53PM %HbA1c-10.7* eAG-260* [MASKED] 01:53PM GLUCOSE-392* UREA N-20 CREAT-1.1 SODIUM-131* POTASSIUM-4.7 CHLORIDE-89* TOTAL CO2-10* ANION GAP-32* [MASKED] 02:02PM O2 SAT-53 [MASKED] 02:02PM PO2-33* PCO2-33* PH-7.20* TOTAL CO2-13* BASE XS--14 [MASKED] 03:55PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE EPI-1 [MASKED] 03:55PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30* GLUCOSE-1000* KETONE-150* BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [MASKED] 03:55PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 03:55PM URINE UCG-NEGATIVE [MASKED] 06:40PM GLUCOSE-226* UREA N-15 CREAT-0.9 SODIUM-133* POTASSIUM-5.2 CHLORIDE-106 TOTAL CO2-12* ANION GAP-15 [MASKED] 06:54PM O2 SAT-62 [MASKED] 06:54PM GLUCOSE-207* NA+-133 K+-4.4 CL--107 TCO2-14* [MASKED] 06:54PM [MASKED] PH-7.23* [MASKED] 09:57PM GLUCOSE-211* UREA N-11 CREAT-0.8 SODIUM-140 POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-15* ANION GAP-17 [MASKED] 10:12PM [MASKED] TEMP-36.1 PO2-28* PCO2-39 PH-7.26* TOTAL CO2-18* BASE XS--9 IMAGING: ========= +CHEST (PA & LAT) [MASKED] IMPRESSION: No acute cardiopulmonary process. DISCHARGE LABS =============== [MASKED] 05:02AM BLOOD WBC-4.8 RBC-4.47 Hgb-13.8 Hct-39.3 MCV-88 MCH-30.9 MCHC-35.1 RDW-12.7 RDWSD-40.7 Plt [MASKED] [MASKED] 05:02AM BLOOD Glucose-225* UreaN-15 Creat-0.8 Na-139 K-3.5 Cl-105 HCO3-24 AnGap-10 [MASKED] 05:02AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.8 Brief Hospital Course: Ms. [MASKED] a [MASKED] year old female with a past medical history of Type 1 DM diagnosed in [MASKED], who presented with nausea, polyuria, polydipsia, weight loss, and fatigue, who was found to be in DKA [MASKED] malfunctioning insulin pump, insufficient subcutaneous insulin, and overall poor compliance to diabetes management. She was initially admitted to the ICU, started on an insulin drip and transitioned to SC insulin based on [MASKED] recommendations. ACUTE ISSUES: ============= # Diabetic Ketoacidosis # T1DM: The patient presented with DKA in setting of occlusion in pump tubing and insufficient supplemental subcutaneous insulin. Of note, her A1c was 10.7, suggesting poor control overall. Her anion gap closed and FSBG ranging from 100 to low 200s on discharge. The patient requested to be switched from an insulin pump to injections. Per [MASKED] recommendation, she will be on Glargine 13U BID (AM and [MASKED], Humalog 8U with all meals, and ISS. She was seen by diabetes educator for education with blood sugar checks and insulin injections. She will be seen by [MASKED] shortly after discharge. CHRONIC ISSUES: =============== # ADHD: The patient has not been on Ritalin for 1 month due to losing her home prescription. She states she was diagnosed with ADHD [MASKED] years ago and has been doing well with Ritalin overall. She did not receive Ritalin while inpatient, but should follow up with her PCP to refill her prescription and continue monitoring her symptoms. She is motivated to taper off this medication eventually. # Anxiety: The patient has not been on Lexapro for >1 week due to not filling her home prescription. She did not require Lexapro during this hospitalization and denied any symptoms of anxiety. She was able to refill her prescription at discharge. TRANSITIONAL ISSUES: ==================== []Please continue to monitor for symptoms of DKA, including nausea, vomiting, diaphoresis. []Please encourage carb counting and close monitoring of her BG []The patient will be following up for further management of her T1DM with [MASKED] []At discharge, her insulin regimen is: Glargine 13U BID (AM and [MASKED], Humalog 8U with all meals, and ISS []FYI: the patient requested to be switched from an insulin pump to SC injections []Please continue to monitor ADHD symptoms and prescribe Ritalin as clinically indicated []her UA on admission showed 30 protein. Would monitor proteinurea for evidence of diabetic nephropathy iso uncontrolled DM. [] make sure she also has a annual fundus exam and neuropathy check Pt was seen and examined w residents on am rounds on [MASKED]. Pt with reasonable blood sugar control and no longer with increased anion gap. Pt wants to leave and I agree she can be safely discharged to home w close f/u in [MASKED] and w her pcp. Okay to DC. >30 min spent on DC related activities. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Escitalopram Oxalate 10 mg PO DAILY 2. Methylphenidate SR 30 mg PO QAM 3. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Basal rate minimum: 1 units/hr Target glucose: 80-180 Discharge Medications: 1. Glargine 13 Units Breakfast Glargine 13 Units Bedtime Humalog 8 Units Breakfast Humalog 8 Units Lunch Humalog 8 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL (3 mL) AS DIR 13 Units before BKFT; 13 Units before BED; Disp #7 Syringe Refills:0 RX insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR Up to 10 Units QID per sliding scale 8 Units before LNCH; Units QID per sliding scale 8 Units before DINR; Units QID per sliding scal Disp #9 Syringe Refills:0 2. Escitalopram Oxalate 10 mg PO DAILY 3. Methylphenidate SR 30 mg PO QAM 4.test strips one touch verio Sig: check BG 8 times daily Disp# 100 (one hundred) strips Refills: 2 (zero) 5.Insulin pen needles 32G, [MASKED] (4 mm nano) Sig: use to inject 5 times daily Disp# 100 (one hundred) needles Refills: 2 (zero) Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: =================== 1. Diabetic ketoacidosis 2. Type 1 DM SECONDARY DIAGNOSES: ================== 1. Generalized Anxiety Disorder 2. ADHD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at [MASKED]! WHY DID I COME TO THE HOSPITAL? You were feeling nauseous and weak at home. You were found to have diabetic ketoacidosis (DKA), which is when your blood glucose becomes very high due to a lack of insulin. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? We gave you insulin and other medications to treat the DKA. At the time of discharge, your sugars and electrolytes were back in the normal range. WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL? -You should follow up with your primary care doctor and outpatient endocrinologist. -Please continue to take all of your medications and follow up with all of your doctors. -[MASKED] continue to monitor your symptoms, and seek medical attention if you experience any nausea, vomiting, sweating, lightheadedness, or any other symptom that concerns you. -Please continue to monitor your sugars, and take your insulin as prescribed. We wish you the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "Z794" ]	[ "T85614A: Breakdown (mechanical) of insulin pump, initial encounter", "E1010: Type 1 diabetes mellitus with ketoacidosis without coma", "Z794: Long term (current) use of insulin", "Z9641: Presence of insulin pump (external) (internal)", "F909: Attention-deficit hyperactivity disorder, unspecified type", "F411: Generalized anxiety disorder", "T43636A: Underdosing of methylphenidate, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "T383X6A: Underdosing of insulin and oral hypoglycemic [antidiabetic] drugs, initial encounter", "T43226A: Underdosing of selective serotonin reuptake inhibitors, initial encounter", "Z91128: Patient's intentional underdosing of medication regimen for other reason" ]
10,089,171	28,194,387	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is ___ with hx of HTN, hypothyroidism, and valvular abnormalities (mild MR, mod TR, AR, moderate pulm HTN) who is presenting after a syncopal episode. Symptoms began yesterday AM after awakening, she felt very dizzy, defined as feeling unstable but no sensation of spinning. En route to bathroom at 630AM with cane, she got up and had been walking for about 10 steps when fell (did not trip over anything) and noted hitting her head (on the left) on the floor, no prior palpitations or chest pain, no warning signs. She attributed it to the feeling of lightheadedness. She believes she had brief loss of consciousness for a few seconds since she does not remember the fall well. She landed on her right wrist and was having pain and called EMS. However, on EMS arrival, the patient was asymptomatic and refused transport; she noted no pain anywhere including no bruising. They noted in their evaluation that exam was unremarkable. It was only hours after EMS left when she developed worsening pain in her right wrist and in the back of her head; she also noted a bruise lateral to her left eye which concerned her and she saw blood on the floor, which she had not noted before. She took a pain medication but could not identify which it was. She has had no prior history of syncope. She reported that she did not feel weaker than usual and at baseline walks with a cane (right leg is shorter than left leg by 1cm). She went to an outpatient appointment today in urgent care and was sent here for evaluation due to persistent lightheadedness with standing and known valvular disease. She denies cp, sob, palpitations, abdominal pain, n/v/d, fevers or chills. She has not had any recent medication changes, no change in PO intake (no decrease in hydration), no diarrhea. She does not have any history of seizure disorder. She manages all her medications and has not taken any extra doses of any of her medications. No history of hypoglycemia. She has a blood pressure cough at home (wrist) and takes her BP regularly. She says SBP sometimes ranges in ___. Yesterday when she checked her BP hours after her fall, she noted her SBP in the 140s. Patient lives at home alone, however has helpers come cook and clean. She is normally very active and swims in the mornings, but she has not done so in last two days due to wrist pain. In the ED, initial vitals: T 97.9 HR 64 BP 144/58 RR 16 O2 Sat 95% RA - Exam notable for: Bruising and diffuse tenderness of right wrist. No obvious head laceration. AAO x 3. - Labs notable for: Troponin negative CMP unremarkable CBC unremarkable UA negative; Ucx- pending - EKG NSR - Imaging notable for: CT spine showing no acute fracture, mild degenerative changes of cervical spine. CT head showing no abnormalities, chronic small vessel ischemic disease. R wrist showing fracture through distal right radius. CXR showing mild cardiomegaly, pulmonary vascular congestion, no consolidation or effusion, probably no edema. - Pt given: 250cc NS / hour - Vitals prior to transfer: 97.6 HR 58 BP 124/73 RR 16 O2 96% RA On the floor, she reports no current pain in her right wrist. She has mild tenderness to palpation on back of her head. No visual changes. Still feels intermittently dizzy with change in position (did feel dizzy upon transfer from transport to bed). She is a good historian and able to answer all questions with clarity. She denies any chest pain or palpitations. Past Medical History: # Insomnia. She has had insomnia and is using zolpidem that Dr. ___ her which has been helpful. NO daytime somnoelnce. # HTN. Remains on current medication. Good control. # Valvular disease. Followed by Dr. ___. All followed periodically by echo. She is asymptomatic. # Hypothyroidism s/o thyroid ca. F/b Dr. ___. Remains on l-thyroxine. # Ostepenia. Taking ca/d. She follws with Dr. ___ - as BMD shows improemnt. Social History: ___ Family History: Mother - lung cancer, Father - heart problems Physical Exam: ADMISSION EXAM ======================= VITALS: T 97.6 HR 58 BP 124/73 RR 16 O2 96% RA GENERAL: AOx3, NAD, conversational, appropriate HEENT: Normocephalic, atraumatic. No hematoma noted, some mild tenderness to palpation on left posterior head. PERRL, EOMI. Moist mucous membranes. NECK: Thyroid is normal in size and texture, no nodules. CARDIAC: Regular rhythm, normal rate. No murmurs noted. No JVD noted (but patient does have hx of moderate TR). LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. Normal work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: R wrist in splint. L wrist normal ROM. No edema in lower extremities. Prominent veins noted. Dry skin. SKIN: Dry skin. Bruise noted 1cm x 2 lateral to left eye NEUROLOGIC: CN2-12 intact. ___ strength in upper extremities and lower extremities (did not test R wrist) Normal sensation. Able to sit up. No dysmetria or dysdiadochokinesia. DISCHARGE EXAM ======================= GENERAL: A/Ox3, NAD, ___ HEENT: normocephalic, left temporal 3 cm hematoma which is non-tender to palpation with overlying ecchymosis, left ___ ecchymosis, EOMI, sclera anicteric, PERRLA, MMM NECK: No thyromegaly, no LAD CARDIAC: RRR, faint systolic ejection murmur, no rubs or gallops LUNGS: CTAB, no wheezes, crackles, or rhonchi, no increased work of breathing ABDOMEN: soft, non-tender, non-distended, +BS throughout EXTREMITIES: right wrist and forearm splinted, no lower extremity edema, warm, well-perfused SKIN: L ___ ecchymosis, L temporal ecchymosis, no lacerations or other scrapes. Several mild papular erythematous lesions on L buttocks without surrounding erythema NEUROLOGIC: CN II-XII intact, intact grip strength bilaterally, A/Ox3 with good attention, moving all four extremities with purpose and no tremors noted, FTN wnl, possible lateral skew on cover/recover test, no nystagmus Pertinent Results: ADMISSION LABS ============================= ___ 12:00PM BLOOD WBC-7.9# RBC-3.90 Hgb-12.3 Hct-38.0 MCV-97 MCH-31.5 MCHC-32.4 RDW-13.2 RDWSD-47.4* Plt ___ ___ 12:00PM BLOOD Neuts-77.2* Lymphs-10.2* Monos-9.2 Eos-2.5 Baso-0.5 Im ___ AbsNeut-6.10 AbsLymp-0.81* AbsMono-0.73 AbsEos-0.20 AbsBaso-0.04 ___ 12:00PM BLOOD Glucose-94 UreaN-20 Creat-0.8 Na-143 K-4.2 Cl-104 HCO3-23 AnGap-16 ___ 12:00PM BLOOD cTropnT-<0.01 ___ 12:00PM BLOOD Calcium-8.9 Phos-3.2 Mg-2.0 ___ 12:42PM BLOOD Lactate-1.5 RELEVANT STUDIES ============================= ___ CT Spine without contrast: 1. 2 mm anterolisthesis of C4 on C5. No priors available. No prevertebral swelling. No acute fracture. 2. Mild degenerative changes of the cervical spine resulting in mild spinalcanal and neural foraminal narrowing at multiple levels. ___ CT head without contrast: 1. No acute intracranial abnormalities. 2. No acute fracture. Small subgaleal hematoma. 3. Global atrophy and likely sequela of chronic small vessel ischemic disease. ___ Wrist (3 view), Right: No prior radiographs of this region are available. Nondisplaced, nonangulated, impacted transverse, subarticular fracture through the distal right radius could extend to the articular surface, but there is no dislocation. No other fractures are seen. Moderate degeneration is present at the first carpal metacarpal joint ___ CXR Compared to chest radiographs ___. Mild cardiomegaly is comparable. Lung volumes are much lower exaggerating pulmonary vascular congestion. There is no consolidation or appreciable pleural effusion, and probably no pulmonary edema. Vascular clips and possible radionuclide seeds denote remote neck surgery, probably involving the thyroid. ___ Bilateral Lower Extremity U/S: No evidence of deep venous thrombosis in the right or left lower extremity veins. MRI ___ ___. No evidence of ___ or cerebellopontine angle mass. 2. No acute infarction. 3. Odontoid is retroflexed by 60 degrees with associated atlantoaxial pannus formation, resulting in mass effect on the medulla and kinking of the cerebellomedullary junction. No evidence for abnormal signal intensity in the upper cord on the T2 or FLAIR images, but this exam is not technically optimized for evaluating the upper spinal cord. 4. 5 x 5 x 5 mm right frontal extra-axial enhancing lesion without mass effect on the ___ parenchyma, most likely a meningioma. 5. Small left frontal and occipital subgaleal hematomas are again noted. CTA Chest ___ 1. No evidence of pulmonary embolism or acute pulmonary parenchymal process. 2. Moderate cardiomegaly. Cervical Spine XR ___ C1 through T1 are visualized on the lateral view. There is 2 mm of anterolisthesis of C3 over C4 on flexion which corrects on extension. There is 1 mm of anterolisthesis of C4 over C5 on flexion which corrects on extension. There is 2 mm of retrolisthesis of C5 over C6 on extension which corrects on flexion. There are moderate to severe degenerative changes with loss of intervertebral disc height worse at C5/C6. Surgical clips are seen along the neck. The odontoid is not well evaluated but is grossly intact. MICROBIOLOGY ======================== No positive cultures DISCHARGE LABS ======================== ___ 06:50AM BLOOD WBC-5.4 RBC-4.30 Hgb-13.7 Hct-41.3 MCV-96 MCH-31.9 MCHC-33.2 RDW-12.8 RDWSD-45.1 Plt ___ ___ 06:50AM BLOOD ___ PTT-27.4 ___ ___ 06:50AM BLOOD Glucose-91 UreaN-25* Creat-0.8 Na-141 K-4.1 Cl-98 HCO3-27 AnGap-16 ___ 06:50AM BLOOD Calcium-9.6 Phos-3.3 Mg-1.9 ___ 06:50AM BLOOD RheuFac-PND ___ CRP-13.4* Brief Hospital Course: Ms. ___ is an ___ female with history of HTN, hypothyroidism, and valvular abnormalities (mild MR, TR, AR, moderate pulm HTN) who presented after a syncopal episode. ACUTE ISSUES: ============= # Syncope: Presented with intermittent dizziness and a right radial fracture after falling. Infectious work-up was unremarkable. D-dimer was elevated so patient was evaluated for pulmonary embolism. Bilateral lower extremity Doppler U/S did not show evidence of DVT. CTA showed no evidence of PE. She did not have any concerning activity on telemetry. Troponins were negative. EKG showed normal sinus rhythm. Orthostatics were negative. Upon further history, it seems that her symptoms were actually more of a mix of orthostatic presyncope and vertigo. HINTs exam showed positive skew so MRI ___ and ___ w/ contrast was ordered and showed a retroflexed odontoid. See below for further details. Patient had positive ___ and therefore there was concern for BPPV and patient worked with ___ doing Epley maneuvers. We discovered she had taken a zolpidem the night prior to her episode and given association with dizziness, we discontinued this medication. Given her age and risk factors, we also discontinued home lorazepam (uses only very rarely). We also decreased HCTZ as below. She will see neurology as an outpatient. # R wrist fracture: Visualized on R wrist radiograph, showing transverse, sub-articular fracture through the distal right radius. Orthopedics evaluated and splinted the patient's right wrist. She had mild pain and did not require acetaminophen. She will follow-up with orthopedics in two weeks. # Retroflexed odontoid Patient noted to have retroflexed odontoid on MRI ___ and ___ with contrast causing some mass effect on medulla and at cerebellomedullary junction. Evaluated by neurosurgery and ortho spine who felt this was not an acute issue, and given lack of symptoms referrable to this lesion there was no need for intervention. Cervical spine flexion and extension X rays were ordered prior to discharge and will be used for further evaluation by neurosurgery for cervical instability. She will follow up with neurosurgery as an outpatient. CHRONIC ISSUES: =============== # Hypothyroidism: TSH 0.88 on ___. Continued home dose of levothyroxine # Hx of valvular abnormalities: TTE ___ showing symmetric LVH with normal global and regional biventricular systolic function. Mild aortic regurgitation. Moderate mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. We did not repeat as we felt low probability of valvular pathology causing syncope within this time frame. # HTN: Home regimen HCTZ 50 mg PO was decreased to 25g daily, atenolol 50 mg PO daily, and lisinopril 20 mg PO daily. PCP was ___ to discuss decreasing HCTZ and agreed with this decision # Hyperlipidemia: Continued home simvastatin # Insomnia: Zolpidem discontinued due to sedating/dizziness effects and fall occurring in the morning. For billing purposes only: >30 minutes spent on patient care and coordination on day of discharge. TRANSITIONAL ISSUES ============================= [] HCTZ was down-titrated in effort to reduce likelihood of orthostatic events, if further blood pressure control is needed consider up titrating Lisinopril. [ ]Discontinued Zolpidem and Lorazepam [ ]Follow up needed in 2 weeks with Dr. ___ in ___ Orthopaedic Trauma Clinic for repeat forearm XR and assessment. [ ]Follow up in neurology for BPPV and assessment of retroflexed odontoid which may be causing mass effect on medulla. [ ]Follow up with neurosurgery for continued monitoring of retroflexed odontoid [ ]Rheumatology follow up given pannus formation of odontoid which can be an indicator of RA. ___ sent per rheum request and will be followed up at clinic appointment. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 50 mg PO DAILY 2. Hydrochlorothiazide 50 mg PO DAILY 3. Hydrocortisone Cream 2.5% 1 Appl TP DAILY:PRN Itching 4. Levothyroxine Sodium 112 mcg PO DAILY 5. Lisinopril 20 mg PO DAILY 6. LORazepam 0.5 mg PO DAILY:PRN anxiety 7. Omeprazole 40 mg PO DAILY 8. penciclovir 1 % topical PRN 9. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID 10. Simvastatin 20 mg PO QPM 11. Tretinoin 0.025% Cream 1 Appl TP QHS 12. Zolpidem Tartrate 2.5 mg PO QHS:PRN Insomnia 13. Acyclovir 400 mg PO Q12H Discharge Medications: 1. Hydrochlorothiazide 25 mg PO DAILY RX hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 2. Acyclovir 400 mg PO Q12H 3. Aspirin 81 mg PO DAILY 4. Atenolol 50 mg PO DAILY 5. Hydrocortisone Cream 2.5% 1 Appl TP DAILY:PRN Itching 6. Levothyroxine Sodium 112 mcg PO 6X/WEEK (___) 7. Lisinopril 20 mg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. penciclovir 1 % topical PRN 10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID 11. Simvastatin 20 mg PO QPM 12. Tretinoin 0.025% Cream 1 Appl TP QHS 13. HELD- Cyanocobalamin Dose is Unknown PO DAILY This medication was held. Do not restart Cyanocobalamin until told to restart by your PCP ___: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: Right radial fracture Syncope Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___. Why was I here? - You fell at home after becoming dizzy. What was done for me while I was here? - X-rays showed your right wrist bone was broken. The orthopedic doctors ___ your ___ and casted it. - You had a CT scan of your head and neck which did not show any bleeding or fractures. - You had an ultrasound which showed you did not have blood clots in your leg. You had a CT scan of your chest which did not show any blood clots. You had an MRI of your head which showed a bone was in the wrong position. X-rays of your neck were obtained so that the neurosurgeons could better evaluate this bone, they will follow up with you after you get home. We are also asking you to see the rheumatologists who can evaluate if you have any autoimmune component to your bone deformity. We ask that you stop taking the zolpidem and Lorazepam as these can cause dizziness and falls, you agreed that you will not take these. We decreased the dose of your HCTZ blood pressure medicine. You should follow up with the orthopedic surgeons for your wrist. What should I do when I go home? - You should take all of your medications as prescribed. - You should attend all of your follow-up appointments. We wish you the best in the future. Sincerely, Your ___ Care Team Followup Instructions: ___	[ "H8113", "I2720", "I083", "S52591A", "R55", "W19XXXA", "T426X5A", "Y92009", "M8580", "E039", "E785", "I10", "G4700", "M5031", "Z85850" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is [MASKED] with hx of HTN, hypothyroidism, and valvular abnormalities (mild MR, mod TR, AR, moderate pulm HTN) who is presenting after a syncopal episode. Symptoms began yesterday AM after awakening, she felt very dizzy, defined as feeling unstable but no sensation of spinning. En route to bathroom at 630AM with cane, she got up and had been walking for about 10 steps when fell (did not trip over anything) and noted hitting her head (on the left) on the floor, no prior palpitations or chest pain, no warning signs. She attributed it to the feeling of lightheadedness. She believes she had brief loss of consciousness for a few seconds since she does not remember the fall well. She landed on her right wrist and was having pain and called EMS. However, on EMS arrival, the patient was asymptomatic and refused transport; she noted no pain anywhere including no bruising. They noted in their evaluation that exam was unremarkable. It was only hours after EMS left when she developed worsening pain in her right wrist and in the back of her head; she also noted a bruise lateral to her left eye which concerned her and she saw blood on the floor, which she had not noted before. She took a pain medication but could not identify which it was. She has had no prior history of syncope. She reported that she did not feel weaker than usual and at baseline walks with a cane (right leg is shorter than left leg by 1cm). She went to an outpatient appointment today in urgent care and was sent here for evaluation due to persistent lightheadedness with standing and known valvular disease. She denies cp, sob, palpitations, abdominal pain, n/v/d, fevers or chills. She has not had any recent medication changes, no change in PO intake (no decrease in hydration), no diarrhea. She does not have any history of seizure disorder. She manages all her medications and has not taken any extra doses of any of her medications. No history of hypoglycemia. She has a blood pressure cough at home (wrist) and takes her BP regularly. She says SBP sometimes ranges in [MASKED]. Yesterday when she checked her BP hours after her fall, she noted her SBP in the 140s. Patient lives at home alone, however has helpers come cook and clean. She is normally very active and swims in the mornings, but she has not done so in last two days due to wrist pain. In the ED, initial vitals: T 97.9 HR 64 BP 144/58 RR 16 O2 Sat 95% RA - Exam notable for: Bruising and diffuse tenderness of right wrist. No obvious head laceration. AAO x 3. - Labs notable for: Troponin negative CMP unremarkable CBC unremarkable UA negative; Ucx- pending - EKG NSR - Imaging notable for: CT spine showing no acute fracture, mild degenerative changes of cervical spine. CT head showing no abnormalities, chronic small vessel ischemic disease. R wrist showing fracture through distal right radius. CXR showing mild cardiomegaly, pulmonary vascular congestion, no consolidation or effusion, probably no edema. - Pt given: 250cc NS / hour - Vitals prior to transfer: 97.6 HR 58 BP 124/73 RR 16 O2 96% RA On the floor, she reports no current pain in her right wrist. She has mild tenderness to palpation on back of her head. No visual changes. Still feels intermittently dizzy with change in position (did feel dizzy upon transfer from transport to bed). She is a good historian and able to answer all questions with clarity. She denies any chest pain or palpitations. Past Medical History: # Insomnia. She has had insomnia and is using zolpidem that Dr. [MASKED] her which has been helpful. NO daytime somnoelnce. # HTN. Remains on current medication. Good control. # Valvular disease. Followed by Dr. [MASKED]. All followed periodically by echo. She is asymptomatic. # Hypothyroidism s/o thyroid ca. F/b Dr. [MASKED]. Remains on l-thyroxine. # Ostepenia. Taking ca/d. She follws with Dr. [MASKED] - as BMD shows improemnt. Social History: [MASKED] Family History: Mother - lung cancer, Father - heart problems Physical Exam: ADMISSION EXAM ======================= VITALS: T 97.6 HR 58 BP 124/73 RR 16 O2 96% RA GENERAL: AOx3, NAD, conversational, appropriate HEENT: Normocephalic, atraumatic. No hematoma noted, some mild tenderness to palpation on left posterior head. PERRL, EOMI. Moist mucous membranes. NECK: Thyroid is normal in size and texture, no nodules. CARDIAC: Regular rhythm, normal rate. No murmurs noted. No JVD noted (but patient does have hx of moderate TR). LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. Normal work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: R wrist in splint. L wrist normal ROM. No edema in lower extremities. Prominent veins noted. Dry skin. SKIN: Dry skin. Bruise noted 1cm x 2 lateral to left eye NEUROLOGIC: CN2-12 intact. [MASKED] strength in upper extremities and lower extremities (did not test R wrist) Normal sensation. Able to sit up. No dysmetria or dysdiadochokinesia. DISCHARGE EXAM ======================= GENERAL: A/Ox3, NAD, [MASKED] HEENT: normocephalic, left temporal 3 cm hematoma which is non-tender to palpation with overlying ecchymosis, left [MASKED] ecchymosis, EOMI, sclera anicteric, PERRLA, MMM NECK: No thyromegaly, no LAD CARDIAC: RRR, faint systolic ejection murmur, no rubs or gallops LUNGS: CTAB, no wheezes, crackles, or rhonchi, no increased work of breathing ABDOMEN: soft, non-tender, non-distended, +BS throughout EXTREMITIES: right wrist and forearm splinted, no lower extremity edema, warm, well-perfused SKIN: L [MASKED] ecchymosis, L temporal ecchymosis, no lacerations or other scrapes. Several mild papular erythematous lesions on L buttocks without surrounding erythema NEUROLOGIC: CN II-XII intact, intact grip strength bilaterally, A/Ox3 with good attention, moving all four extremities with purpose and no tremors noted, FTN wnl, possible lateral skew on cover/recover test, no nystagmus Pertinent Results: ADMISSION LABS ============================= [MASKED] 12:00PM BLOOD WBC-7.9# RBC-3.90 Hgb-12.3 Hct-38.0 MCV-97 MCH-31.5 MCHC-32.4 RDW-13.2 RDWSD-47.4* Plt [MASKED] [MASKED] 12:00PM BLOOD Neuts-77.2* Lymphs-10.2* Monos-9.2 Eos-2.5 Baso-0.5 Im [MASKED] AbsNeut-6.10 AbsLymp-0.81* AbsMono-0.73 AbsEos-0.20 AbsBaso-0.04 [MASKED] 12:00PM BLOOD Glucose-94 UreaN-20 Creat-0.8 Na-143 K-4.2 Cl-104 HCO3-23 AnGap-16 [MASKED] 12:00PM BLOOD cTropnT-<0.01 [MASKED] 12:00PM BLOOD Calcium-8.9 Phos-3.2 Mg-2.0 [MASKED] 12:42PM BLOOD Lactate-1.5 RELEVANT STUDIES ============================= [MASKED] CT Spine without contrast: 1. 2 mm anterolisthesis of C4 on C5. No priors available. No prevertebral swelling. No acute fracture. 2. Mild degenerative changes of the cervical spine resulting in mild spinalcanal and neural foraminal narrowing at multiple levels. [MASKED] CT head without contrast: 1. No acute intracranial abnormalities. 2. No acute fracture. Small subgaleal hematoma. 3. Global atrophy and likely sequela of chronic small vessel ischemic disease. [MASKED] Wrist (3 view), Right: No prior radiographs of this region are available. Nondisplaced, nonangulated, impacted transverse, subarticular fracture through the distal right radius could extend to the articular surface, but there is no dislocation. No other fractures are seen. Moderate degeneration is present at the first carpal metacarpal joint [MASKED] CXR Compared to chest radiographs [MASKED]. Mild cardiomegaly is comparable. Lung volumes are much lower exaggerating pulmonary vascular congestion. There is no consolidation or appreciable pleural effusion, and probably no pulmonary edema. Vascular clips and possible radionuclide seeds denote remote neck surgery, probably involving the thyroid. [MASKED] Bilateral Lower Extremity U/S: No evidence of deep venous thrombosis in the right or left lower extremity veins. MRI [MASKED] [MASKED]. No evidence of [MASKED] or cerebellopontine angle mass. 2. No acute infarction. 3. Odontoid is retroflexed by 60 degrees with associated atlantoaxial pannus formation, resulting in mass effect on the medulla and kinking of the cerebellomedullary junction. No evidence for abnormal signal intensity in the upper cord on the T2 or FLAIR images, but this exam is not technically optimized for evaluating the upper spinal cord. 4. 5 x 5 x 5 mm right frontal extra-axial enhancing lesion without mass effect on the [MASKED] parenchyma, most likely a meningioma. 5. Small left frontal and occipital subgaleal hematomas are again noted. CTA Chest [MASKED] 1. No evidence of pulmonary embolism or acute pulmonary parenchymal process. 2. Moderate cardiomegaly. Cervical Spine XR [MASKED] C1 through T1 are visualized on the lateral view. There is 2 mm of anterolisthesis of C3 over C4 on flexion which corrects on extension. There is 1 mm of anterolisthesis of C4 over C5 on flexion which corrects on extension. There is 2 mm of retrolisthesis of C5 over C6 on extension which corrects on flexion. There are moderate to severe degenerative changes with loss of intervertebral disc height worse at C5/C6. Surgical clips are seen along the neck. The odontoid is not well evaluated but is grossly intact. MICROBIOLOGY ======================== No positive cultures DISCHARGE LABS ======================== [MASKED] 06:50AM BLOOD WBC-5.4 RBC-4.30 Hgb-13.7 Hct-41.3 MCV-96 MCH-31.9 MCHC-33.2 RDW-12.8 RDWSD-45.1 Plt [MASKED] [MASKED] 06:50AM BLOOD [MASKED] PTT-27.4 [MASKED] [MASKED] 06:50AM BLOOD Glucose-91 UreaN-25* Creat-0.8 Na-141 K-4.1 Cl-98 HCO3-27 AnGap-16 [MASKED] 06:50AM BLOOD Calcium-9.6 Phos-3.3 Mg-1.9 [MASKED] 06:50AM BLOOD RheuFac-PND [MASKED] CRP-13.4* Brief Hospital Course: Ms. [MASKED] is an [MASKED] female with history of HTN, hypothyroidism, and valvular abnormalities (mild MR, TR, AR, moderate pulm HTN) who presented after a syncopal episode. ACUTE ISSUES: ============= # Syncope: Presented with intermittent dizziness and a right radial fracture after falling. Infectious work-up was unremarkable. D-dimer was elevated so patient was evaluated for pulmonary embolism. Bilateral lower extremity Doppler U/S did not show evidence of DVT. CTA showed no evidence of PE. She did not have any concerning activity on telemetry. Troponins were negative. EKG showed normal sinus rhythm. Orthostatics were negative. Upon further history, it seems that her symptoms were actually more of a mix of orthostatic presyncope and vertigo. HINTs exam showed positive skew so MRI [MASKED] and [MASKED] w/ contrast was ordered and showed a retroflexed odontoid. See below for further details. Patient had positive [MASKED] and therefore there was concern for BPPV and patient worked with [MASKED] doing Epley maneuvers. We discovered she had taken a zolpidem the night prior to her episode and given association with dizziness, we discontinued this medication. Given her age and risk factors, we also discontinued home lorazepam (uses only very rarely). We also decreased HCTZ as below. She will see neurology as an outpatient. # R wrist fracture: Visualized on R wrist radiograph, showing transverse, sub-articular fracture through the distal right radius. Orthopedics evaluated and splinted the patient's right wrist. She had mild pain and did not require acetaminophen. She will follow-up with orthopedics in two weeks. # Retroflexed odontoid Patient noted to have retroflexed odontoid on MRI [MASKED] and [MASKED] with contrast causing some mass effect on medulla and at cerebellomedullary junction. Evaluated by neurosurgery and ortho spine who felt this was not an acute issue, and given lack of symptoms referrable to this lesion there was no need for intervention. Cervical spine flexion and extension X rays were ordered prior to discharge and will be used for further evaluation by neurosurgery for cervical instability. She will follow up with neurosurgery as an outpatient. CHRONIC ISSUES: =============== # Hypothyroidism: TSH 0.88 on [MASKED]. Continued home dose of levothyroxine # Hx of valvular abnormalities: TTE [MASKED] showing symmetric LVH with normal global and regional biventricular systolic function. Mild aortic regurgitation. Moderate mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. We did not repeat as we felt low probability of valvular pathology causing syncope within this time frame. # HTN: Home regimen HCTZ 50 mg PO was decreased to 25g daily, atenolol 50 mg PO daily, and lisinopril 20 mg PO daily. PCP was [MASKED] to discuss decreasing HCTZ and agreed with this decision # Hyperlipidemia: Continued home simvastatin # Insomnia: Zolpidem discontinued due to sedating/dizziness effects and fall occurring in the morning. For billing purposes only: >30 minutes spent on patient care and coordination on day of discharge. TRANSITIONAL ISSUES ============================= [] HCTZ was down-titrated in effort to reduce likelihood of orthostatic events, if further blood pressure control is needed consider up titrating Lisinopril. [ ]Discontinued Zolpidem and Lorazepam [ ]Follow up needed in 2 weeks with Dr. [MASKED] in [MASKED] Orthopaedic Trauma Clinic for repeat forearm XR and assessment. [ ]Follow up in neurology for BPPV and assessment of retroflexed odontoid which may be causing mass effect on medulla. [ ]Follow up with neurosurgery for continued monitoring of retroflexed odontoid [ ]Rheumatology follow up given pannus formation of odontoid which can be an indicator of RA. [MASKED] sent per rheum request and will be followed up at clinic appointment. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 50 mg PO DAILY 2. Hydrochlorothiazide 50 mg PO DAILY 3. Hydrocortisone Cream 2.5% 1 Appl TP DAILY:PRN Itching 4. Levothyroxine Sodium 112 mcg PO DAILY 5. Lisinopril 20 mg PO DAILY 6. LORazepam 0.5 mg PO DAILY:PRN anxiety 7. Omeprazole 40 mg PO DAILY 8. penciclovir 1 % topical PRN 9. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID 10. Simvastatin 20 mg PO QPM 11. Tretinoin 0.025% Cream 1 Appl TP QHS 12. Zolpidem Tartrate 2.5 mg PO QHS:PRN Insomnia 13. Acyclovir 400 mg PO Q12H Discharge Medications: 1. Hydrochlorothiazide 25 mg PO DAILY RX hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 2. Acyclovir 400 mg PO Q12H 3. Aspirin 81 mg PO DAILY 4. Atenolol 50 mg PO DAILY 5. Hydrocortisone Cream 2.5% 1 Appl TP DAILY:PRN Itching 6. Levothyroxine Sodium 112 mcg PO 6X/WEEK ([MASKED]) 7. Lisinopril 20 mg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. penciclovir 1 % topical PRN 10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID 11. Simvastatin 20 mg PO QPM 12. Tretinoin 0.025% Cream 1 Appl TP QHS 13. HELD- Cyanocobalamin Dose is Unknown PO DAILY This medication was held. Do not restart Cyanocobalamin until told to restart by your PCP [MASKED]: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary diagnosis: Right radial fracture Syncope 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 was I here? - You fell at home after becoming dizzy. What was done for me while I was here? - X-rays showed your right wrist bone was broken. The orthopedic doctors [MASKED] your [MASKED] and casted it. - You had a CT scan of your head and neck which did not show any bleeding or fractures. - You had an ultrasound which showed you did not have blood clots in your leg. You had a CT scan of your chest which did not show any blood clots. You had an MRI of your head which showed a bone was in the wrong position. X-rays of your neck were obtained so that the neurosurgeons could better evaluate this bone, they will follow up with you after you get home. We are also asking you to see the rheumatologists who can evaluate if you have any autoimmune component to your bone deformity. We ask that you stop taking the zolpidem and Lorazepam as these can cause dizziness and falls, you agreed that you will not take these. We decreased the dose of your HCTZ blood pressure medicine. You should follow up with the orthopedic surgeons for your wrist. What should I do when I go home? - You should take all of your medications as prescribed. - You should attend all of your follow-up appointments. We wish you the best in the future. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "E039", "E785", "I10", "G4700" ]	[ "H8113: Benign paroxysmal vertigo, bilateral", "I2720: Pulmonary hypertension, unspecified", "I083: Combined rheumatic disorders of mitral, aortic and tricuspid valves", "S52591A: Other fractures of lower end of right radius, initial encounter for closed fracture", "R55: Syncope and collapse", "W19XXXA: Unspecified fall, initial encounter", "T426X5A: Adverse effect of other antiepileptic and sedative-hypnotic drugs, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "M8580: Other specified disorders of bone density and structure, unspecified site", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "G4700: Insomnia, unspecified", "M5031: Other cervical disc degeneration, high cervical region", "Z85850: Personal history of malignant neoplasm of thyroid" ]
10,089,199	27,816,056	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: morphine Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with a PMH of asthma and crohn's disease which has been usually affecting her ilium. Pt's first line of treatment was Pentasa but she continued to have symptoms so she was switched to Humira in ___. She developed skin lesions and Humira was stopped ___. Pt was started on ustekinumab (Stelara) in ___, which was initially given via injection every 8 weeks. She had improvement on Stelara but continued to have some mild ileitis so her Stelara was increased to every 6 weeks. Last MR ___ in ___ showed: 1. Compared to ___, there has been interval improvement in disease involving a short segment of distal terminal ileum. Otherwise, there is a similar extent of active inflammatory disease involving a 22 cm long segment of distal ileum and proximal terminal ileum. 2. No evidence of fistula, abscess or obstruction. The pt reports that she usually does not drink alcohol. Yesterday she had half a glass of wine and two bottles of ___ hard lemonade. That night, she began to develop ___ periumbilical pain which she initially attributed to eating Taco Bell. The pain then worsened around 1 or 2 am, waking her from sleep. The pain continued to worsen throughout the morning, so she eventually went to urgent care for evaluation. She reports that the pain is ___ only, sharp/stabbing, and feels different than prior Crohn's flares which were usually lower abd pain. She denies nausea, vomiting, diarrhea, or blood in her stool. She denies black stool. She denies dysuria or hematuria. At the urgent care, a CT abd/pelvis was performed which showed ileitis consistent with her Crohn's. Pt was asked to go to the ER for further evaluation. In the ER, she as found to be hemodynamically stable with normal renal function, unremarkable LFTs, normal WBC, no anemia, and elevated CRP to 7.3. Pt was evaluated by GI in the ER who recommended the following (quoted from the ER note): - if develops loose stools, please check C. Diff - keep NPO for now - please start Cipro/Flagyl - please avoid NSAIDs and opiates if possible. Try IV tylenol for pain - on floor, please ensure patient getting DVT ppx ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: PAST MEDICAL HISTORY: Asthma Crohn's disease 11 surgeries on her foot after a trauma Family History: FAMILY HISTORY: Mother: ___, diverticulosis Maternal grandfather: Stomach cancer Physical Exam: Physical Exam Gen: Well appearing, well groomed, no apparent distress HENT: NCAT. Mucus membranes moist. No oral lesions or ulcer. Eyes: Conjuctiva clear. No periorbital edema. CV: RRR. No m/r/g. Resp: Lungs CTAB. Good air movement. Breathing non-labored. Abd: Soft, non-distended, normoactive BS. Tender directly over the umbilicus. No guarding, no rebound. GU: No suprapubic or CVA tenderness Ext: No ___ edema or erythema Skin: No rashes or skin lesions Neuro: Face symmetric. Ox4. Normally conversant. Moves all four extremities. Psych: Normal tone and affect . discharge exam: well appearing, minimal abdominal tenderness. Pertinent Results: DATA: I have reviewed the relevant labs, radiology studies, tracings, medical records, and they are notable for: - Normal WBC - Normal Hb - Normal renal function - Unremarkable LFTs - CRP 7.3 - Negative UA CT abd/pelvis on ___ at outside facility (available in CHA records): 1. Distal ileitis extending into the proximal portion of the terminal ileum, consistent with known Crohn's disease. 2. Normal appendix. 3. Left adnexal 3 cm cystic lesion. Pelvic ultrasound recommended for further evaluation when the patient is stable. Re-read here (second opinion of same CT): 1. Active Crohn's disease involving an approximately 25 cm contiguous segment of mid and distal ileum, similar in extent and appearance when compared to the prior MR enterography from ___. No evidence of bowel obstruction, abscess, or fistulizing disease. No new sites of inflammatory bowel disease identified. 2. Normal appendix. discharge labs: ___ 06:31AM BLOOD WBC-3.8* RBC-3.98 Hgb-10.7* Hct-34.5 MCV-87 MCH-26.9 MCHC-31.0* RDW-13.4 RDWSD-42.8 Plt ___ ___ 06:31AM BLOOD Glucose-90 UreaN-5* Creat-0.7 Na-140 K-4.0 Cl-110* HCO3-20* AnGap-10 ___ 06:31AM BLOOD Calcium-8.5 Phos-2.6* Mg-1.8 Brief Hospital Course: SUMMARY/ASSESSMENT: Ms. ___ is a ___ female with the past medical history and findings noted above who presented with abdominal pain, likely related to dietary indiscretion, but on a background of likely persistently active Crohn's disease. #Abdominal pain #Crohn's disease with proximal terminal ileitis The pt p/w ___ pain, quite rapid onset, no nausea/vomiting/diarrhea/melena/hematochezia. CT shows her known Crohn's disease which is active in the terminal ileum. Her acute symptoms resolved with bowel rest, and antibiotics were stopped. Her acute symptoms were not felt to represent a flare of her Crohn's disease, but rather a reaction to the dietary indiscretions. In regards to her Crohn's disease, her imaging remains unchanged since ___ despite treatment with stellara at increasing dose, so the GI consult advised start of budesonide and follow up regarding changes in her chronic treatment for Crohn's. #Asthma Currently asymptomatic, usually seasonal. - she was treated with Duonebs PRN # GYN OCPs continued Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN shortness of breath 2. Stelara (ustekinumab) 90 mg/mL subcutaneous every 6 weeks 3. Sronyx (levonorgestreL-ethinyl estrad) 0.1-20 mg-mcg oral DAILY 4. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Budesonide 9 mg PO DAILY RX budesonide 9 mg 1 capsule(s) by mouth once a day Disp #30 Tablet Refills:0 2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN shortness of breath 3. Sronyx (levonorgestreL-ethinyl estrad) 0.1-20 mg-mcg oral DAILY 4. Stelara (ustekinumab) 90 mg/mL subcutaneous every 6 weeks 5. Vitamin D ___ UNIT PO DAILY 1. Budesonide 9 mg PO DAILY RX budesonide 9 mg 1 capsule(s) by mouth once a day Disp #30 Tablet Refills:0 2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN shortness of breath 3. Sronyx (levonorgestreL-ethinyl estrad) 0.1-20 mg-mcg oral DAILY 4. Stelara (ustekinumab) 90 mg/mL subcutaneous every 6 weeks 5. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Crohn's disease Acute abdominal pain Chronic asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted to ___ with abdominal pain after some alcohol consumption and fast food consumption. Your acute pain went away with bowel rest and time. You were seen by the GI doctors who ___ that your underlying Crohn's disease was not adequately treated with your present regimen of medication and they advised that we start you on budesonide daily. Followup Instructions: ___	[ "K5000", "J45909" ]	Allergies: morphine Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] female with a PMH of asthma and crohn's disease which has been usually affecting her ilium. Pt's first line of treatment was Pentasa but she continued to have symptoms so she was switched to Humira in [MASKED]. She developed skin lesions and Humira was stopped [MASKED]. Pt was started on ustekinumab (Stelara) in [MASKED], which was initially given via injection every 8 weeks. She had improvement on Stelara but continued to have some mild ileitis so her Stelara was increased to every 6 weeks. Last MR [MASKED] in [MASKED] showed: 1. Compared to [MASKED], there has been interval improvement in disease involving a short segment of distal terminal ileum. Otherwise, there is a similar extent of active inflammatory disease involving a 22 cm long segment of distal ileum and proximal terminal ileum. 2. No evidence of fistula, abscess or obstruction. The pt reports that she usually does not drink alcohol. Yesterday she had half a glass of wine and two bottles of [MASKED] hard lemonade. That night, she began to develop [MASKED] periumbilical pain which she initially attributed to eating Taco Bell. The pain then worsened around 1 or 2 am, waking her from sleep. The pain continued to worsen throughout the morning, so she eventually went to urgent care for evaluation. She reports that the pain is [MASKED] only, sharp/stabbing, and feels different than prior Crohn's flares which were usually lower abd pain. She denies nausea, vomiting, diarrhea, or blood in her stool. She denies black stool. She denies dysuria or hematuria. At the urgent care, a CT abd/pelvis was performed which showed ileitis consistent with her Crohn's. Pt was asked to go to the ER for further evaluation. In the ER, she as found to be hemodynamically stable with normal renal function, unremarkable LFTs, normal WBC, no anemia, and elevated CRP to 7.3. Pt was evaluated by GI in the ER who recommended the following (quoted from the ER note): - if develops loose stools, please check C. Diff - keep NPO for now - please start Cipro/Flagyl - please avoid NSAIDs and opiates if possible. Try IV tylenol for pain - on floor, please ensure patient getting DVT ppx ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: PAST MEDICAL HISTORY: Asthma Crohn's disease 11 surgeries on her foot after a trauma Family History: FAMILY HISTORY: Mother: [MASKED], diverticulosis Maternal grandfather: Stomach cancer Physical Exam: Physical Exam Gen: Well appearing, well groomed, no apparent distress HENT: NCAT. Mucus membranes moist. No oral lesions or ulcer. Eyes: Conjuctiva clear. No periorbital edema. CV: RRR. No m/r/g. Resp: Lungs CTAB. Good air movement. Breathing non-labored. Abd: Soft, non-distended, normoactive BS. Tender directly over the umbilicus. No guarding, no rebound. GU: No suprapubic or CVA tenderness Ext: No [MASKED] edema or erythema Skin: No rashes or skin lesions Neuro: Face symmetric. Ox4. Normally conversant. Moves all four extremities. Psych: Normal tone and affect . discharge exam: well appearing, minimal abdominal tenderness. Pertinent Results: DATA: I have reviewed the relevant labs, radiology studies, tracings, medical records, and they are notable for: - Normal WBC - Normal Hb - Normal renal function - Unremarkable LFTs - CRP 7.3 - Negative UA CT abd/pelvis on [MASKED] at outside facility (available in CHA records): 1. Distal ileitis extending into the proximal portion of the terminal ileum, consistent with known Crohn's disease. 2. Normal appendix. 3. Left adnexal 3 cm cystic lesion. Pelvic ultrasound recommended for further evaluation when the patient is stable. Re-read here (second opinion of same CT): 1. Active Crohn's disease involving an approximately 25 cm contiguous segment of mid and distal ileum, similar in extent and appearance when compared to the prior MR enterography from [MASKED]. No evidence of bowel obstruction, abscess, or fistulizing disease. No new sites of inflammatory bowel disease identified. 2. Normal appendix. discharge labs: [MASKED] 06:31AM BLOOD WBC-3.8* RBC-3.98 Hgb-10.7* Hct-34.5 MCV-87 MCH-26.9 MCHC-31.0* RDW-13.4 RDWSD-42.8 Plt [MASKED] [MASKED] 06:31AM BLOOD Glucose-90 UreaN-5* Creat-0.7 Na-140 K-4.0 Cl-110* HCO3-20* AnGap-10 [MASKED] 06:31AM BLOOD Calcium-8.5 Phos-2.6* Mg-1.8 Brief Hospital Course: SUMMARY/ASSESSMENT: Ms. [MASKED] is a [MASKED] female with the past medical history and findings noted above who presented with abdominal pain, likely related to dietary indiscretion, but on a background of likely persistently active Crohn's disease. #Abdominal pain #Crohn's disease with proximal terminal ileitis The pt p/w [MASKED] pain, quite rapid onset, no nausea/vomiting/diarrhea/melena/hematochezia. CT shows her known Crohn's disease which is active in the terminal ileum. Her acute symptoms resolved with bowel rest, and antibiotics were stopped. Her acute symptoms were not felt to represent a flare of her Crohn's disease, but rather a reaction to the dietary indiscretions. In regards to her Crohn's disease, her imaging remains unchanged since [MASKED] despite treatment with stellara at increasing dose, so the GI consult advised start of budesonide and follow up regarding changes in her chronic treatment for Crohn's. #Asthma Currently asymptomatic, usually seasonal. - she was treated with Duonebs PRN # GYN OCPs continued Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN shortness of breath 2. Stelara (ustekinumab) 90 mg/mL subcutaneous every 6 weeks 3. Sronyx (levonorgestreL-ethinyl estrad) 0.1-20 mg-mcg oral DAILY 4. Vitamin D [MASKED] UNIT PO DAILY Discharge Medications: 1. Budesonide 9 mg PO DAILY RX budesonide 9 mg 1 capsule(s) by mouth once a day Disp #30 Tablet Refills:0 2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN shortness of breath 3. Sronyx (levonorgestreL-ethinyl estrad) 0.1-20 mg-mcg oral DAILY 4. Stelara (ustekinumab) 90 mg/mL subcutaneous every 6 weeks 5. Vitamin D [MASKED] UNIT PO DAILY 1. Budesonide 9 mg PO DAILY RX budesonide 9 mg 1 capsule(s) by mouth once a day Disp #30 Tablet Refills:0 2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN shortness of breath 3. Sronyx (levonorgestreL-ethinyl estrad) 0.1-20 mg-mcg oral DAILY 4. Stelara (ustekinumab) 90 mg/mL subcutaneous every 6 weeks 5. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Crohn's disease Acute abdominal pain Chronic asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted to [MASKED] with abdominal pain after some alcohol consumption and fast food consumption. Your acute pain went away with bowel rest and time. You were seen by the GI doctors who [MASKED] that your underlying Crohn's disease was not adequately treated with your present regimen of medication and they advised that we start you on budesonide daily. Followup Instructions: [MASKED]	[]	[ "J45909" ]	[ "K5000: Crohn's disease of small intestine without complications", "J45909: Unspecified asthma, uncomplicated" ]
10,089,344	22,143,411	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim / Penicillins / Keflex / eggs / Percocet / etodolac Attending: ___. Chief Complaint: rash, fever Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a ___ y.o woman with h.o hip pain, HTN with recent worsening of R.hip pain who presented to her PCP and was prescribed etodolac on ___. Pt states she took this rx for 1 week with improvement in her pain. However, on ___ pain returned and pt reports she could not walk. She called her PCP and was prescribed a second course of etodolac beginning ___. However, ___ she developed a "slight rash" on her abdomen. This rash progressed over the weekend until today when it had spread to her groin, back and arms. Pt denies pain or pruritis to rash, denies mouth/tongue lesions or any respiratory difficulties. However, she did report lip swelling that has now since improved. Pt was also noted to have a fever to 102.5. Pt states she's had prior drug rash before to antibiotics but never with a fever. Otherwise, she denies headache, dizziness, ST, CP, sob, palpitations, abdominal pain, n/v/d/c/dysuria, paresthesias, sore throat, dysphagia. In the ED, pt was noted to be febrile. Other 10pt ROS reviewed and otherwise negative Past Medical History: hip pain ureters "replanted" HTN Social History: ___ Family History: father with disease of the aorta mom with ___, CAD Physical Exam: GEN: well appearing, NAD, speaking in full sentences vitals:99.1 PO 111 / 66 R Sitting 72 18 97 ra HEENT: ncat EOMI anicteric MMM, no oral lesions or swelling noted chest: b/l ae no w/c/r heart: s1s2 rr no m/r/g abd: +bs, soft, NT, ND ext: no c/c/e skin: diffuse maculopapular confluent rash on the back, abdomen, breasts, groin. Rash includes the arms and thighs but is more sparinging on these locations. neuro: face symmetric, speech fluent psych: calm, cooperative Pertinent Results: ___ 10:35PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 10:05PM URINE HOURS-RANDOM ___ 10:05PM URINE UHOLD-HOLD ___ 10:05PM URINE COLOR-Straw APPEAR-Hazy SP ___ ___ 10:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 10:05PM URINE RBC-<1 WBC-1 BACTERIA-MANY YEAST-NONE EPI-10 ___ 10:05PM URINE MUCOUS-FEW ___ 09:30PM LACTATE-1.1 ___ 09:20PM GLUCOSE-88 UREA N-13 CREAT-0.6 SODIUM-138 POTASSIUM-2.7* CHLORIDE-96 TOTAL CO2-28 ANION GAP-17 ___ 09:20PM estGFR-Using this ___ 09:20PM ALT(SGPT)-73* AST(SGOT)-69* ALK PHOS-115* TOT BILI-0.5 ___ 09:20PM ALBUMIN-4.1 ___ 09:20PM WBC-4.1 RBC-4.36 HGB-13.6 HCT-39.9 MCV-92 MCH-31.2 MCHC-34.1 RDW-13.6 RDWSD-45.6 ___ 09:20PM NEUTS-79.1* LYMPHS-10.1* MONOS-4.9* EOS-5.2 BASOS-0.2 IM ___ AbsNeut-3.21 AbsLymp-0.41* AbsMono-0.20 AbsEos-0.21 AbsBaso-0.01 ___ 09:20PM PLT COUNT-105* CXR: IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: ___ y.o woman with h.o arthritis and hip pain, prior drug reaction, HTN who presents with diffuse body rash and fever. #rash, fever, slight transaminemia. -Rash developed after ___ course of etodolac. No other new medications, sick contacts, or fever. Not pruritic or painful. No oral involvement noted. Suspect that rash which per pt is c/w prior drug rashes is c/w drug rash. She has a mild transaminitis but does not have eosinophilia to meet dx of DRESS. Could be viral exanthum or infectious process but does not have any other localizing signs of infection including GI/GYN/respiratory/GU symptoms. -added etordolac to allergy list, and took off active med list, instructed pt. to avoid this and other nsaids (asa ok, as she has been taking this daily for years, so do not suspect this is asa allergy) -dermatology consulted and agreed with above (see consult note in OMR). Improved with topical therapies alone. See d/c instructions (worksheet) and instructions below. #hypokalemia-repleted with 60 additional meq K. #Chronic R.hip pain-monitor for now given above; f/u with ortho in two days arranged. #HTN- continued home meds Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Estrogens Conjugated 0.625 gm VG DAILY 2. Alendronate Sodium 70 mg PO QSAT 3. Aspirin 325 mg PO DAILY:PRN pain 4. Atenolol 50 mg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Vitamin D 1000 UNIT PO DAILY 7. Citalopram 10 mg PO DAILY 8. etodolac 400 mg oral BID:PRN 9. Hydrochlorothiazide 25 mg PO DAILY 10. Potassium Chloride 10 mEq PO TID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild MAXIMUM OF ___ mg per day RX acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as needed Disp #60 Tablet Refills:0 2. Sarna Lotion 1 Appl TP TID:PRN rash/itching RX camphor-menthol [Anti-Itch (menthol/camphor)] 0.5 %-0.5 % apply to rash TID:PRN TID:PRN Refills:0 3. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID rash trunk only, not to skin folds (groin, armpit, etc) or face RX triamcinolone acetonide 0.1 % apply to rash twice ___ twice a day Refills:*1 4. Alendronate Sodium 70 mg PO QSAT 5. Aspirin 325 mg PO DAILY:PRN pain 6. Atenolol 50 mg PO DAILY 7. Atorvastatin 10 mg PO QPM 8. Citalopram 10 mg PO DAILY 9. Estrogens Conjugated 0.625 gm VG DAILY 10. Hydrochlorothiazide 25 mg PO DAILY 11. Potassium Chloride 10 mEq PO TID 12. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: ADE: rash, fever, slight liver inflammation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: DO NOT TAKE ANY FURTHER NSAIDS (other than aspirin, one tab daily) - do not take ETODOLAC, and recommend avoiding ibuprofen and Naprosyn as well; you had a significant allergic reaction with diffuse rash, fever, and mild liver inflammation. You were seen by dermatology here and we feel that this syndrome will resolve with avoidance of the medication and topical therapies (crèmes/ointments) alone. You should see Dr. ___ one week for repeat assessment of your rash, symptoms, and check of labs: cbc and chemistry-20. Dermatology recommended the following management: - recommend topical triamcinolone 0.1% ointment twice daily to trunk x 14 days; avoid skin folds, genitals and face - Sarna lotion three times daily as needed for itching, keep in refrigerator to keep the lotion cool for comfort - for moderate to severe itching, can also use oral antihistamines (Zyrtec during day, Benadryl at night) - but you have not needed this here, and would recommend avoiding if possible - liberal moisturizers with topical Vaseline or Cetaphil prn - call or report to the ED for facial swelling/edema, lymphadenopathy, fever and mucosal involvement (mucosal involvement means of the mouth and or genitals, which may manifest as pain, swelling, and ulceration). If the rash is worsening or becomes more bothersome to the patient, please page us at ___ during business hours or call ___ and request pager ___ after hours. Followup Instructions: ___	[ "R21", "R509", "E876", "R740", "G8929", "M25551", "I10", "M810" ]	Allergies: Bactrim / Penicillins / Keflex / eggs / Percocet / etodolac Chief Complaint: rash, fever Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a [MASKED] y.o woman with h.o hip pain, HTN with recent worsening of R.hip pain who presented to her PCP and was prescribed etodolac on [MASKED]. Pt states she took this rx for 1 week with improvement in her pain. However, on [MASKED] pain returned and pt reports she could not walk. She called her PCP and was prescribed a second course of etodolac beginning [MASKED]. However, [MASKED] she developed a "slight rash" on her abdomen. This rash progressed over the weekend until today when it had spread to her groin, back and arms. Pt denies pain or pruritis to rash, denies mouth/tongue lesions or any respiratory difficulties. However, she did report lip swelling that has now since improved. Pt was also noted to have a fever to 102.5. Pt states she's had prior drug rash before to antibiotics but never with a fever. Otherwise, she denies headache, dizziness, ST, CP, sob, palpitations, abdominal pain, n/v/d/c/dysuria, paresthesias, sore throat, dysphagia. In the ED, pt was noted to be febrile. Other 10pt ROS reviewed and otherwise negative Past Medical History: hip pain ureters "replanted" HTN Social History: [MASKED] Family History: father with disease of the aorta mom with [MASKED], CAD Physical Exam: GEN: well appearing, NAD, speaking in full sentences vitals:99.1 PO 111 / 66 R Sitting 72 18 97 ra HEENT: ncat EOMI anicteric MMM, no oral lesions or swelling noted chest: b/l ae no w/c/r heart: s1s2 rr no m/r/g abd: +bs, soft, NT, ND ext: no c/c/e skin: diffuse maculopapular confluent rash on the back, abdomen, breasts, groin. Rash includes the arms and thighs but is more sparinging on these locations. neuro: face symmetric, speech fluent psych: calm, cooperative Pertinent Results: [MASKED] 10:35PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE [MASKED] 10:05PM URINE HOURS-RANDOM [MASKED] 10:05PM URINE UHOLD-HOLD [MASKED] 10:05PM URINE COLOR-Straw APPEAR-Hazy SP [MASKED] [MASKED] 10:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.0 LEUK-NEG [MASKED] 10:05PM URINE RBC-<1 WBC-1 BACTERIA-MANY YEAST-NONE EPI-10 [MASKED] 10:05PM URINE MUCOUS-FEW [MASKED] 09:30PM LACTATE-1.1 [MASKED] 09:20PM GLUCOSE-88 UREA N-13 CREAT-0.6 SODIUM-138 POTASSIUM-2.7* CHLORIDE-96 TOTAL CO2-28 ANION GAP-17 [MASKED] 09:20PM estGFR-Using this [MASKED] 09:20PM ALT(SGPT)-73* AST(SGOT)-69* ALK PHOS-115* TOT BILI-0.5 [MASKED] 09:20PM ALBUMIN-4.1 [MASKED] 09:20PM WBC-4.1 RBC-4.36 HGB-13.6 HCT-39.9 MCV-92 MCH-31.2 MCHC-34.1 RDW-13.6 RDWSD-45.6 [MASKED] 09:20PM NEUTS-79.1* LYMPHS-10.1* MONOS-4.9* EOS-5.2 BASOS-0.2 IM [MASKED] AbsNeut-3.21 AbsLymp-0.41* AbsMono-0.20 AbsEos-0.21 AbsBaso-0.01 [MASKED] 09:20PM PLT COUNT-105* CXR: IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: [MASKED] y.o woman with h.o arthritis and hip pain, prior drug reaction, HTN who presents with diffuse body rash and fever. #rash, fever, slight transaminemia. -Rash developed after [MASKED] course of etodolac. No other new medications, sick contacts, or fever. Not pruritic or painful. No oral involvement noted. Suspect that rash which per pt is c/w prior drug rashes is c/w drug rash. She has a mild transaminitis but does not have eosinophilia to meet dx of DRESS. Could be viral exanthum or infectious process but does not have any other localizing signs of infection including GI/GYN/respiratory/GU symptoms. -added etordolac to allergy list, and took off active med list, instructed pt. to avoid this and other nsaids (asa ok, as she has been taking this daily for years, so do not suspect this is asa allergy) -dermatology consulted and agreed with above (see consult note in OMR). Improved with topical therapies alone. See d/c instructions (worksheet) and instructions below. #hypokalemia-repleted with 60 additional meq K. #Chronic R.hip pain-monitor for now given above; f/u with ortho in two days arranged. #HTN- continued home meds Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Estrogens Conjugated 0.625 gm VG DAILY 2. Alendronate Sodium 70 mg PO QSAT 3. Aspirin 325 mg PO DAILY:PRN pain 4. Atenolol 50 mg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Vitamin D 1000 UNIT PO DAILY 7. Citalopram 10 mg PO DAILY 8. etodolac 400 mg oral BID:PRN 9. Hydrochlorothiazide 25 mg PO DAILY 10. Potassium Chloride 10 mEq PO TID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild MAXIMUM OF [MASKED] mg per day RX acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as needed Disp #60 Tablet Refills:0 2. Sarna Lotion 1 Appl TP TID:PRN rash/itching RX camphor-menthol [Anti-Itch (menthol/camphor)] 0.5 %-0.5 % apply to rash TID:PRN TID:PRN Refills:0 3. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID rash trunk only, not to skin folds (groin, armpit, etc) or face RX triamcinolone acetonide 0.1 % apply to rash twice [MASKED] twice a day Refills:*1 4. Alendronate Sodium 70 mg PO QSAT 5. Aspirin 325 mg PO DAILY:PRN pain 6. Atenolol 50 mg PO DAILY 7. Atorvastatin 10 mg PO QPM 8. Citalopram 10 mg PO DAILY 9. Estrogens Conjugated 0.625 gm VG DAILY 10. Hydrochlorothiazide 25 mg PO DAILY 11. Potassium Chloride 10 mEq PO TID 12. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: ADE: rash, fever, slight liver inflammation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: DO NOT TAKE ANY FURTHER NSAIDS (other than aspirin, one tab daily) - do not take ETODOLAC, and recommend avoiding ibuprofen and Naprosyn as well; you had a significant allergic reaction with diffuse rash, fever, and mild liver inflammation. You were seen by dermatology here and we feel that this syndrome will resolve with avoidance of the medication and topical therapies (crèmes/ointments) alone. You should see Dr. [MASKED] one week for repeat assessment of your rash, symptoms, and check of labs: cbc and chemistry-20. Dermatology recommended the following management: - recommend topical triamcinolone 0.1% ointment twice daily to trunk x 14 days; avoid skin folds, genitals and face - Sarna lotion three times daily as needed for itching, keep in refrigerator to keep the lotion cool for comfort - for moderate to severe itching, can also use oral antihistamines (Zyrtec during day, Benadryl at night) - but you have not needed this here, and would recommend avoiding if possible - liberal moisturizers with topical Vaseline or Cetaphil prn - call or report to the ED for facial swelling/edema, lymphadenopathy, fever and mucosal involvement (mucosal involvement means of the mouth and or genitals, which may manifest as pain, swelling, and ulceration). If the rash is worsening or becomes more bothersome to the patient, please page us at [MASKED] during business hours or call [MASKED] and request pager [MASKED] after hours. Followup Instructions: [MASKED]	[]	[ "G8929", "I10" ]	[ "R21: Rash and other nonspecific skin eruption", "R509: Fever, unspecified", "E876: Hypokalemia", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "G8929: Other chronic pain", "M25551: Pain in right hip", "I10: Essential (primary) hypertension", "M810: Age-related osteoporosis without current pathological fracture" ]
10,089,618	25,754,704	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: lisinopril Attending: ___ Chief Complaint: Chest pain and shortness of breath Major Surgical or Invasive Procedure: ___: Extensive pericardial debridement; Coronary artery bypass grafts x 3 (Left internal mammary artery > left anterior descending, Saphenous vein graft > diagonal, Saphenous vein graft > posterior descending artery) Endovascular saphenous vein harvest Bilateral Lower Extremity History of Present Illness: ___ year old male who was seen for his yearly physical and had complaints of exertional chest pain and shortness of breath. He was referred for a stress echo which revealed ischemic EKG changes and he now presents today for a cardiac catheterization to further evaluate. Catheterization revealed three vessel disease and he is now referred to cardiac surgery for revascularization. Past Medical History: Hyperlipidemia Diabetes Mellitus type II Gout Hypertension Chronic Kidney Disease (unknown baseline, pt denies) GERD Right total knee replacement ___ Left total knee replacement ___ Left carpal tunnel release ___ Nasal Polyps removal Social History: ___ Family History: non contributory Physical Exam: Pulse:72 Resp:16 O2 sat: 96/RA B/P Right:156/96 Left: 170/95 Height: 5'6" Weight:99 kg General: 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] Extremities: Warm [x], well-perfused [x] No Edema [x]; right radial and right femoral access sites soft without evidence of hematoma Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: limited by dressing Left: 2+ DP Right: 2+ Left: 2+ ___ Right: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit: Right: none Left: none Pertinent Results: Chest film: ___ Severe cardiomegaly and calcification of the pericardium is stable. Small left pneumothorax is unchanged. Small left pleural effusion and adjacent atelectasis is stable. There is no pulmonary edema. Right IJ catheter tip in the right atrium as before. Sternal wires are aligned. IMPRESSION: Stable appearance of the chest with small left pneumothorax and small pleural effusion. ___ Echocardiogram Left Ventricle - Ejection Fraction: 40% to 55% >= 55% Aorta - Sinus Level: 3.5 cm <= 3.6 cm Aorta - Ascending: 3.6 cm <= 3.4 cm Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Mild ___. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mildly depressed LVEF. RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Simple atheroma in aortic root. Normal ascending aorta diameter. Mildly dilated descending aorta. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. ___ MR ___ normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: The pericardium may be thickened. Conclusions PRE-BYPASS: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is mildly depressed (LVEF= XX %). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There are simple atheroma in the aortic root. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The pericardium may be thickened. POST CPB: 1. Extremely limited echo windows. 2. Unchanges bi-ventricular function. 3. No change in valve structure and function . ___ 04:48AM BLOOD Hct-24.4 ___ 04:04AM BLOOD WBC-8.7 RBC-2.66* Hgb-8.3* Hct-23.9* MCV-90 MCH-31.2 MCHC-34.7 RDW-13.3 RDWSD-43.0 Plt ___ ___ 04:48AM BLOOD Glucose-131* UreaN-25* Creat-1.1 Na-137 K-3.8 Cl-96 HCO3-30 AnGap-15 ___ 04:48AM BLOOD Mg-2.2 ___ 02:03AM BLOOD Calcium-7.9* Phos-1.3* Mg-2.0 Brief Hospital Course: Presented same day admission and was brought to the operating room for coronary artery bypass graft surgery. Due to extensive calcification of the pericardium he required extensive pericardial debridement. He did require transfusions of blood due to acute blood loss in the operating room. Please see operative report for further details. Post operatively he was taken to the intensive care unit for management on Propofol, epinephrine and neosynephrine. He remained intubated overnight and epinephrine was progressively weaned down and off by am post operative day one. Post operative day one he was off all sedation and was extubated. He remained on neosynephrine for blood pressure support. That evening as hematocrit had trended down with fluid resuscitation he was transfused with packed red blood cell, he remained in the intensive care unit for monitoring. By post operative day two he was weaned off the neosynephrine, started on Lasix for diuresis and then betablocker as blood pressure would tolerate. Later that evening he developed atrial fibrillation treated with betablockers and converted back to sinus rhythm. He was clinically stable and transitioned to the floor. His chest tubes and epicardial wires were removed per protocol. He was noted for bradycardia on post operative day three which resolved and betablockers were adjusted. He worked with physical therapy on strength and mobility with recommendation for rehab due to deconditioning. He continued to progress and was ready for discharge to ___ rehab on post operative day six. Medications on Admission: ProAir HFA 90 mcg/actuation aerosol inhaler. ___ puffs Q4-6H PRN Atorvastatin 20 mg Daily Colchicine 0.6 mg Daily PRN Losartan 50 mg Daily Metformin ER ___ mg Daily Metoprolol Succinate ER 25 mg Daily Nitroglycerin 0.3 mg sublingual PRN Omeprazole 40 mg Daily Aspirin 81 mg Daily Vitamin D3 unknown dose, Daily Discharge Medications: 1. Acetaminophen 1000 mg PO QID:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID 3. Furosemide 40 mg PO BID Duration: 7 Days 4. Metoprolol Tartrate 25 mg PO BID 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Potassium Chloride 20 mEq PO Q12H Duration: 7 Days 7. Atorvastatin 40 mg PO QPM 8. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Colchicine 0.6 mg PO DAILY:PRN gout 11. Omeprazole 40 mg PO DAILY 12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 13. Vitamin D 800 UNIT PO DAILY 14. HELD- Losartan Potassium 50 mg PO DAILY This medication was held. Do not restart Losartan Potassium until discussed with PCP or ___ ___ Disposition: Extended Care Facility: ___ Discharge Diagnosis: Coronary Artery Disease s/p coronary revascularization Anemia acute blood loss Post operative atrial fibrillation Secondary diagnosis Hyperlipidemia Diabetes Mellitus type II Gout Hypertension Chronic Kidney Disease (unknown baseline, pt denies) GERD Discharge Condition: Alert and oriented x3 non-focal Ambulating with assistance Incisional pain managed with Acetaminophen Incisions: Sternal - healing well, no erythema or drainage Leg Bilateral EVH - healing well, no erythema or drainage Edema - 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours Followup Instructions: ___	[ "I25119", "I310", "E1122", "I4891", "R001", "D62", "I9789", "I2510", "E785", "I129", "N189", "K219", "M109", "J45909", "E669", "Z96653", "Z6835", "Y92239" ]	Allergies: lisinopril Chief Complaint: Chest pain and shortness of breath Major Surgical or Invasive Procedure: [MASKED]: Extensive pericardial debridement; Coronary artery bypass grafts x 3 (Left internal mammary artery > left anterior descending, Saphenous vein graft > diagonal, Saphenous vein graft > posterior descending artery) Endovascular saphenous vein harvest Bilateral Lower Extremity History of Present Illness: [MASKED] year old male who was seen for his yearly physical and had complaints of exertional chest pain and shortness of breath. He was referred for a stress echo which revealed ischemic EKG changes and he now presents today for a cardiac catheterization to further evaluate. Catheterization revealed three vessel disease and he is now referred to cardiac surgery for revascularization. Past Medical History: Hyperlipidemia Diabetes Mellitus type II Gout Hypertension Chronic Kidney Disease (unknown baseline, pt denies) GERD Right total knee replacement [MASKED] Left total knee replacement [MASKED] Left carpal tunnel release [MASKED] Nasal Polyps removal Social History: [MASKED] Family History: non contributory Physical Exam: Pulse:72 Resp:16 O2 sat: 96/RA B/P Right:156/96 Left: 170/95 Height: 5'6" Weight:99 kg General: 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] Extremities: Warm [x], well-perfused [x] No Edema [x]; right radial and right femoral access sites soft without evidence of hematoma Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: limited by dressing Left: 2+ DP Right: 2+ Left: 2+ [MASKED] Right: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit: Right: none Left: none Pertinent Results: Chest film: [MASKED] Severe cardiomegaly and calcification of the pericardium is stable. Small left pneumothorax is unchanged. Small left pleural effusion and adjacent atelectasis is stable. There is no pulmonary edema. Right IJ catheter tip in the right atrium as before. Sternal wires are aligned. IMPRESSION: Stable appearance of the chest with small left pneumothorax and small pleural effusion. [MASKED] Echocardiogram Left Ventricle - Ejection Fraction: 40% to 55% >= 55% Aorta - Sinus Level: 3.5 cm <= 3.6 cm Aorta - Ascending: 3.6 cm <= 3.4 cm Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Mild [MASKED]. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mildly depressed LVEF. RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Simple atheroma in aortic root. Normal ascending aorta diameter. Mildly dilated descending aorta. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. [MASKED] MR [MASKED] normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: The pericardium may be thickened. Conclusions PRE-BYPASS: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is mildly depressed (LVEF= XX %). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There are simple atheroma in the aortic root. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The pericardium may be thickened. POST CPB: 1. Extremely limited echo windows. 2. Unchanges bi-ventricular function. 3. No change in valve structure and function . [MASKED] 04:48AM BLOOD Hct-24.4 [MASKED] 04:04AM BLOOD WBC-8.7 RBC-2.66* Hgb-8.3* Hct-23.9* MCV-90 MCH-31.2 MCHC-34.7 RDW-13.3 RDWSD-43.0 Plt [MASKED] [MASKED] 04:48AM BLOOD Glucose-131* UreaN-25* Creat-1.1 Na-137 K-3.8 Cl-96 HCO3-30 AnGap-15 [MASKED] 04:48AM BLOOD Mg-2.2 [MASKED] 02:03AM BLOOD Calcium-7.9* Phos-1.3* Mg-2.0 Brief Hospital Course: Presented same day admission and was brought to the operating room for coronary artery bypass graft surgery. Due to extensive calcification of the pericardium he required extensive pericardial debridement. He did require transfusions of blood due to acute blood loss in the operating room. Please see operative report for further details. Post operatively he was taken to the intensive care unit for management on Propofol, epinephrine and neosynephrine. He remained intubated overnight and epinephrine was progressively weaned down and off by am post operative day one. Post operative day one he was off all sedation and was extubated. He remained on neosynephrine for blood pressure support. That evening as hematocrit had trended down with fluid resuscitation he was transfused with packed red blood cell, he remained in the intensive care unit for monitoring. By post operative day two he was weaned off the neosynephrine, started on Lasix for diuresis and then betablocker as blood pressure would tolerate. Later that evening he developed atrial fibrillation treated with betablockers and converted back to sinus rhythm. He was clinically stable and transitioned to the floor. His chest tubes and epicardial wires were removed per protocol. He was noted for bradycardia on post operative day three which resolved and betablockers were adjusted. He worked with physical therapy on strength and mobility with recommendation for rehab due to deconditioning. He continued to progress and was ready for discharge to [MASKED] rehab on post operative day six. Medications on Admission: ProAir HFA 90 mcg/actuation aerosol inhaler. [MASKED] puffs Q4-6H PRN Atorvastatin 20 mg Daily Colchicine 0.6 mg Daily PRN Losartan 50 mg Daily Metformin ER [MASKED] mg Daily Metoprolol Succinate ER 25 mg Daily Nitroglycerin 0.3 mg sublingual PRN Omeprazole 40 mg Daily Aspirin 81 mg Daily Vitamin D3 unknown dose, Daily Discharge Medications: 1. Acetaminophen 1000 mg PO QID:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID 3. Furosemide 40 mg PO BID Duration: 7 Days 4. Metoprolol Tartrate 25 mg PO BID 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Potassium Chloride 20 mEq PO Q12H Duration: 7 Days 7. Atorvastatin 40 mg PO QPM 8. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Colchicine 0.6 mg PO DAILY:PRN gout 11. Omeprazole 40 mg PO DAILY 12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 13. Vitamin D 800 UNIT PO DAILY 14. HELD- Losartan Potassium 50 mg PO DAILY This medication was held. Do not restart Losartan Potassium until discussed with PCP or [MASKED] [MASKED] Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Coronary Artery Disease s/p coronary revascularization Anemia acute blood loss Post operative atrial fibrillation Secondary diagnosis Hyperlipidemia Diabetes Mellitus type II Gout Hypertension Chronic Kidney Disease (unknown baseline, pt denies) GERD Discharge Condition: Alert and oriented x3 non-focal Ambulating with assistance Incisional pain managed with Acetaminophen Incisions: Sternal - healing well, no erythema or drainage Leg Bilateral EVH - healing well, no erythema or drainage Edema - 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours Followup Instructions: [MASKED]	[]	[ "E1122", "I4891", "D62", "I2510", "E785", "I129", "N189", "K219", "M109", "J45909", "E669" ]	[ "I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris", "I310: Chronic adhesive pericarditis", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I4891: Unspecified atrial fibrillation", "R001: Bradycardia, unspecified", "D62: Acute posthemorrhagic anemia", "I9789: Other postprocedural complications and disorders of the circulatory system, not elsewhere classified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "M109: Gout, unspecified", "J45909: Unspecified asthma, uncomplicated", "E669: Obesity, unspecified", "Z96653: Presence of artificial knee joint, bilateral", "Z6835: Body mass index [BMI] 35.0-35.9, adult", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]
10,089,865	26,512,557	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Levaquin / citrus fruits / cyclobenzaprine Attending: ___. Chief Complaint: Chiari Malformation Major Surgical or Invasive Procedure: ___ Suboccipital craniectomy for Chiari Type I History of Present Illness: Ms. ___ is a ___ yrs old female patient who was initially referred to neurosurgery in ___ for evaluation of a pineal cyst. It has also been noted that at the craniocervical junction, that the cerebellar tonsils were approximately 3-4 mm below the level of foramen magnum. Patient presents electively for suboccipital craniectomy, Past Medical History: Pineal cyst, Chiari Malformation, Pre-eclampsia with recent pregnancy with HTN C-section Social History: ___ Family History: NC Physical Exam: ============ ON DISCHARGE ============ PHYSICAL EXAM: Gen: WD/WN, comfortable, NAD. Neck: Cervical collar. Lungs: No respiratory distress. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: C-Collar in place. Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch Skin: Posterior neck incision with sutures open to air, clean, dry and intact without edema, erythema or exudate. Pertinent Results: =========== IMAGING =========== ___: CT HEAD W/O CONTRAST Patient is status post Chiari decompression with expected post operative changes. ___: MR HEAD W/ CONTRAST Tonsillar ectopia. No enhancing brain lesions. Examination performed for surgical planning. =========== LABS =========== ___ 05:55AM BLOOD WBC-12.8* RBC-3.84* Hgb-10.8* Hct-32.7* MCV-85 MCH-28.1 MCHC-33.0 RDW-13.1 RDWSD-40.3 Plt ___ ___ 04:46AM BLOOD WBC-17.2* RBC-3.97 Hgb-11.0* Hct-33.2* MCV-84 MCH-27.7 MCHC-33.1 RDW-13.1 RDWSD-39.8 Plt ___ ___ 06:16PM BLOOD WBC-17.9# RBC-4.30 Hgb-11.8 Hct-35.8 MCV-83 MCH-27.4 MCHC-33.0 RDW-12.9 RDWSD-38.8 Plt ___ ___ 06:16PM BLOOD ___ PTT-23.0 ___ ___ 05:55AM BLOOD Glucose-100 UreaN-8 Creat-0.5 Na-135 K-3.8 Cl-100 HCO3-25 AnGap-14 ___ 04:46AM BLOOD Glucose-135* UreaN-10 Creat-0.6 Na-136 K-3.6 Cl-104 HCO3-24 AnGap-12 ___ 06:16PM BLOOD Glucose-168* UreaN-10 Creat-0.8 Na-139 K-3.5 Cl-106 HCO3-23 AnGap-14 ___ 05:55AM BLOOD Calcium-8.5 Phos-2.1* Mg-2.0 ___ 06:16PM BLOOD Calcium-8.2* Phos-3.1 Mg-1.8 Brief Hospital Course: Patient was electively admitted for suboccipital craniectomy for Chiari decompression. Patient was extubated in the OR and brought to the PACU for continued observation and care. In the PACU patient complaints including nausea and pain. Nausea medications adjusted and flexeril added for presumed muscle spasm given surgery. On ___, the patient remained neurologically and hemodynamically stable. Her WBC count was elevated, but downtrending. She continued to have complaints of nausea and pain. On ___, the patient remained neurologically and hemodynamically stable. Her WBC count continued to downtrend. Her pain and nausea were improved. She was ambulating with nursing. On ___, the patient remained neurologically and hemodynamically stable. Pain was well managed with oral medications. She was ambulating with a steady gait. On ___, the patient remained neurologically and hemodynamically stable. Her pain continued to be well-managed. She was discharged home in stable condition. Medications on Admission: None Discharge Medications: 1. Acetaminophen 325-650 mg PO Q8H 2. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm RX cyclobenzaprine 10 mg 1 tablet(s) by mouth Q8H PRN Disp #24 Tablet Refills:0 3. Diazepam 2 mg PO Q6H:PRN Spasm RX diazepam 2 mg 1 tab by mouth Q6H PRN Disp #30 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg 2 tablet(s) by mouth Q4H PRN Disp #45 Tablet Refills:*0 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Senna 8.6 mg PO BID:PRN constipation 8. Ondansetron 4 mg PO Q8H:PRN nausea Discharge Disposition: Home Discharge Diagnosis: ___ Malformation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Surgery · You underwent a surgery called a sub-craniotomy for Chiari Decompression. · Please keep your sutures or staples along your incision dry until they are removed. · It is best to keep your incision open to air but it is ok to cover it when outside. · Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity · We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. · You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. · No driving while taking any narcotic or sedating medication. · If you experienced a seizure while admitted, you are NOT allowed to drive by law. · No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications · Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. · You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: · You may have difficulty paying attention, concentrating, and remembering new information. · Emotional and/or behavioral difficulties are common. · Feeling more tired, restlessness, irritability, and mood swings are also common. · You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. · You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. · 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. Headaches: · Headache is one of the most common symptoms after a brain bleed. · Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. · Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. · There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: · Severe pain, swelling, redness or drainage from the incision site. · Fever greater than 101.5 degrees Fahrenheit · Nausea and/or vomiting · Extreme sleepiness and not being able to stay awake · Severe headaches not relieved by pain relievers · Seizures · Any new problems with your vision or ability to speak · Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: · Sudden numbness or weakness in the face, arm, or leg · Sudden confusion or trouble speaking or understanding · Sudden trouble walking, dizziness, or loss of balance or coordination · Sudden severe headaches with no known reason Followup Instructions: ___	[ "G935" ]	Allergies: Levaquin / citrus fruits / cyclobenzaprine Chief Complaint: Chiari Malformation Major Surgical or Invasive Procedure: [MASKED] Suboccipital craniectomy for Chiari Type I History of Present Illness: Ms. [MASKED] is a [MASKED] yrs old female patient who was initially referred to neurosurgery in [MASKED] for evaluation of a pineal cyst. It has also been noted that at the craniocervical junction, that the cerebellar tonsils were approximately 3-4 mm below the level of foramen magnum. Patient presents electively for suboccipital craniectomy, Past Medical History: Pineal cyst, Chiari Malformation, Pre-eclampsia with recent pregnancy with HTN C-section Social History: [MASKED] Family History: NC Physical Exam: ============ ON DISCHARGE ============ PHYSICAL EXAM: Gen: WD/WN, comfortable, NAD. Neck: Cervical collar. Lungs: No respiratory distress. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: C-Collar in place. Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [MASKED] throughout. No pronator drift Sensation: Intact to light touch Skin: Posterior neck incision with sutures open to air, clean, dry and intact without edema, erythema or exudate. Pertinent Results: =========== IMAGING =========== [MASKED]: CT HEAD W/O CONTRAST Patient is status post Chiari decompression with expected post operative changes. [MASKED]: MR HEAD W/ CONTRAST Tonsillar ectopia. No enhancing brain lesions. Examination performed for surgical planning. =========== LABS =========== [MASKED] 05:55AM BLOOD WBC-12.8* RBC-3.84* Hgb-10.8* Hct-32.7* MCV-85 MCH-28.1 MCHC-33.0 RDW-13.1 RDWSD-40.3 Plt [MASKED] [MASKED] 04:46AM BLOOD WBC-17.2* RBC-3.97 Hgb-11.0* Hct-33.2* MCV-84 MCH-27.7 MCHC-33.1 RDW-13.1 RDWSD-39.8 Plt [MASKED] [MASKED] 06:16PM BLOOD WBC-17.9# RBC-4.30 Hgb-11.8 Hct-35.8 MCV-83 MCH-27.4 MCHC-33.0 RDW-12.9 RDWSD-38.8 Plt [MASKED] [MASKED] 06:16PM BLOOD [MASKED] PTT-23.0 [MASKED] [MASKED] 05:55AM BLOOD Glucose-100 UreaN-8 Creat-0.5 Na-135 K-3.8 Cl-100 HCO3-25 AnGap-14 [MASKED] 04:46AM BLOOD Glucose-135* UreaN-10 Creat-0.6 Na-136 K-3.6 Cl-104 HCO3-24 AnGap-12 [MASKED] 06:16PM BLOOD Glucose-168* UreaN-10 Creat-0.8 Na-139 K-3.5 Cl-106 HCO3-23 AnGap-14 [MASKED] 05:55AM BLOOD Calcium-8.5 Phos-2.1* Mg-2.0 [MASKED] 06:16PM BLOOD Calcium-8.2* Phos-3.1 Mg-1.8 Brief Hospital Course: Patient was electively admitted for suboccipital craniectomy for Chiari decompression. Patient was extubated in the OR and brought to the PACU for continued observation and care. In the PACU patient complaints including nausea and pain. Nausea medications adjusted and flexeril added for presumed muscle spasm given surgery. On [MASKED], the patient remained neurologically and hemodynamically stable. Her WBC count was elevated, but downtrending. She continued to have complaints of nausea and pain. On [MASKED], the patient remained neurologically and hemodynamically stable. Her WBC count continued to downtrend. Her pain and nausea were improved. She was ambulating with nursing. On [MASKED], the patient remained neurologically and hemodynamically stable. Pain was well managed with oral medications. She was ambulating with a steady gait. On [MASKED], the patient remained neurologically and hemodynamically stable. Her pain continued to be well-managed. She was discharged home in stable condition. Medications on Admission: None Discharge Medications: 1. Acetaminophen 325-650 mg PO Q8H 2. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm RX cyclobenzaprine 10 mg 1 tablet(s) by mouth Q8H PRN Disp #24 Tablet Refills:0 3. Diazepam 2 mg PO Q6H:PRN Spasm RX diazepam 2 mg 1 tab by mouth Q6H PRN Disp #30 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID 5. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX oxycodone 5 mg 2 tablet(s) by mouth Q4H PRN Disp #45 Tablet Refills:*0 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Senna 8.6 mg PO BID:PRN constipation 8. Ondansetron 4 mg PO Q8H:PRN nausea Discharge Disposition: Home Discharge Diagnosis: [MASKED] Malformation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Surgery · You underwent a surgery called a sub-craniotomy for Chiari Decompression. · Please keep your sutures or staples along your incision dry until they are removed. · It is best to keep your incision open to air but it is ok to cover it when outside. · Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity · We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. · You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. [MASKED] try to do too much all at once. · No driving while taking any narcotic or sedating medication. · If you experienced a seizure while admitted, you are NOT allowed to drive by law. · No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications · Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. · You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You [MASKED] Experience: · You may have difficulty paying attention, concentrating, and remembering new information. · Emotional and/or behavioral difficulties are common. · Feeling more tired, restlessness, irritability, and mood swings are also common. · You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. · You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. · 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. Headaches: · Headache is one of the most common symptoms after a brain bleed. · Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. · Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. · There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at [MASKED] for: · Severe pain, swelling, redness or drainage from the incision site. · Fever greater than 101.5 degrees Fahrenheit · Nausea and/or vomiting · Extreme sleepiness and not being able to stay awake · Severe headaches not relieved by pain relievers · Seizures · Any new problems with your vision or ability to speak · Weakness or changes in sensation in your face, arms, or leg Call [MASKED] and go to the nearest Emergency Room if you experience any of the following: · Sudden numbness or weakness in the face, arm, or leg · Sudden confusion or trouble speaking or understanding · Sudden trouble walking, dizziness, or loss of balance or coordination · Sudden severe headaches with no known reason Followup Instructions: [MASKED]	[]	[]	[ "G935: Compression of brain" ]
10,089,903	26,568,335	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: persistent cough, SOB Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH COPD, depression presenting with productive cough and shortness of breath. He was treated for pneumonia at ___ earlier this month (discharged on ___. He says he was in the hospital for around 6 days and received IV antibiotics during that time. He was discharged on a 4 day course of oral antibiotics which he took 2 pills in the morning and 2 pills in the evening. He states since leaving the hospital, his breathing has improved. His cough has somewhat worsened. His sputum is white colored mainly. He has not had a fever in awhile and no shaking chills. Patient endorses a history of depression after his wife died ___ years ago. He has also been living on the streets and drinking alcohol daily since then (7 42 ounce beers a day) . His last drink was immediately prior to showing up in the emergency department. He states that he is just at a point in his life where he is just tired of living. It has been rough for him on the streets. He has never hurt himself before. He has a history of withdrawal seizures, the most recent one being many years ago. In the ED apparently, he told someone that he would hear a voice telling him not to kill himself. Upon asking him at the end of the interview, he was too somnolent to answer appropriately. In the ED, - Initial vitals were: 98.3 97 116/88 18 95% RA - Labs were notable for: WBC 5.4 H/H ___ Plt 329 BMP wnl with Cr 0.7 and BUN 5 LFTs wnl Serum tox positive for ethanol ___ Lactate 3.5 -> 2.9 Influenza negative - Studies were notable for: CXR: Ill-defined patchy opacity in the right upper lobe concerning for pneumonia. Follow up radiographs after treatment are recommended to ensure resolution of this finding. - Psych consulted: Attempted to see patient at 0230. Patient was sedated and unable to participate fully in formal interview. Patient may not leave the hospital. Continue constant observation as safety assessment on-going. - Patient was given: ___ 21:29 IH Ipratropium-Albuterol Neb 1 NEB ___ 21:29 PO Diazepam - CIWA protocol 10 mg ___ 23:08 IV Thiamine 200 mg ___ 23:43 IVF NS 500 mL ___ 00:15 IV CefePIME 2g ___ 02:52 IV Vancomycin 1000 mg ___ 03:04 PO Diazepam - CIWA protocol 10 mg On arrival to the floor, he states he has had a rough go. He states his breathing is better but his cough is worse. He has not had any fevers. Past Medical History: -Alcohol use disorder -COPD -Depression Social History: ___ Family History: Father with MI Rest of family history difficult to attain as patient was somnolent Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: reviewed in ___ GENERAL: somnolent but answers questions upon shaking HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: supple CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: Warm. No rashes. NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. ___ strength throughout. DISCHARGE PHYSICAL EXAM: ======================= PHYSICAL EXAM: 24 HR Data (last updated ___ @ 920) Temp: 97.4 (Tm 98.8), BP: 163/90 (123-163/80-97), HR: 77 (77-110), RR: 18 (___), O2 sat: 95% (93-96), O2 delivery: RA GENERAL: Sitting up in bed watching TV, in NAD. HEENT: Head is normocephalic. Sclera anicteric. CARDIAC: Audible S1 and S2. RRR. No r/m/g LUNG: Appears in no respiratory distress. CTAB posteriorly. Bibasilar hyperresonance to percussion bilaterally. ABD: Soft, nontender to palpation, nondistended. No rebound or guarding. EXT: Warm, well perfused, no lower extremity edema. 2+ radial pulses NEURO: Alert, oriented, moves all extremities. SKIN: No rashes noted on extremities or face/neck or extremities. Pertinent Results: ADMISSION LABS: ___ 07:35PM PLT COUNT-329 ___ 07:35PM NEUTS-46.9 ___ MONOS-8.1 EOS-4.1 BASOS-0.9 IM ___ AbsNeut-2.54 AbsLymp-2.13 AbsMono-0.44 AbsEos-0.22 AbsBaso-0.05 ___ 07:35PM WBC-5.4 RBC-4.60 HGB-16.0 HCT-47.4 MCV-103* MCH-34.8* MCHC-33.8 RDW-13.4 RDWSD-51.5* ___ 07:35PM ASA-NEG ___ ACETMNPHN-NEG tricyclic-NEG ___ 07:35PM ALBUMIN-4.6 ___ 07:35PM estGFR-Using this ___ 07:35PM GLUCOSE-104* UREA N-5* CREAT-0.7 SODIUM-141 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-24 ANION GAP-16 ___ 07:40PM LACTATE-3.5* OTHER STUDIES: ___ 06:21PM URINE Streptococcus pneumoniae Antigen Detection-PND ___ 11:35PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE MICRO: ___ 6:21 pm URINE Source: ___ MORE THAN 12 HRS OLD. FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. __________________________________________________________ ___ 11:50 am SPUTUM Source: Expectorated. FINAL REPORT ___ GRAM STAIN (Final ___: ___ PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. __________________________________________________________ ___ 5:28 am MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Pending): __________________________________________________________ ___ 12:00 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. __________________________________________________________ ___ 7:40 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. IMAGING: ___ CXR FINDINGS: Heart size is normal. The thoracic aorta is tortuous. Mediastinal and hilar contours are otherwise unremarkable. The pulmonary vasculature is normal. Lungs are hyperinflatedA. Ill-defined patchy opacity is seen within the right upper lobe posteriorly. Minimal scarring versus atelectasis is seen in the left lung base. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: Ill-defined patchy opacity in the right upper lobe concerning for pneumonia. Follow up radiographs after treatment are recommended to ensure resolution of this finding. DISCHARGE LABS: ___ 06:10AM BLOOD WBC-4.4 RBC-3.78* Hgb-13.2* Hct-40.3 MCV-107* MCH-34.9* MCHC-32.8 RDW-13.3 RDWSD-53.1* Plt ___ ___ 06:10AM BLOOD Glucose-90 UreaN-8 Creat-0.9 Na-143 K-4.6 Cl-107 HCO3-26 AnGap-10 ___ 06:10AM BLOOD Calcium-9.1 Phos-4.4 Mg-1.5* Brief Hospital Course: This is a ___ year old male with past medical history of COPD, depression, recent reported OSH admission for pneumonia, admitted ___ with cough secondary to acute COPD exacerbation in setting of his inhalers being stolen, course complicated by alcohol withdrawal, restarted on bronchodilators and treated with benzodiazpines per CIWA, subsequently stable and off benzodiazepines for greater than 1 day, able to be discharged # Acute COPD exacerbation # Recent bacterial pneumonia Patient recently discharged from ___ on ___ after admission for reported necrotizing pneumonia (per verbal report was streptococcus and legionella positive, AFB negative). Patient reported improvement to baseline following that admission, with subsequent worsening of his symptoms after having his home tiotropium and albuterol inhaler stolen at a shelter. He presented with cough and wheezing. CXR showed a RUL consolidation. In absence of leukocytosis and fever, his symptoms were felt to be secondary to COPD exacerbation without new acute pnuemonia--consolidation was felt to be explained by recent pnuemonia. He was treated with restarting of bronchodilator regimen. Over subsequent day his symptoms resolved without the need for antibiotics or systemic steroids. He was able to ambulate without symptom or issue. Patient was re-prescribed tiotropium and albuterol inhalers, which were delivered to his bedside. # Orthostatic hypotension: Patient reported sensation of lightheadedness at time of admission. He had nonfocal neuro exam. Workup notable for orthostatic hypotention. Felt to be secondary to poor PO intake in setting of alcohol binge. Resolved with IV fluids. # Unspecified Depressive disorder, likely alcohol-induced mood disorder In ED patient reported thoughts of hurting self. He was initially placed on 1:1 sitter and admitted to medicine. Once no longer intoxicated he denied any thoughts of hurting self or others. Psychiatry felt safe for discharge. He was seen by ___ social work, but declined all outpatient supports. A referral was made to elder services for at risk elder. # Alcohol withdrawal # Alcohol Use Disorder Patient with longstanding heavy alcohol use, with prior alcohol withdrawal and seizures, presented to ED intoxicated with alcohol level of ~300. Course was complicated by withdrawal for which patient was treated with diazapem per CIWA. Treated with folate, multivitamin and high dose thiamine. He was seen by social work, but was not ready to think about quitting. He was monitored off of benzodiazepines for > 24 hours without signs of ongoing withdrawal. # ___ Patient was offered resources for safety or shelter referrals, which he declined. He was referred to Elder Services as an at risk elder. TRANSITIONAL ISSUES: ================= [ ] Would repeat CXR in ___ weeks to assess for resolution of RUL consolidation. # CODE: Full code presumed # CONTACT: none > 30 minutes spent on discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tiotropium Bromide 1 CAP IH DAILY 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 2. Multivitamins 1 TAB PO DAILY RX multivitamin 1 tab-cap by mouth once a day Disp #30 Tablet Refills:0 3. Thiamine 100 mg PO DAILY RX thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob RX albuterol sulfate 90 mcg 2 PUFF IH every four (4) hours Disp #1 Inhaler Refills:3 5. Tiotropium Bromide 1 CAP IH DAILY RX tiotropium bromide [Spiriva Respimat] 1.25 mcg/actuation 1 IH once a day Disp #1 Inhaler Refills:*3 Discharge Disposition: Home Discharge Diagnosis: COPD EtOH use disorder Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___, It was a privilege taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== -You were admitted to the hospital because you felt short of breath. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== -Your COPD inhalers were re-started and your breathing improved. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your ___ appointments. We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___	[ "J441", "R45851", "F1014", "F17210", "F10129", "Y908", "Z590", "I951", "E8342", "T443X6A", "T486X6A", "Z91138", "F329", "R740" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: persistent cough, SOB Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] PMH COPD, depression presenting with productive cough and shortness of breath. He was treated for pneumonia at [MASKED] earlier this month (discharged on [MASKED]. He says he was in the hospital for around 6 days and received IV antibiotics during that time. He was discharged on a 4 day course of oral antibiotics which he took 2 pills in the morning and 2 pills in the evening. He states since leaving the hospital, his breathing has improved. His cough has somewhat worsened. His sputum is white colored mainly. He has not had a fever in awhile and no shaking chills. Patient endorses a history of depression after his wife died [MASKED] years ago. He has also been living on the streets and drinking alcohol daily since then (7 42 ounce beers a day) . His last drink was immediately prior to showing up in the emergency department. He states that he is just at a point in his life where he is just tired of living. It has been rough for him on the streets. He has never hurt himself before. He has a history of withdrawal seizures, the most recent one being many years ago. In the ED apparently, he told someone that he would hear a voice telling him not to kill himself. Upon asking him at the end of the interview, he was too somnolent to answer appropriately. In the ED, - Initial vitals were: 98.3 97 116/88 18 95% RA - Labs were notable for: WBC 5.4 H/H [MASKED] Plt 329 BMP wnl with Cr 0.7 and BUN 5 LFTs wnl Serum tox positive for ethanol [MASKED] Lactate 3.5 -> 2.9 Influenza negative - Studies were notable for: CXR: Ill-defined patchy opacity in the right upper lobe concerning for pneumonia. Follow up radiographs after treatment are recommended to ensure resolution of this finding. - Psych consulted: Attempted to see patient at 0230. Patient was sedated and unable to participate fully in formal interview. Patient may not leave the hospital. Continue constant observation as safety assessment on-going. - Patient was given: [MASKED] 21:29 IH Ipratropium-Albuterol Neb 1 NEB [MASKED] 21:29 PO Diazepam - CIWA protocol 10 mg [MASKED] 23:08 IV Thiamine 200 mg [MASKED] 23:43 IVF NS 500 mL [MASKED] 00:15 IV CefePIME 2g [MASKED] 02:52 IV Vancomycin 1000 mg [MASKED] 03:04 PO Diazepam - CIWA protocol 10 mg On arrival to the floor, he states he has had a rough go. He states his breathing is better but his cough is worse. He has not had any fevers. Past Medical History: -Alcohol use disorder -COPD -Depression Social History: [MASKED] Family History: Father with MI Rest of family history difficult to attain as patient was somnolent Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: reviewed in [MASKED] GENERAL: somnolent but answers questions upon shaking HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: supple CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: Warm. No rashes. NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. [MASKED] strength throughout. DISCHARGE PHYSICAL EXAM: ======================= PHYSICAL EXAM: 24 HR Data (last updated [MASKED] @ 920) Temp: 97.4 (Tm 98.8), BP: 163/90 (123-163/80-97), HR: 77 (77-110), RR: 18 ([MASKED]), O2 sat: 95% (93-96), O2 delivery: RA GENERAL: Sitting up in bed watching TV, in NAD. HEENT: Head is normocephalic. Sclera anicteric. CARDIAC: Audible S1 and S2. RRR. No r/m/g LUNG: Appears in no respiratory distress. CTAB posteriorly. Bibasilar hyperresonance to percussion bilaterally. ABD: Soft, nontender to palpation, nondistended. No rebound or guarding. EXT: Warm, well perfused, no lower extremity edema. 2+ radial pulses NEURO: Alert, oriented, moves all extremities. SKIN: No rashes noted on extremities or face/neck or extremities. Pertinent Results: ADMISSION LABS: [MASKED] 07:35PM PLT COUNT-329 [MASKED] 07:35PM NEUTS-46.9 [MASKED] MONOS-8.1 EOS-4.1 BASOS-0.9 IM [MASKED] AbsNeut-2.54 AbsLymp-2.13 AbsMono-0.44 AbsEos-0.22 AbsBaso-0.05 [MASKED] 07:35PM WBC-5.4 RBC-4.60 HGB-16.0 HCT-47.4 MCV-103* MCH-34.8* MCHC-33.8 RDW-13.4 RDWSD-51.5* [MASKED] 07:35PM ASA-NEG [MASKED] ACETMNPHN-NEG tricyclic-NEG [MASKED] 07:35PM ALBUMIN-4.6 [MASKED] 07:35PM estGFR-Using this [MASKED] 07:35PM GLUCOSE-104* UREA N-5* CREAT-0.7 SODIUM-141 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-24 ANION GAP-16 [MASKED] 07:40PM LACTATE-3.5* OTHER STUDIES: [MASKED] 06:21PM URINE Streptococcus pneumoniae Antigen Detection-PND [MASKED] 11:35PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE MICRO: [MASKED] 6:21 pm URINE Source: [MASKED] MORE THAN 12 HRS OLD. FINAL REPORT [MASKED] Legionella Urinary Antigen (Final [MASKED]: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. [MASKED] [MASKED] 11:50 am SPUTUM Source: Expectorated. FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: [MASKED] PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [MASKED]: TEST CANCELLED, PATIENT CREDITED. [MASKED] [MASKED] 5:28 am MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Pending): [MASKED] [MASKED] 12:00 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. [MASKED] [MASKED] 7:40 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. IMAGING: [MASKED] CXR FINDINGS: Heart size is normal. The thoracic aorta is tortuous. Mediastinal and hilar contours are otherwise unremarkable. The pulmonary vasculature is normal. Lungs are hyperinflatedA. Ill-defined patchy opacity is seen within the right upper lobe posteriorly. Minimal scarring versus atelectasis is seen in the left lung base. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: Ill-defined patchy opacity in the right upper lobe concerning for pneumonia. Follow up radiographs after treatment are recommended to ensure resolution of this finding. DISCHARGE LABS: [MASKED] 06:10AM BLOOD WBC-4.4 RBC-3.78* Hgb-13.2* Hct-40.3 MCV-107* MCH-34.9* MCHC-32.8 RDW-13.3 RDWSD-53.1* Plt [MASKED] [MASKED] 06:10AM BLOOD Glucose-90 UreaN-8 Creat-0.9 Na-143 K-4.6 Cl-107 HCO3-26 AnGap-10 [MASKED] 06:10AM BLOOD Calcium-9.1 Phos-4.4 Mg-1.5* Brief Hospital Course: This is a [MASKED] year old male with past medical history of COPD, depression, recent reported OSH admission for pneumonia, admitted [MASKED] with cough secondary to acute COPD exacerbation in setting of his inhalers being stolen, course complicated by alcohol withdrawal, restarted on bronchodilators and treated with benzodiazpines per CIWA, subsequently stable and off benzodiazepines for greater than 1 day, able to be discharged # Acute COPD exacerbation # Recent bacterial pneumonia Patient recently discharged from [MASKED] on [MASKED] after admission for reported necrotizing pneumonia (per verbal report was streptococcus and legionella positive, AFB negative). Patient reported improvement to baseline following that admission, with subsequent worsening of his symptoms after having his home tiotropium and albuterol inhaler stolen at a shelter. He presented with cough and wheezing. CXR showed a RUL consolidation. In absence of leukocytosis and fever, his symptoms were felt to be secondary to COPD exacerbation without new acute pnuemonia--consolidation was felt to be explained by recent pnuemonia. He was treated with restarting of bronchodilator regimen. Over subsequent day his symptoms resolved without the need for antibiotics or systemic steroids. He was able to ambulate without symptom or issue. Patient was re-prescribed tiotropium and albuterol inhalers, which were delivered to his bedside. # Orthostatic hypotension: Patient reported sensation of lightheadedness at time of admission. He had nonfocal neuro exam. Workup notable for orthostatic hypotention. Felt to be secondary to poor PO intake in setting of alcohol binge. Resolved with IV fluids. # Unspecified Depressive disorder, likely alcohol-induced mood disorder In ED patient reported thoughts of hurting self. He was initially placed on 1:1 sitter and admitted to medicine. Once no longer intoxicated he denied any thoughts of hurting self or others. Psychiatry felt safe for discharge. He was seen by [MASKED] social work, but declined all outpatient supports. A referral was made to elder services for at risk elder. # Alcohol withdrawal # Alcohol Use Disorder Patient with longstanding heavy alcohol use, with prior alcohol withdrawal and seizures, presented to ED intoxicated with alcohol level of ~300. Course was complicated by withdrawal for which patient was treated with diazapem per CIWA. Treated with folate, multivitamin and high dose thiamine. He was seen by social work, but was not ready to think about quitting. He was monitored off of benzodiazepines for > 24 hours without signs of ongoing withdrawal. # [MASKED] Patient was offered resources for safety or shelter referrals, which he declined. He was referred to Elder Services as an at risk elder. TRANSITIONAL ISSUES: ================= [ ] Would repeat CXR in [MASKED] weeks to assess for resolution of RUL consolidation. # CODE: Full code presumed # CONTACT: none > 30 minutes spent on discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tiotropium Bromide 1 CAP IH DAILY 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 2. Multivitamins 1 TAB PO DAILY RX multivitamin 1 tab-cap by mouth once a day Disp #30 Tablet Refills:0 3. Thiamine 100 mg PO DAILY RX thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob RX albuterol sulfate 90 mcg 2 PUFF IH every four (4) hours Disp #1 Inhaler Refills:3 5. Tiotropium Bromide 1 CAP IH DAILY RX tiotropium bromide [Spiriva Respimat] 1.25 mcg/actuation 1 IH once a day Disp #1 Inhaler Refills:*3 Discharge Disposition: Home Discharge Diagnosis: COPD EtOH use disorder Depression 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 privilege taking care of you at [MASKED] [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== -You were admitted to the hospital because you felt short of breath. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== -Your COPD inhalers were re-started and your breathing improved. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your [MASKED] appointments. We wish you all the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "F17210", "F329" ]	[ "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "R45851: Suicidal ideations", "F1014: Alcohol abuse with alcohol-induced mood disorder", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F10129: Alcohol abuse with intoxication, unspecified", "Y908: Blood alcohol level of 240 mg/100 ml or more", "Z590: Homelessness", "I951: Orthostatic hypotension", "E8342: Hypomagnesemia", "T443X6A: Underdosing of other parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics, initial encounter", "T486X6A: Underdosing of antiasthmatics, initial encounter", "Z91138: Patient's unintentional underdosing of medication regimen for other reason", "F329: Major depressive disorder, single episode, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]" ]
10,089,922	20,015,409	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fatigue. Major Surgical or Invasive Procedure: None. History of Present Illness: HPI: ___ year old woman with history of HTN, HLD, GERD who presents for evaluation of fatigue. The patient endorses a flulike illness approximately one month ago. She felt better for about a week and then experienced a progressive decline. She's been increasingly more fatigued since that time. She is also noted that her eyes looked pale. She's also noted dark colored urine. She denies any other questions or complaints. She specifically denies any hematuria, bloody or dark bowel movements, hemoptysis, abdominal pain or distention. No recent travel. Is originally from ___. In the ED, initial vitals were: 99.4 103 153/74 12 Labs notable for: profound normocytic anemia with H/H 6.3/20.6, clumped platelets, INR 1.1, PTT 24.6, fibrinogen 574, mild transaminitis with LDH 684 T bili 1.6, normal chem, hapto <10. Smear positive for parasites, burden 1.4%. CXR negative. RUQ U/s normal gallbladder, no cystic lesions, + splenomegaly Patient was given: no medications Vitals prior to transfer: 98.1 97 126/73 16 97% RA On the floor via ___ phone interpreter patient is feeling fatigued without any specific complaints. ROS as above. Past Medical History: HTN HLD GERD Social History: ___ Family History: Parents both died in ___ of CVAs. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vital Signs: 98.3 PO 141 / 78 L Lying 97 18 98 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, slightly pale conjunctiva, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: regular 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 , no CVA tenderness Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema; no joint swelling, crepitus, pain on palpation Neuro: CNII-XII grossly intact, ___ strength upper/lower extremities, grossly normal sensation DISCHARGE PHYSICAL EXAM ======================= Vital Signs: Tmax 98.3 BP 100-130/50-70s HR 70-80s RR 18 ___ on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI CV: regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact, moving all extremities evenly and well Pertinent Results: ADMISSION LABS ============== ___ 10:24AM BLOOD WBC-4.7 RBC-2.23# Hgb-6.6# Hct-21.7# MCV-97# MCH-29.6 MCHC-30.4 RDW-17.1* RDWSD-58.1* Plt Ct-UNABLE TO ___ 10:24AM BLOOD Neuts-68.0 Lymphs-18.7* Monos-12.3 Eos-0.2* Baso-0.2 Im ___ AbsNeut-3.20 AbsLymp-0.88* AbsMono-0.58 AbsEos-0.01* AbsBaso-0.01 ___ 11:02PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ ___ 11:02PM BLOOD ___ PTT-24.6* ___ ___ 11:02PM BLOOD ___ ___ 10:24AM BLOOD Ret Aut-5.4* Abs Ret-0.12* ___ 11:02PM BLOOD Glucose-129* UreaN-10 Creat-0.8 Na-136 K-4.0 Cl-102 HCO3-24 AnGap-14 ___ 11:02PM BLOOD ALT-54* AST-52* LD(LDH)-684* CK(CPK)-59 AlkPhos-472* TotBili-1.6* ___ 11:02PM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.6 Mg-2.2 ___ 10:24AM BLOOD %HbA1c-5.4 eAG-108 ___ 10:24AM BLOOD TSH-0.95 ___ 11:07PM BLOOD ___ pH-7.42 Comment-GREEN TOP ___ 11:07PM BLOOD freeCa-1.06* PERTINENT LABS ============== Parasite smear positive throughout admission, 1.2% on ___ decreased to 0.1% on ___ MICROBIOLOGY ============== ___ (LYME)Lyme IgG-PRELIMINARY; Lyme IgM-PRELIMINARYINPATIENT Lyme IgG (Preliminary): Sent to ___ Laboratories for Lyme Western Blot testing. Lyme IgM (Preliminary): Sent to ___ Laboratories for Lyme Western Blot testing. ___ CULTUREBlood Culture, Routine-FINALINPATIENT ___ CULTUREBlood Culture, Routine-FINALINPATIENT ___ (Malaria)Malaria Antigen Test-FINALINPATIENT ___ (Malaria)Malaria Antigen Test-FINAL IMAGING ============== ___ CXR: The lungs are well-expanded and clear. The cardiomediastinal and hilar contours are unremarkable. There is no pneumothorax, pleural effusion, or consolidation. ___ RUQ US IMPRESSION: 1. Normal gallbladder. 2. No cystic lesions identified. 3. Splenomegaly. DISCHARGE LABS ============== ___ 04:20AM BLOOD WBC-5.2 RBC-2.36* Hgb-7.1* Hct-22.5* MCV-95 MCH-30.1 MCHC-31.6* RDW-18.7* RDWSD-60.4* Plt Ct-UNBALE TO ___ 04:20AM BLOOD Plt Smr-UNABLE TO Plt Ct-UNBALE TO ___ 03:16AM BLOOD Parst S-POSITIVE ___ 03:16AM BLOOD Glucose-101* UreaN-14 Creat-0.6 Na-138 K-4.1 Cl-105 HCO3-26 AnGap-11 ___ 03:16AM BLOOD ALT-29 AST-26 LD(LDH)-509* AlkPhos-276* TotBili-1.2 DirBili-0.3 IndBili-0.9 ___ 03:16AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.1 ___ 03:16AM BLOOD Hapto-<10* Brief Hospital Course: Ms. ___ is ___ old generally healthy female who presented to her PCP with fatigue and profound anemia, was admitted to ___ with a Hb 5.6, found to have parasites on smear and treated for babesiosis. Patient received one unit of blood on ___ with good response and was started on atovaquone, azithromycin, and doxycycline (day 1 = ___ for treatment of babesia and empirically for parasitic co-infection. Patient had expectedly elevated hemolysis labs and also elevated LFTs, especially alk phos (and GGT). Patient was generally asymptomatic after blood transfusion, felt as baseline with no symptoms. Blood smear on admission ___ showed 1.2% parasitemia, by discharge on ___ smear showed only 0.1% parasitemia. Per recommendation from infectious disease, patient should continue blood smears for parasite until there are no parasites, after which the patient will continue azithromycin and atovaquone for 7 more days. Patient will get CBC and parasite smear at ___ ___ on ___ and ___. Regardless of blood smears patient should continue taking doxycycline empirically for 14-day course (until ___. ACTIVE ISSUES ============= #Parasites: Patient with smear positive for parasites. Night-float review of smear no evidence of malaria or specific ___ crosses. Given no recent travel history, patient's hemolytic anemia, elevated LFTs and splenomegaly most likely diagnosis is babesiosis. Started at___ 750mg PO BID and azithromycin, 500mg PO first day, then 250mg PO (D1 = ___. Starting doxycycline 100mg PO BID (D1 = ___ given high possibility of co-transmitted parasitic diseases, will take for 14 day course. Medications delivered to patient at bedside. Checked Babesia PCR, Lyme serology, Anaplasma PCR and serology; pending at time of discharge. Trended parasite smear, decreased burden to 0.1% on ___, will recheck at ___ office on ___ and ___ to ensure elimination, and will take azithromycin and atovaquone for 7 days post-clearance. ID will see patient next week outpatient on ___. #Anemia: Hemolytic with elevated LDH, retic, bili and low haptoglobin. Most likely secondary to acute parasitic infection. Patient responded well to PRBC transfusion on admission, Hb stable afterwards and at discharge (Hb 7.1). #Transaminitis and splenomegaly: No evidence of biliary obstruction on RUQ u/s. Most likely ___ acute parasitic infection which was worked up and treated (see above). ___ GGT elevated along with alk phos indicating GI source, no anatomic cause seen in RUQ US, minimal elevation and asymptomatic so no further inpatient w/u needed, will be transitional issue at d/c to track after infection resolves CHRONIC MEDICAL ISSUES ====================== #HTN: Initially held anti-hypertensives in setting of acute hemolytic anemia, restarted home metoprolol on ___, patient stable after restarting. #HLD: Continued home statin. #GERD: Continued home PPI. Transitional issues =================== [] CBC and parasite smear at ___ on ___ [] Follow up with primary care physician ___ on ___, should recheck CBC, parasites, and LFTs to ensure hemoglobin stable and that elevated LFTs (especially alk phos) have declined; if they have not, patient would merit further workup of these elevations [] Follow up with Dr. ___ infectious disease at ___ on ___ at 10:00 AM [] Continue taking atovaquone and azithromycin for 7 days AFTER no longer any parasites on smear, will need new prescription beyond current medications [] Continue doxycycline for 2 week course (last day ___ for empiric coverage of any other parasites Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 50 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Simvastatin 40 mg PO QPM 4. Lisinopril 10 mg PO DAILY 5. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500 mg)-800 unit oral DAILY Discharge Medications: 1. Atovaquone Suspension 750 mg PO BID ___ po bid RX atovaquone 750 mg/5 mL 750 mg by mouth twice a day Refills:0 2. Azithromycin 250 mg PO Q24H 250 mg po qd RX azithromycin 250 mg 1 tablet(s) by mouth once per day Disp #7 Tablet Refills:0 3. Doxycycline Hyclate 100 mg PO Q12H RX doxycycline hyclate 100 mg 1 tablet(s) by mouth twice per day Disp #22 Tablet Refills:0 4. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500 mg)-800 unit oral DAILY 5. Lisinopril 10 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Simvastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis -Babesiosis -Anemia Secondary diagnosis -Hypertension -Hyperlipidemia -Gastroesophageal reflux disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because you had anemia, also known as low blood counts of something called hemoglobin. We believe this anemia was caused by an infection called Babesia, which is spread by ticks. We started you on three strong antibiotics to fight this infection: atovaquone, azithromycin, and doxycycline. You will continue to take the doxycycline for 14 days total (until ___. You will get your blood checked for parasites on ___ and ___ with Dr. ___ checking your blood until there are no more parasites. After they are all gone, you will keep taking the azithromycin and atovaquone for another 7 days. You will need an additional prescription from Dr. ___ these pills. You also have an appointment with the infectious disease doctors here at ___ on ___ at 10:00 AM. We also noticed that you high blood tests of chemicals from your liver. This may be caused by the Babesia infection, but just in case, we would like your primary care doctor Dr. ___ to repeat those tests to make sure they go down as we treat your infection. Please follow up with all medical appointments and take all medications as prescribed. It was a pleasure to help take part in your medical care. Sincerely, Your ___ Health Team Followup Instructions: ___	[ "B600", "D599", "I10", "E785", "K219" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Fatigue. Major Surgical or Invasive Procedure: None. History of Present Illness: HPI: [MASKED] year old woman with history of HTN, HLD, GERD who presents for evaluation of fatigue. The patient endorses a flulike illness approximately one month ago. She felt better for about a week and then experienced a progressive decline. She's been increasingly more fatigued since that time. She is also noted that her eyes looked pale. She's also noted dark colored urine. She denies any other questions or complaints. She specifically denies any hematuria, bloody or dark bowel movements, hemoptysis, abdominal pain or distention. No recent travel. Is originally from [MASKED]. In the ED, initial vitals were: 99.4 103 153/74 12 Labs notable for: profound normocytic anemia with H/H 6.3/20.6, clumped platelets, INR 1.1, PTT 24.6, fibrinogen 574, mild transaminitis with LDH 684 T bili 1.6, normal chem, hapto <10. Smear positive for parasites, burden 1.4%. CXR negative. RUQ U/s normal gallbladder, no cystic lesions, + splenomegaly Patient was given: no medications Vitals prior to transfer: 98.1 97 126/73 16 97% RA On the floor via [MASKED] phone interpreter patient is feeling fatigued without any specific complaints. ROS as above. Past Medical History: HTN HLD GERD Social History: [MASKED] Family History: Parents both died in [MASKED] of CVAs. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vital Signs: 98.3 PO 141 / 78 L Lying 97 18 98 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, slightly pale conjunctiva, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: regular 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 , no CVA tenderness Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema; no joint swelling, crepitus, pain on palpation Neuro: CNII-XII grossly intact, [MASKED] strength upper/lower extremities, grossly normal sensation DISCHARGE PHYSICAL EXAM ======================= Vital Signs: Tmax 98.3 BP 100-130/50-70s HR 70-80s RR 18 [MASKED] on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI CV: regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact, moving all extremities evenly and well Pertinent Results: ADMISSION LABS ============== [MASKED] 10:24AM BLOOD WBC-4.7 RBC-2.23# Hgb-6.6# Hct-21.7# MCV-97# MCH-29.6 MCHC-30.4 RDW-17.1* RDWSD-58.1* Plt Ct-UNABLE TO [MASKED] 10:24AM BLOOD Neuts-68.0 Lymphs-18.7* Monos-12.3 Eos-0.2* Baso-0.2 Im [MASKED] AbsNeut-3.20 AbsLymp-0.88* AbsMono-0.58 AbsEos-0.01* AbsBaso-0.01 [MASKED] 11:02PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ [MASKED] 11:02PM BLOOD [MASKED] PTT-24.6* [MASKED] [MASKED] 11:02PM BLOOD [MASKED] [MASKED] 10:24AM BLOOD Ret Aut-5.4* Abs Ret-0.12* [MASKED] 11:02PM BLOOD Glucose-129* UreaN-10 Creat-0.8 Na-136 K-4.0 Cl-102 HCO3-24 AnGap-14 [MASKED] 11:02PM BLOOD ALT-54* AST-52* LD(LDH)-684* CK(CPK)-59 AlkPhos-472* TotBili-1.6* [MASKED] 11:02PM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.6 Mg-2.2 [MASKED] 10:24AM BLOOD %HbA1c-5.4 eAG-108 [MASKED] 10:24AM BLOOD TSH-0.95 [MASKED] 11:07PM BLOOD [MASKED] pH-7.42 Comment-GREEN TOP [MASKED] 11:07PM BLOOD freeCa-1.06* PERTINENT LABS ============== Parasite smear positive throughout admission, 1.2% on [MASKED] decreased to 0.1% on [MASKED] MICROBIOLOGY ============== [MASKED] (LYME)Lyme IgG-PRELIMINARY; Lyme IgM-PRELIMINARYINPATIENT Lyme IgG (Preliminary): Sent to [MASKED] Laboratories for Lyme Western Blot testing. Lyme IgM (Preliminary): Sent to [MASKED] Laboratories for Lyme Western Blot testing. [MASKED] CULTUREBlood Culture, Routine-FINALINPATIENT [MASKED] CULTUREBlood Culture, Routine-FINALINPATIENT [MASKED] (Malaria)Malaria Antigen Test-FINALINPATIENT [MASKED] (Malaria)Malaria Antigen Test-FINAL IMAGING ============== [MASKED] CXR: The lungs are well-expanded and clear. The cardiomediastinal and hilar contours are unremarkable. There is no pneumothorax, pleural effusion, or consolidation. [MASKED] RUQ US IMPRESSION: 1. Normal gallbladder. 2. No cystic lesions identified. 3. Splenomegaly. DISCHARGE LABS ============== [MASKED] 04:20AM BLOOD WBC-5.2 RBC-2.36* Hgb-7.1* Hct-22.5* MCV-95 MCH-30.1 MCHC-31.6* RDW-18.7* RDWSD-60.4* Plt Ct-UNBALE TO [MASKED] 04:20AM BLOOD Plt Smr-UNABLE TO Plt Ct-UNBALE TO [MASKED] 03:16AM BLOOD Parst S-POSITIVE [MASKED] 03:16AM BLOOD Glucose-101* UreaN-14 Creat-0.6 Na-138 K-4.1 Cl-105 HCO3-26 AnGap-11 [MASKED] 03:16AM BLOOD ALT-29 AST-26 LD(LDH)-509* AlkPhos-276* TotBili-1.2 DirBili-0.3 IndBili-0.9 [MASKED] 03:16AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.1 [MASKED] 03:16AM BLOOD Hapto-<10* Brief Hospital Course: Ms. [MASKED] is [MASKED] old generally healthy female who presented to her PCP with fatigue and profound anemia, was admitted to [MASKED] with a Hb 5.6, found to have parasites on smear and treated for babesiosis. Patient received one unit of blood on [MASKED] with good response and was started on atovaquone, azithromycin, and doxycycline (day 1 = [MASKED] for treatment of babesia and empirically for parasitic co-infection. Patient had expectedly elevated hemolysis labs and also elevated LFTs, especially alk phos (and GGT). Patient was generally asymptomatic after blood transfusion, felt as baseline with no symptoms. Blood smear on admission [MASKED] showed 1.2% parasitemia, by discharge on [MASKED] smear showed only 0.1% parasitemia. Per recommendation from infectious disease, patient should continue blood smears for parasite until there are no parasites, after which the patient will continue azithromycin and atovaquone for 7 more days. Patient will get CBC and parasite smear at [MASKED] [MASKED] on [MASKED] and [MASKED]. Regardless of blood smears patient should continue taking doxycycline empirically for 14-day course (until [MASKED]. ACTIVE ISSUES ============= #Parasites: Patient with smear positive for parasites. Night-float review of smear no evidence of malaria or specific [MASKED] crosses. Given no recent travel history, patient's hemolytic anemia, elevated LFTs and splenomegaly most likely diagnosis is babesiosis. Started at 750mg PO BID and azithromycin, 500mg PO first day, then 250mg PO (D1 = [MASKED]. Starting doxycycline 100mg PO BID (D1 = [MASKED] given high possibility of co-transmitted parasitic diseases, will take for 14 day course. Medications delivered to patient at bedside. Checked Babesia PCR, Lyme serology, Anaplasma PCR and serology; pending at time of discharge. Trended parasite smear, decreased burden to 0.1% on [MASKED], will recheck at [MASKED] office on [MASKED] and [MASKED] to ensure elimination, and will take azithromycin and atovaquone for 7 days post-clearance. ID will see patient next week outpatient on [MASKED]. #Anemia: Hemolytic with elevated LDH, retic, bili and low haptoglobin. Most likely secondary to acute parasitic infection. Patient responded well to PRBC transfusion on admission, Hb stable afterwards and at discharge (Hb 7.1). #Transaminitis and splenomegaly: No evidence of biliary obstruction on RUQ u/s. Most likely [MASKED] acute parasitic infection which was worked up and treated (see above). [MASKED] GGT elevated along with alk phos indicating GI source, no anatomic cause seen in RUQ US, minimal elevation and asymptomatic so no further inpatient w/u needed, will be transitional issue at d/c to track after infection resolves CHRONIC MEDICAL ISSUES ====================== #HTN: Initially held anti-hypertensives in setting of acute hemolytic anemia, restarted home metoprolol on [MASKED], patient stable after restarting. #HLD: Continued home statin. #GERD: Continued home PPI. Transitional issues =================== [] CBC and parasite smear at [MASKED] on [MASKED] [] Follow up with primary care physician [MASKED] on [MASKED], should recheck CBC, parasites, and LFTs to ensure hemoglobin stable and that elevated LFTs (especially alk phos) have declined; if they have not, patient would merit further workup of these elevations [] Follow up with Dr. [MASKED] infectious disease at [MASKED] on [MASKED] at 10:00 AM [] Continue taking atovaquone and azithromycin for 7 days AFTER no longer any parasites on smear, will need new prescription beyond current medications [] Continue doxycycline for 2 week course (last day [MASKED] for empiric coverage of any other parasites Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 50 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Simvastatin 40 mg PO QPM 4. Lisinopril 10 mg PO DAILY 5. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500 mg)-800 unit oral DAILY Discharge Medications: 1. Atovaquone Suspension 750 mg PO BID [MASKED] po bid RX atovaquone 750 mg/5 mL 750 mg by mouth twice a day Refills:0 2. Azithromycin 250 mg PO Q24H 250 mg po qd RX azithromycin 250 mg 1 tablet(s) by mouth once per day Disp #7 Tablet Refills:0 3. Doxycycline Hyclate 100 mg PO Q12H RX doxycycline hyclate 100 mg 1 tablet(s) by mouth twice per day Disp #22 Tablet Refills:0 4. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg (1,500 mg)-800 unit oral DAILY 5. Lisinopril 10 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Simvastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis -Babesiosis -Anemia Secondary diagnosis -Hypertension -Hyperlipidemia -Gastroesophageal reflux disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the hospital because you had anemia, also known as low blood counts of something called hemoglobin. We believe this anemia was caused by an infection called Babesia, which is spread by ticks. We started you on three strong antibiotics to fight this infection: atovaquone, azithromycin, and doxycycline. You will continue to take the doxycycline for 14 days total (until [MASKED]. You will get your blood checked for parasites on [MASKED] and [MASKED] with Dr. [MASKED] checking your blood until there are no more parasites. After they are all gone, you will keep taking the azithromycin and atovaquone for another 7 days. You will need an additional prescription from Dr. [MASKED] these pills. You also have an appointment with the infectious disease doctors here at [MASKED] on [MASKED] at 10:00 AM. We also noticed that you high blood tests of chemicals from your liver. This may be caused by the Babesia infection, but just in case, we would like your primary care doctor Dr. [MASKED] to repeat those tests to make sure they go down as we treat your infection. Please follow up with all medical appointments and take all medications as prescribed. It was a pleasure to help take part in your medical care. Sincerely, Your [MASKED] Health Team Followup Instructions: [MASKED]	[]	[ "I10", "E785", "K219" ]	[ "B600: Babesiosis", "D599: Acquired hemolytic anemia, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis" ]
10,090,148	26,354,377	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: tamsulosin / amoxicillin / dutasteride / nicotine Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ with a ischemic HFrEF 40% s/p ICD, HTN, HLD, COPD, macular degeneration, hearing impairment, pAF on asa daily transferred from an outside hospital after a fall on the night of ___ with a CT scan notable for a small right frontal intraparenchymal hemorrhage, pericardial effusion, and a right lower lung effusion. Patient reports that last night he was getting up from his computer when he is right leg felt numb, which occasionally does, and he fell hitting his left chest and the left side of his head. Patient reports that when he woke up this morning, he noted that he had pain in his left chest and bruising on his face and went to ___ for evaluation. Reports feeling intermittently short of breath during the last few weeks. Denies chest pain, fever, chills. Patient was recently discharged from ___ for a congestive heart failure exacerbation ___ weeks ago. On arrival, patient reports pain in his left face, left rib cage. Denies any visual changes, weakness, numbness, confusion. In the ED, initial vitals were: T98.4, HR 86, RR18, BP 117/64, PO2 92% on RA - Exam notable for: Neuro: GCS 14. Moving all extremities without any problems. Oriented and talking with fluent speach. No gross deficits. Walking about department. Neck: supple neck, no tenderness. No JVD. Resp: Decreased lung sounds on right CV: RRR, no murmur, non-tender chest wall. - Labs notable for: WBC 3.0, Hgb 9.3, Hct 31.6, Plt 59, INR 1.2, Alb 2.6. UA with 5 RBC's and 43 WBC's per HPF with Few bacteria. - Imaging was notable for: Normal left wrist XR CT head + for 1.6x1cm right frontal IPH w/o edema CT torso: +moderate right pleural effusion, w/ consolidation and radiodense material, enlarged heart w/ 14 mm effusion, 4.4 cm aortic aneurysm - Patient was given: IV CefTRIAXone amLODIPine 5 mg ___ Finasteride 5 mg ___ Furosemide 60 mg ___ Sotalol 120 mg ___ Tiotropium Bromide 1 CAP ___ Cyanocobalamin 100 mcg ___ Upon arrival to the floor, patient reports feeling well. Denies SOB, CP, palpitations, nausea, vomiting, abdominal pain, dizziness, headache, weakness, numbness/tingling. He believes his volume status is under control. Patient confirmed above history and believes his fall was mechanical. Denies suprapubic pain, dysuria, urinary hesitancy/frequency. Past Medical History: CAD s/p ___ PLMI Dilated ischemic cardiomyopathy w/ HFrEF HTN HLD COPD Ascending aortic aneurysm Bladder cancer Colonic polyps Diverticulitis Asymptomatic gallstones CRI VT ___, maintained on sotalol ICD implant ___ GIB s/p gastric ulcer clipping ?pAF Macular degeneration Hearing loss History of asbestos exposure with pleural plaques Social History: ___ Family History: noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: ========================== VITAL SIGNS: T98.5, BP 141 / 64, HR 90, RR20, ___ NC GENERAL: NAD, with NC in place HEENT: clear oropharynx, no conjunctival pallor; some white residue on soft palate NECK: JVP up to mandible CARDIAC: irregularly irregular; normal S1 and S2; no mrg LUNGS: bibasilar crackles; no wheezing or rhonchi ABDOMEN: +BS; soft NTND, no organomegaly EXTREMITIES: 1+ pitting edema up to ankles bilaterally NEUROLOGIC: no focal deficits SKIN: diffuse ecchymoses and raised/scaly yellow lesions DISCHARGE PHYSICAL EXAM: ========================== VITAL SIGNS: reviewed in OMR GENERAL: NAD, with NC in place HEENT: clear oropharynx, no conjunctival pallor NECK: JVP to mid-neck CARDIAC: irregularly irregular; normal S1 and S2; no mrg LUNGS: bibasilar crackles improved; no wheezing or rhonchi ABDOMEN: +BS; soft NTND, no organomegaly EXTREMITIES: 1+ pitting edema up to ankles bilaterally NEUROLOGIC: no focal deficits SKIN: diffuse ecchymoses and raised/scaly yellow lesions ___: erythematous and swollen left wrist with black sutures in place, no purulence: unable to clench fist ___ swelling, TTP; some numbness Pertinent Results: ADMISSION LABS: ================ ___ 03:20PM BLOOD WBC-3.0* RBC-3.55* Hgb-9.3* Hct-31.6* MCV-89 MCH-26.2 MCHC-29.4* RDW-16.9* RDWSD-54.4* Plt Ct-59* ___ 03:20PM BLOOD ___ PTT-33.2 ___ ___ 03:20PM BLOOD Glucose-91 UreaN-14 Creat-0.9 Na-145 K-4.1 Cl-106 HCO3-28 AnGap-11 ___ 03:20PM BLOOD ALT-9 AST-19 LD(LDH)-245 CK(CPK)-54 AlkPhos-54 TotBili-0.5 ___ 08:08AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.0 DISCHARGE LABS: ================ ___ 07:05AM BLOOD WBC-2.1* RBC-3.08* Hgb-8.0* Hct-27.2* MCV-88 MCH-26.0 MCHC-29.4* RDW-17.0* RDWSD-54.2* Plt Ct-49* ___ 07:05AM BLOOD Glucose-85 UreaN-24* Creat-1.0 Na-142 K-4.1 Cl-103 HCO3-31 AnGap-8* ___ 07:05AM BLOOD Calcium-7.9* Phos-3.7 Mg-2.0 MICRO: ====== ___ 3:29 pm URINE TAKEN FROM ___. **FINAL REPORT ___ URINE CULTURE (Final ___: Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. GRAM POSITIVE BACTERIA. >100,000 CFU/mL. IMAGING: ========= Xray left wrist: Significant swelling over the left ___ and wrist within no evidence of subcutaneous gas or radiographic evidence of osteomyelitis. EKG ___ irregularly irregular, rate 75, PVCs, no acute ST changes TTE ___ The left atrium is moderately dilated. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is mild regional left ventricular systolic dysfunction with severe hyypokinesis of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 40 %). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. 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 root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild to moderate (___) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. IMPRESSION: Suboptimal image quality. Left ventricular cavity cavity dilation with regional systolic dysfunction most c/w CAD (PDA distribution). Mild-moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. Mild aortic regurgitation. Small circumferential pericardial effusion. Dilated aorta. ___ ICD Interrogation Interrogation: Battery voltage/time to ERI: 75%/3.12 V Presenting rhythm: AS/VS Underlying rhythm: AS/VS Mode,base and upper track rate: DDD 50/120 Lead Testing P waves: 2.2 mv A thresh: 1.2 V@ ms A imp: 505ohms R waves: 19 mv RV thresh: 1.0 V@ ms RV imp: 404ohms shock impedance: 43 ohms Diagnostics: AP: 6% VP: 7% Events: none Summary: 1. Pacer function normal with acceptable lead measurements and battery status 2. Programming changes: none 3. Unable to verify abnormal rhythms by ED physicians as telemetry deleted. 4. Follow-up: as per ED, follows up at ___ for device OSH IMAGING: ============ CT CHEST: IMPRESSION: 1. Moderate size right pleural effusion. Hounsfield units near 20 are less than expected for hemorrhagic fluid. No acute bony abnormality. 2. Right lower lobe consolidation with radiodense material within the consolidated area lung. 3. There is lung emphysema. Bilateral pleural calcifications suggest asbestos exposure. 4. Enlarged heart with pericardial effusion measuring 14 mm thick. Aortic root measures 4.4 cm in diameter. 5. No acute finding in the abdomen and pelvis. 6. Renal and pancreatic cysts. Prostate is 6.9 cm in diameter. Spleen is 13.8 cm in length. Cranial CT scan: There is an area of high density towards the high right frontal lobe adjacent to the interhemispheric fissure which measures 1.6 x 1 cm most likely representing parenchymal hemorrhage although a small component of extra parenchymal hemorrhage cannot be excluded. There is no edema within the region. There is diffuse atrophy. There is no evidence of mass effect. Cervical spine CT scan: There are degenerative changes throughout the cervical spine. No fractures are seen. There is a right-sided pleural effusion. Maxillofacial CT scan: No fractures are appreciated. There is soft tissue swelling along the right side of the mandible and over the left supraorbital rim. There is a small amount of mucosal thickening within the right maxillary sinus is and portions of the ethmoidal sinus. Xray L wrist: IMPRESSION: Normal left wrist. Brief Hospital Course: Mr. ___ is a ___ with ischemic HFrEF 40% s/p ICD, HTN, HLD, COPD on O2 overnight intermittently, macular degeneration, hearing impairment, pAF on ASA who initially presented to an outside hospital after suffering a fall found to have a small intraparenchymal hemorrhage on CT head and a left ___ laceration (repaired at OS___) prompting transfer to ___. Upon arrival to ___, she was evaluated by the neurosurgery team who deemed that no further intervention or imaging was needed. He was admitted to the medicine service for further monitoring. His hospital course was complicated by cellulitis of the left ___ laceration site initially on vancomycin/clindamycin (severe PCN allergy) later transitioned to clindamycin alone per ___ Surgery recommendation. # Intraparenchymal hemorrhage: Patient found to have small right frontal intraparenchymal hemorrhage 1.6cm s/p fall. Evaluated by neurosurgery, with recommendations for no acute intervention and no keppra prophylaxis. Patient without headache or focal neuro deficits. Held home aspirin in the setting of thrombocytopenia and bleed. Will need to discuss restarting aspirin as an out-patient given underlying risks of bleed with fall and thrombocytopenia versus known CAD. # Fall # ?Syncope As per patient report, fall sounds mechanical in nature as patient says his right leg tripped on the side of the rug in the setting of neuropathy in that leg. Denied prodromal or neurologic symptoms prior to or after the incident. No SOB, CP, palpitations, dizziness, warmth, post-ictal confusion, incontinence, or other concerning symptoms. With history of VT and pAF but no arrhythmias or therapies detected on ICD interrogation. EKG without concerning findings other than PVCs. TTE with EF 40% and mild-mod MR but no other significant valvular pathology. Trop negative and no ischemic signs on EKG to suggest MI. No hypoxia/tachycardia to suggest PE. No report of LOC, patient remembers falling and getting up. Monitored on telemetry with no acute events. Orthostatics negative, ___ cleared for discharge. Will need close monitoring as an out-patient. # Left wrist laceration c/b cellulitis: Patient suffered a left ___ laceration with the fall (injury caused by the watch he was wearing) which was repaired at the OSH. He developed increased swelling, pain and erythema along the ___ and suture site with concern for cellulitis. ___ surgery was consulted and xray imaging was negative for any fracture, subcutaneous gas, or osteo. He was initially on Clinda/Vanc IV later transitioned to clindamycin PO for planned 7 day course (clinda chosen as he cannot take beta lactams given allergy, or fluoroquinolone given QTc concerns on sotalol, and Bactrim would not adequately cover streptococci), and clindamycin monotherapy would cover CA-MRSA, MSSA, streptocci, and anaerobes. Will continue to apply ACE-wraps and elevate the ___ to ensure swelling improves. Will need stitches to be removed ___ with planned follow-up with PCP and ___ surgery for further monitoring. Of note, patient received tetnus booster while at ___. # Positive UA: asymptomatic with no dysuria, hesitancy, frequency. Afebrile, HDS. In the setting of the fall treated empirically with ceftriaxone in the ED. Given lack of symptoms, however, further antibiotics for UTI were held. Urine culture positive for gram positive bacteria, speciation with mixed flora and the patient remained asymptomatic. His home finasteride and terazosin were continued for his BPH. # pAF: patient with history of PAF on past device checks, not on most recent interrogation but irregularly irregular on exam. High risk to start anticoagulation due to history of hematuria, thrombocytopenia, and bladder cancer. CHADsVASc 5. Continued sotalol. Held aspirin in the setting of thrombocytopenia and fall with hemorrhagic bleed. # Thrombocytopenia: patient with history of thrombocytopenia/pancytopenia of unclear etiology, however, have a high suspicion for MDS given relative pancytopenia. Last plt count 74 in ___. Now down to 40-50s. Held subQ heparin with plat<50, and held aspirin with ICH. Will need repeat CBC within 1 week of discharge and consider further work-up as out-patient if within goals of care. He is pancytopenic, and this is most likely due to MDS given his age - it was our understanding that he had previously declined bone marrow biopsy and further evaluation, which seems reasonable (to defer) given his age and comorbidities. # HFrEF (EF 40%): Stable during this admission and continued on home furosemide 40mg daily, lisinopril 40mg daily, and sotalol 120mg BID. Desatted to the ___ with ambulation so will discharge on home oxygen 2L to be used continuously. # VT s/p ICD placement on sotalol: patient with no events or therapies recorded on recent ICD interrogation. Patient denies LOC or palpitations. PVCs on EKG. Maintained on home sotalol. # Small pericardial effusion: noted on TTE, HDS stable without concern for tamponade physiology. Unsure etiology but could be malignant vs transudative volume from CHF. Stable from prior TTE imaging. # Pleural effusion: Known moderate right sided pleural effusion on CT torso. Etiology unclear but likely volume from HFrEF or malignant effusion in the setting of lung nodules. Patient was discharged on 2L NC with plans to follow-up with PCP and cardiologist for further monitoring. CHRONIC ISSUES ================ # CAD: continued rosuvastatin daily. Held aspirin iso thrombocytopenia and ICH # COPD: continued albuterol prn, symbicort BID, Spiriva daily # HTN: continued amlodipine and lisinopril # CT Chest Findings: moderate right sided pleural effusion with RLL relaxation atelectasis, moderate pericardial effusion, re-demonstration of bilateral pleural plaques. Also with LLL nodule mildly increased in size since ___ (15mm), 10mm nodule in RUL unchanged since ___. Patient has been on oxygen and discharged on oxygen with ambulation. Hemodynamically stable with no findings of diastolic LV/RV/RA collapse concerning for tamponade on echo. Will need outpatient follow up for nodules. TRANSITIONAL ISSUES ==================== DISCHARGE WEIGHT: 158.07 lb NEW MEDICATION: home oxygen continuously Clindamycin (___) STOPPED MEDICATION: aspirin 81mg daily [] discharged to use oxygen at home continuously [] left wrist laceration stitches to be removed by ___, follow up ___ clinic [] will need to have left limb wrapped from ___ up to elbow with ACE compression, with dry gauze dressing underneath, and careful surveillance by ___ of the edema and erythema for resolution of cellulitis. [] follow up of CT torso findings including nodules, pleural effusion, and small pericardial effusion [] follow up neuro exam to monitor for changes in the setting of ICH [] follow up CBC in 1 week to monitor pancytopenia, stable this admission [] please have ___ monitor for headache, dizziness, vision changes, focal neurologic findings (concern for worsening of IPH iso thrombocytopenia); also look for increase in weight, shortness of breath for HF signs; worsened arm swelling, erythema, tenderness, fevers (to suggest progression of skin and soft tissue infection) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing/SOB 3. amLODIPine 5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. Fluticasone-Salmeterol Diskus (100/50) 2 INH IH BID 7. Finasteride 5 mg PO QHS 8. Furosemide 40 mg PO DAILY 9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 10. Rosuvastatin Calcium 20 mg PO QPM 11. Sotalol 120 mg PO BID 12. Terazosin 2 mg PO QHS 13. Tiotropium Bromide 1 CAP IH DAILY 14. Lisinopril 40 mg PO DAILY Discharge Medications: 1. Clindamycin 450 mg PO Q6H Duration: 7 Days 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing/SOB 4. amLODIPine 5 mg PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. Finasteride 5 mg PO QHS 7. Fluticasone-Salmeterol Diskus (100/50) 2 INH IH BID 8. Furosemide 40 mg PO DAILY 9. Lisinopril 40 mg PO DAILY 10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 11. Rosuvastatin Calcium 20 mg PO QPM 12. Sotalol 120 mg PO BID 13. Terazosin 2 mg PO QHS 14. Tiotropium Bromide 1 CAP IH DAILY 15.Outpatient Lab Work Please check CBC for platelet stability. Send results to Dr. ___ at ___ ICD: ___ Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: PRIMARY DIAGNOSIS ================== Intraparenchymal hemorrhage Fall Left wrist laceration Positive UA Paroxysmal Atrial Fibrillation Thrombocytopenia SECONDARY DIAGNOSES =================== HFrEF (EF 40% VT s/p ICD placement on sotalol Small pericardial effusion Pleural effusion CAD COPD HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___, WHY YOU WERE ADMITTED TO THE HOSPITAL - You had a fall after which you developed a small bleed in your brain WHAT WE DID FOR YOU HERE - We checked your imaging and had the neurosurgeons evaluate you. They said the bleed was stable and there is no need for intervention or further imaging - We stopped your aspirin with the bleed and your low platelet counts - You were monitored on telemetry and had your ICD interrogated that showed no abnormal heart rhythms - You had an echocardiogram of your heart that was stable from your prior echocardiograms - Your ___ laceration showed evidence of infection and you were evaluated by the ___ Surgeons. An xray of the ___ was negative for any fracture or infection in your bone. You will take a 7 day course of an antibiotic called Clindamycin to treat the infection and continue an ACE-wrap ___ elevation to help with your swelling. WHAT YOU SHOULD DO WHEN YOU LEAVE - You should continue taking all your medications as prescribed - You should follow up with your primary care doctor, ___, and ___ specialist - You will need to keep an ACE compression bandage on your left wrist and elevated your ___ as much as possible to help relieve the swelling in your left ___. Please follow-up with the ___ Surgeons for monitoring of your wound. -Please use your 2L of oxygen at all times to ensure your oxygen levels stay at a safe level WHEN YOU SHOULD COME BACK - If you are experiencing headache, dizziness, weakness, paresthesias, visual changes, shortness of breath, chest pain, fevers, chills, worsening left ___ swelling, pain, redness, or any other symptoms that concern you It was a pleasure caring for you here! Sincerely, Your ___ Team Followup Instructions: ___	[ "S06360A", "I5022", "D61818", "D696", "I313", "G629", "I480", "Z9981", "I420", "I130", "L03114", "J9811", "R0902", "R0781", "I2510", "J449", "E785", "S61512A", "W1831XA", "R8271", "N400", "N189", "I714", "S0512XA", "H548", "I255", "J61", "H3530", "Z4502", "Z8551", "Z9181", "Z87891", "Z95810", "Y92009" ]	Allergies: tamsulosin / amoxicillin / dutasteride / nicotine Chief Complaint: Fall Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] with a ischemic HFrEF 40% s/p ICD, HTN, HLD, COPD, macular degeneration, hearing impairment, pAF on asa daily transferred from an outside hospital after a fall on the night of [MASKED] with a CT scan notable for a small right frontal intraparenchymal hemorrhage, pericardial effusion, and a right lower lung effusion. Patient reports that last night he was getting up from his computer when he is right leg felt numb, which occasionally does, and he fell hitting his left chest and the left side of his head. Patient reports that when he woke up this morning, he noted that he had pain in his left chest and bruising on his face and went to [MASKED] for evaluation. Reports feeling intermittently short of breath during the last few weeks. Denies chest pain, fever, chills. Patient was recently discharged from [MASKED] for a congestive heart failure exacerbation [MASKED] weeks ago. On arrival, patient reports pain in his left face, left rib cage. Denies any visual changes, weakness, numbness, confusion. In the ED, initial vitals were: T98.4, HR 86, RR18, BP 117/64, PO2 92% on RA - Exam notable for: Neuro: GCS 14. Moving all extremities without any problems. Oriented and talking with fluent speach. No gross deficits. Walking about department. Neck: supple neck, no tenderness. No JVD. Resp: Decreased lung sounds on right CV: RRR, no murmur, non-tender chest wall. - Labs notable for: WBC 3.0, Hgb 9.3, Hct 31.6, Plt 59, INR 1.2, Alb 2.6. UA with 5 RBC's and 43 WBC's per HPF with Few bacteria. - Imaging was notable for: Normal left wrist XR CT head + for 1.6x1cm right frontal IPH w/o edema CT torso: +moderate right pleural effusion, w/ consolidation and radiodense material, enlarged heart w/ 14 mm effusion, 4.4 cm aortic aneurysm - Patient was given: IV CefTRIAXone amLODIPine 5 mg [MASKED] Finasteride 5 mg [MASKED] Furosemide 60 mg [MASKED] Sotalol 120 mg [MASKED] Tiotropium Bromide 1 CAP [MASKED] Cyanocobalamin 100 mcg [MASKED] Upon arrival to the floor, patient reports feeling well. Denies SOB, CP, palpitations, nausea, vomiting, abdominal pain, dizziness, headache, weakness, numbness/tingling. He believes his volume status is under control. Patient confirmed above history and believes his fall was mechanical. Denies suprapubic pain, dysuria, urinary hesitancy/frequency. Past Medical History: CAD s/p [MASKED] PLMI Dilated ischemic cardiomyopathy w/ HFrEF HTN HLD COPD Ascending aortic aneurysm Bladder cancer Colonic polyps Diverticulitis Asymptomatic gallstones CRI VT [MASKED], maintained on sotalol ICD implant [MASKED] GIB s/p gastric ulcer clipping ?pAF Macular degeneration Hearing loss History of asbestos exposure with pleural plaques Social History: [MASKED] Family History: noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: ========================== VITAL SIGNS: T98.5, BP 141 / 64, HR 90, RR20, [MASKED] NC GENERAL: NAD, with NC in place HEENT: clear oropharynx, no conjunctival pallor; some white residue on soft palate NECK: JVP up to mandible CARDIAC: irregularly irregular; normal S1 and S2; no mrg LUNGS: bibasilar crackles; no wheezing or rhonchi ABDOMEN: +BS; soft NTND, no organomegaly EXTREMITIES: 1+ pitting edema up to ankles bilaterally NEUROLOGIC: no focal deficits SKIN: diffuse ecchymoses and raised/scaly yellow lesions DISCHARGE PHYSICAL EXAM: ========================== VITAL SIGNS: reviewed in OMR GENERAL: NAD, with NC in place HEENT: clear oropharynx, no conjunctival pallor NECK: JVP to mid-neck CARDIAC: irregularly irregular; normal S1 and S2; no mrg LUNGS: bibasilar crackles improved; no wheezing or rhonchi ABDOMEN: +BS; soft NTND, no organomegaly EXTREMITIES: 1+ pitting edema up to ankles bilaterally NEUROLOGIC: no focal deficits SKIN: diffuse ecchymoses and raised/scaly yellow lesions [MASKED]: erythematous and swollen left wrist with black sutures in place, no purulence: unable to clench fist [MASKED] swelling, TTP; some numbness Pertinent Results: ADMISSION LABS: ================ [MASKED] 03:20PM BLOOD WBC-3.0* RBC-3.55* Hgb-9.3* Hct-31.6* MCV-89 MCH-26.2 MCHC-29.4* RDW-16.9* RDWSD-54.4* Plt Ct-59* [MASKED] 03:20PM BLOOD [MASKED] PTT-33.2 [MASKED] [MASKED] 03:20PM BLOOD Glucose-91 UreaN-14 Creat-0.9 Na-145 K-4.1 Cl-106 HCO3-28 AnGap-11 [MASKED] 03:20PM BLOOD ALT-9 AST-19 LD(LDH)-245 CK(CPK)-54 AlkPhos-54 TotBili-0.5 [MASKED] 08:08AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.0 DISCHARGE LABS: ================ [MASKED] 07:05AM BLOOD WBC-2.1* RBC-3.08* Hgb-8.0* Hct-27.2* MCV-88 MCH-26.0 MCHC-29.4* RDW-17.0* RDWSD-54.2* Plt Ct-49* [MASKED] 07:05AM BLOOD Glucose-85 UreaN-24* Creat-1.0 Na-142 K-4.1 Cl-103 HCO3-31 AnGap-8* [MASKED] 07:05AM BLOOD Calcium-7.9* Phos-3.7 Mg-2.0 MICRO: ====== [MASKED] 3:29 pm URINE TAKEN FROM [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. GRAM POSITIVE BACTERIA. >100,000 CFU/mL. IMAGING: ========= Xray left wrist: Significant swelling over the left [MASKED] and wrist within no evidence of subcutaneous gas or radiographic evidence of osteomyelitis. EKG [MASKED] irregularly irregular, rate 75, PVCs, no acute ST changes TTE [MASKED] The left atrium is moderately dilated. The estimated right atrial pressure is [MASKED] mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is mild regional left ventricular systolic dysfunction with severe hyypokinesis of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 40 %). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. 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 root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild to moderate ([MASKED]) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. IMPRESSION: Suboptimal image quality. Left ventricular cavity cavity dilation with regional systolic dysfunction most c/w CAD (PDA distribution). Mild-moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. Mild aortic regurgitation. Small circumferential pericardial effusion. Dilated aorta. [MASKED] ICD Interrogation Interrogation: Battery voltage/time to ERI: 75%/3.12 V Presenting rhythm: AS/VS Underlying rhythm: AS/VS Mode,base and upper track rate: DDD 50/120 Lead Testing P waves: 2.2 mv A thresh: 1.2 V@ ms A imp: 505ohms R waves: 19 mv RV thresh: 1.0 V@ ms RV imp: 404ohms shock impedance: 43 ohms Diagnostics: AP: 6% VP: 7% Events: none Summary: 1. Pacer function normal with acceptable lead measurements and battery status 2. Programming changes: none 3. Unable to verify abnormal rhythms by ED physicians as telemetry deleted. 4. Follow-up: as per ED, follows up at [MASKED] for device OSH IMAGING: ============ CT CHEST: IMPRESSION: 1. Moderate size right pleural effusion. Hounsfield units near 20 are less than expected for hemorrhagic fluid. No acute bony abnormality. 2. Right lower lobe consolidation with radiodense material within the consolidated area lung. 3. There is lung emphysema. Bilateral pleural calcifications suggest asbestos exposure. 4. Enlarged heart with pericardial effusion measuring 14 mm thick. Aortic root measures 4.4 cm in diameter. 5. No acute finding in the abdomen and pelvis. 6. Renal and pancreatic cysts. Prostate is 6.9 cm in diameter. Spleen is 13.8 cm in length. Cranial CT scan: There is an area of high density towards the high right frontal lobe adjacent to the interhemispheric fissure which measures 1.6 x 1 cm most likely representing parenchymal hemorrhage although a small component of extra parenchymal hemorrhage cannot be excluded. There is no edema within the region. There is diffuse atrophy. There is no evidence of mass effect. Cervical spine CT scan: There are degenerative changes throughout the cervical spine. No fractures are seen. There is a right-sided pleural effusion. Maxillofacial CT scan: No fractures are appreciated. There is soft tissue swelling along the right side of the mandible and over the left supraorbital rim. There is a small amount of mucosal thickening within the right maxillary sinus is and portions of the ethmoidal sinus. Xray L wrist: IMPRESSION: Normal left wrist. Brief Hospital Course: Mr. [MASKED] is a [MASKED] with ischemic HFrEF 40% s/p ICD, HTN, HLD, COPD on O2 overnight intermittently, macular degeneration, hearing impairment, pAF on ASA who initially presented to an outside hospital after suffering a fall found to have a small intraparenchymal hemorrhage on CT head and a left [MASKED] laceration (repaired at OS ) prompting transfer to [MASKED]. Upon arrival to [MASKED], she was evaluated by the neurosurgery team who deemed that no further intervention or imaging was needed. He was admitted to the medicine service for further monitoring. His hospital course was complicated by cellulitis of the left [MASKED] laceration site initially on vancomycin/clindamycin (severe PCN allergy) later transitioned to clindamycin alone per [MASKED] Surgery recommendation. # Intraparenchymal hemorrhage: Patient found to have small right frontal intraparenchymal hemorrhage 1.6cm s/p fall. Evaluated by neurosurgery, with recommendations for no acute intervention and no keppra prophylaxis. Patient without headache or focal neuro deficits. Held home aspirin in the setting of thrombocytopenia and bleed. Will need to discuss restarting aspirin as an out-patient given underlying risks of bleed with fall and thrombocytopenia versus known CAD. # Fall # ?Syncope As per patient report, fall sounds mechanical in nature as patient says his right leg tripped on the side of the rug in the setting of neuropathy in that leg. Denied prodromal or neurologic symptoms prior to or after the incident. No SOB, CP, palpitations, dizziness, warmth, post-ictal confusion, incontinence, or other concerning symptoms. With history of VT and pAF but no arrhythmias or therapies detected on ICD interrogation. EKG without concerning findings other than PVCs. TTE with EF 40% and mild-mod MR but no other significant valvular pathology. Trop negative and no ischemic signs on EKG to suggest MI. No hypoxia/tachycardia to suggest PE. No report of LOC, patient remembers falling and getting up. Monitored on telemetry with no acute events. Orthostatics negative, [MASKED] cleared for discharge. Will need close monitoring as an out-patient. # Left wrist laceration c/b cellulitis: Patient suffered a left [MASKED] laceration with the fall (injury caused by the watch he was wearing) which was repaired at the OSH. He developed increased swelling, pain and erythema along the [MASKED] and suture site with concern for cellulitis. [MASKED] surgery was consulted and xray imaging was negative for any fracture, subcutaneous gas, or osteo. He was initially on Clinda/Vanc IV later transitioned to clindamycin PO for planned 7 day course (clinda chosen as he cannot take beta lactams given allergy, or fluoroquinolone given QTc concerns on sotalol, and Bactrim would not adequately cover streptococci), and clindamycin monotherapy would cover CA-MRSA, MSSA, streptocci, and anaerobes. Will continue to apply ACE-wraps and elevate the [MASKED] to ensure swelling improves. Will need stitches to be removed [MASKED] with planned follow-up with PCP and [MASKED] surgery for further monitoring. Of note, patient received tetnus booster while at [MASKED]. # Positive UA: asymptomatic with no dysuria, hesitancy, frequency. Afebrile, HDS. In the setting of the fall treated empirically with ceftriaxone in the ED. Given lack of symptoms, however, further antibiotics for UTI were held. Urine culture positive for gram positive bacteria, speciation with mixed flora and the patient remained asymptomatic. His home finasteride and terazosin were continued for his BPH. # pAF: patient with history of PAF on past device checks, not on most recent interrogation but irregularly irregular on exam. High risk to start anticoagulation due to history of hematuria, thrombocytopenia, and bladder cancer. CHADsVASc 5. Continued sotalol. Held aspirin in the setting of thrombocytopenia and fall with hemorrhagic bleed. # Thrombocytopenia: patient with history of thrombocytopenia/pancytopenia of unclear etiology, however, have a high suspicion for MDS given relative pancytopenia. Last plt count 74 in [MASKED]. Now down to 40-50s. Held subQ heparin with plat<50, and held aspirin with ICH. Will need repeat CBC within 1 week of discharge and consider further work-up as out-patient if within goals of care. He is pancytopenic, and this is most likely due to MDS given his age - it was our understanding that he had previously declined bone marrow biopsy and further evaluation, which seems reasonable (to defer) given his age and comorbidities. # HFrEF (EF 40%): Stable during this admission and continued on home furosemide 40mg daily, lisinopril 40mg daily, and sotalol 120mg BID. Desatted to the [MASKED] with ambulation so will discharge on home oxygen 2L to be used continuously. # VT s/p ICD placement on sotalol: patient with no events or therapies recorded on recent ICD interrogation. Patient denies LOC or palpitations. PVCs on EKG. Maintained on home sotalol. # Small pericardial effusion: noted on TTE, HDS stable without concern for tamponade physiology. Unsure etiology but could be malignant vs transudative volume from CHF. Stable from prior TTE imaging. # Pleural effusion: Known moderate right sided pleural effusion on CT torso. Etiology unclear but likely volume from HFrEF or malignant effusion in the setting of lung nodules. Patient was discharged on 2L NC with plans to follow-up with PCP and cardiologist for further monitoring. CHRONIC ISSUES ================ # CAD: continued rosuvastatin daily. Held aspirin iso thrombocytopenia and ICH # COPD: continued albuterol prn, symbicort BID, Spiriva daily # HTN: continued amlodipine and lisinopril # CT Chest Findings: moderate right sided pleural effusion with RLL relaxation atelectasis, moderate pericardial effusion, re-demonstration of bilateral pleural plaques. Also with LLL nodule mildly increased in size since [MASKED] (15mm), 10mm nodule in RUL unchanged since [MASKED]. Patient has been on oxygen and discharged on oxygen with ambulation. Hemodynamically stable with no findings of diastolic LV/RV/RA collapse concerning for tamponade on echo. Will need outpatient follow up for nodules. TRANSITIONAL ISSUES ==================== DISCHARGE WEIGHT: 158.07 lb NEW MEDICATION: home oxygen continuously Clindamycin ([MASKED]) STOPPED MEDICATION: aspirin 81mg daily [] discharged to use oxygen at home continuously [] left wrist laceration stitches to be removed by [MASKED], follow up [MASKED] clinic [] will need to have left limb wrapped from [MASKED] up to elbow with ACE compression, with dry gauze dressing underneath, and careful surveillance by [MASKED] of the edema and erythema for resolution of cellulitis. [] follow up of CT torso findings including nodules, pleural effusion, and small pericardial effusion [] follow up neuro exam to monitor for changes in the setting of ICH [] follow up CBC in 1 week to monitor pancytopenia, stable this admission [] please have [MASKED] monitor for headache, dizziness, vision changes, focal neurologic findings (concern for worsening of IPH iso thrombocytopenia); also look for increase in weight, shortness of breath for HF signs; worsened arm swelling, erythema, tenderness, fevers (to suggest progression of skin and soft tissue infection) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Albuterol Inhaler [MASKED] PUFF IH Q4H:PRN wheezing/SOB 3. amLODIPine 5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. Fluticasone-Salmeterol Diskus (100/50) 2 INH IH BID 7. Finasteride 5 mg PO QHS 8. Furosemide 40 mg PO DAILY 9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 10. Rosuvastatin Calcium 20 mg PO QPM 11. Sotalol 120 mg PO BID 12. Terazosin 2 mg PO QHS 13. Tiotropium Bromide 1 CAP IH DAILY 14. Lisinopril 40 mg PO DAILY Discharge Medications: 1. Clindamycin 450 mg PO Q6H Duration: 7 Days 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Albuterol Inhaler [MASKED] PUFF IH Q4H:PRN wheezing/SOB 4. amLODIPine 5 mg PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. Finasteride 5 mg PO QHS 7. Fluticasone-Salmeterol Diskus (100/50) 2 INH IH BID 8. Furosemide 40 mg PO DAILY 9. Lisinopril 40 mg PO DAILY 10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 11. Rosuvastatin Calcium 20 mg PO QPM 12. Sotalol 120 mg PO BID 13. Terazosin 2 mg PO QHS 14. Tiotropium Bromide 1 CAP IH DAILY 15.Outpatient Lab Work Please check CBC for platelet stability. Send results to Dr. [MASKED] at [MASKED] ICD: [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] [MASKED] Diagnosis: PRIMARY DIAGNOSIS ================== Intraparenchymal hemorrhage Fall Left wrist laceration Positive UA Paroxysmal Atrial Fibrillation Thrombocytopenia SECONDARY DIAGNOSES =================== HFrEF (EF 40% VT s/p ICD placement on sotalol Small pericardial effusion Pleural effusion CAD COPD HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [MASKED], WHY YOU WERE ADMITTED TO THE HOSPITAL - You had a fall after which you developed a small bleed in your brain WHAT WE DID FOR YOU HERE - We checked your imaging and had the neurosurgeons evaluate you. They said the bleed was stable and there is no need for intervention or further imaging - We stopped your aspirin with the bleed and your low platelet counts - You were monitored on telemetry and had your ICD interrogated that showed no abnormal heart rhythms - You had an echocardiogram of your heart that was stable from your prior echocardiograms - Your [MASKED] laceration showed evidence of infection and you were evaluated by the [MASKED] Surgeons. An xray of the [MASKED] was negative for any fracture or infection in your bone. You will take a 7 day course of an antibiotic called Clindamycin to treat the infection and continue an ACE-wrap [MASKED] elevation to help with your swelling. WHAT YOU SHOULD DO WHEN YOU LEAVE - You should continue taking all your medications as prescribed - You should follow up with your primary care doctor, [MASKED], and [MASKED] specialist - You will need to keep an ACE compression bandage on your left wrist and elevated your [MASKED] as much as possible to help relieve the swelling in your left [MASKED]. Please follow-up with the [MASKED] Surgeons for monitoring of your wound. -Please use your 2L of oxygen at all times to ensure your oxygen levels stay at a safe level WHEN YOU SHOULD COME BACK - If you are experiencing headache, dizziness, weakness, paresthesias, visual changes, shortness of breath, chest pain, fevers, chills, worsening left [MASKED] swelling, pain, redness, or any other symptoms that concern you It was a pleasure caring for you here! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "D696", "I480", "I130", "I2510", "J449", "E785", "N400", "N189", "Z87891" ]	[ "S06360A: Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, initial encounter", "I5022: Chronic systolic (congestive) heart failure", "D61818: Other pancytopenia", "D696: Thrombocytopenia, unspecified", "I313: Pericardial effusion (noninflammatory)", "G629: Polyneuropathy, unspecified", "I480: Paroxysmal atrial fibrillation", "Z9981: Dependence on supplemental oxygen", "I420: Dilated cardiomyopathy", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "L03114: Cellulitis of left upper limb", "J9811: Atelectasis", "R0902: Hypoxemia", "R0781: Pleurodynia", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "J449: Chronic obstructive pulmonary disease, unspecified", "E785: Hyperlipidemia, unspecified", "S61512A: Laceration without foreign body of left wrist, initial encounter", "W1831XA: Fall on same level due to stepping on an object, initial encounter", "R8271: Bacteriuria", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "N189: Chronic kidney disease, unspecified", "I714: Abdominal aortic aneurysm, without rupture", "S0512XA: Contusion of eyeball and orbital tissues, left eye, initial encounter", "H548: Legal blindness, as defined in USA", "I255: Ischemic cardiomyopathy", "J61: Pneumoconiosis due to asbestos and other mineral fibers", "H3530: Unspecified macular degeneration", "Z4502: Encounter for adjustment and management of automatic implantable cardiac defibrillator", "Z8551: Personal history of malignant neoplasm of bladder", "Z9181: History of falling", "Z87891: Personal history of nicotine dependence", "Z95810: Presence of automatic (implantable) cardiac defibrillator", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]
10,090,190	21,564,652	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left hand table saw injury Major Surgical or Invasive Procedure: Exploration, D5 FDS/FDP repair, DA/Neurorrhaphy History of Present Illness: ___ yo RHD M with BPH presents 8 hours after a table saw injury to the L ___ webspace Past Medical History: BPH Social History: ___ Family History: Noncontributory Physical Exam: Left Hand: Surgical dressing clean and dry Dorsal blocking splint in place at 30 deg wrist flexion, 50 degrees MCP flexion. Decreased sensation at ___ digits, otherwise NVID All digits WWP Pertinent Results: ___ 07:06AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 07:06AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 03:03AM WBC-10.7* RBC-5.13 HGB-13.9 HCT-43.1 MCV-84 MCH-27.1 MCHC-32.3 RDW-14.5 RDWSD-44.6 ___ 03:03AM NEUTS-62.0 ___ MONOS-7.5 EOS-10.1* BASOS-0.9 IM ___ AbsNeut-6.66* AbsLymp-2.04 AbsMono-0.81* AbsEos-1.08* AbsBaso-0.10* ___ 03:03AM PLT COUNT-172 ___ 03:03AM ___ PTT-33.4 ___ Brief Hospital Course: The patient presented to the emergency department and was evaluated by the hand surgery team. The patient was found to have deep laceration to his left ___ web space and was admitted to the hand surgery service. The patient was taken to the operating room on ___ for I+D, repair of nerves, vessels, tendons, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with OT and a dorsal blocking splint was made. A Bair hugger was in place for the first 3 days after surgery. 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 will be discharged on ASA 121 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. OT worked with Mr. ___ consistently throughout his hospital stay and was diligent, through the use of an interpreter, in ensuring that he understood his rehab precautions and instructions for home exercises as part of a Zone 3 tendon repair protocol. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. Aspirin 121.5 mg PO DAILY Duration: 30 Days RX aspirin 81 mg 1.5 tablet(s) by mouth Daily Disp #30 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth BID PRN Disp #40 Capsule Refills:0 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe RX oxycodone 5 mg 1 tablet(s) by mouth Q4 PRN Disp #30 Tablet Refills:*0 4. Acetaminophen 650 mg PO Q6H 5. Tamsulosin 0.4 mg PO DAILY 6.Outpatient Occupational Therapy NWB LUE, Dorsal blocking splint, OT in morning for dorsal blocking splint - flexor tendon protocol - wrist at 30, MCP at 50. Zone 3 protocol. Discharge Disposition: Home Discharge Diagnosis: Traumatic table saw injury to left hand Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions: INSTRUCTIONS AFTER HAND SURGERY: - You were in the hospital for hand 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: - Do not lift anything with your left hand. Keep arm elevated as often as possible. Keep dorsal blocking splint in place. 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 daily aspirin 121mg daily (will continue for 30 days postop) 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 Followup Instructions: ___	[ "S64497A", "S66127A", "N390", "S65517A", "S65515A", "S64495A", "S61412A", "W312XXA", "Y92098", "N400", "Z87891" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Left hand table saw injury Major Surgical or Invasive Procedure: Exploration, D5 FDS/FDP repair, DA/Neurorrhaphy History of Present Illness: [MASKED] yo RHD M with BPH presents 8 hours after a table saw injury to the L [MASKED] webspace Past Medical History: BPH Social History: [MASKED] Family History: Noncontributory Physical Exam: Left Hand: Surgical dressing clean and dry Dorsal blocking splint in place at 30 deg wrist flexion, 50 degrees MCP flexion. Decreased sensation at [MASKED] digits, otherwise NVID All digits WWP Pertinent Results: [MASKED] 07:06AM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 07:06AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [MASKED] 03:03AM WBC-10.7* RBC-5.13 HGB-13.9 HCT-43.1 MCV-84 MCH-27.1 MCHC-32.3 RDW-14.5 RDWSD-44.6 [MASKED] 03:03AM NEUTS-62.0 [MASKED] MONOS-7.5 EOS-10.1* BASOS-0.9 IM [MASKED] AbsNeut-6.66* AbsLymp-2.04 AbsMono-0.81* AbsEos-1.08* AbsBaso-0.10* [MASKED] 03:03AM PLT COUNT-172 [MASKED] 03:03AM [MASKED] PTT-33.4 [MASKED] Brief Hospital Course: The patient presented to the emergency department and was evaluated by the hand surgery team. The patient was found to have deep laceration to his left [MASKED] web space and was admitted to the hand surgery service. The patient was taken to the operating room on [MASKED] for I+D, repair of nerves, vessels, tendons, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with OT and a dorsal blocking splint was made. A Bair hugger was in place for the first 3 days after surgery. 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 will be discharged on ASA 121 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. OT worked with Mr. [MASKED] consistently throughout his hospital stay and was diligent, through the use of an interpreter, in ensuring that he understood his rehab precautions and instructions for home exercises as part of a Zone 3 tendon repair protocol. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. Aspirin 121.5 mg PO DAILY Duration: 30 Days RX aspirin 81 mg 1.5 tablet(s) by mouth Daily Disp #30 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth BID PRN Disp #40 Capsule Refills:0 3. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Severe RX oxycodone 5 mg 1 tablet(s) by mouth Q4 PRN Disp #30 Tablet Refills:*0 4. Acetaminophen 650 mg PO Q6H 5. Tamsulosin 0.4 mg PO DAILY 6.Outpatient Occupational Therapy NWB LUE, Dorsal blocking splint, OT in morning for dorsal blocking splint - flexor tendon protocol - wrist at 30, MCP at 50. Zone 3 protocol. Discharge Disposition: Home Discharge Diagnosis: Traumatic table saw injury to left hand Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions: INSTRUCTIONS AFTER HAND SURGERY: - You were in the hospital for hand 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: - Do not lift anything with your left hand. Keep arm elevated as often as possible. Keep dorsal blocking splint in place. 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 daily aspirin 121mg daily (will continue for 30 days postop) 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 Followup Instructions: [MASKED]	[]	[ "N390", "N400", "Z87891" ]	[ "S64497A: Injury of digital nerve of left little finger, initial encounter", "S66127A: Laceration of flexor muscle, fascia and tendon of left little finger at wrist and hand level, initial encounter", "N390: Urinary tract infection, site not specified", "S65517A: Laceration of blood vessel of left little finger, initial encounter", "S65515A: Laceration of blood vessel of left ring finger, initial encounter", "S64495A: Injury of digital nerve of left ring finger, initial encounter", "S61412A: Laceration without foreign body of left hand, initial encounter", "W312XXA: Contact with powered woodworking and forming machines, initial encounter", "Y92098: Other place in other non-institutional residence as the place of occurrence of the external cause", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z87891: Personal history of nicotine dependence" ]
10,090,755	21,527,537	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: ___ - ___ pleural drain ___ - IP bedside chest tube placement VATs/Decortication/Pulmonary Nodule Biopsy Bronchoscopy History of Present Illness: HPI: The patient is a ___ male w/PMHx including hepatitis B (on tenofovir) complicated by hepatocellular carcinoma, and a 6mm solid right lower lobe nodule lung, s/p right hepatic lobectomy (at which time it was found the tumor infiltrated the diaphragmatic muscle, but did not extend to the inked margin of the diaphragm), who was admitted ___ with right-sided pleural effusion and negative cytology. Now presenting with subjective fevers, shortness of breath, and tachycardia. The patient started to have subjective fevers ~1mth ago, and then 1.5 weeks ago (around the time of his ___ admission), started to have low-grade temperatures, for which he began to take standing acetaminophen. During the patient's ___ admission to the transplant surgery service, he had quite a few temps in the ___, up to 100.6 at most (on ___. During that admission he was found to have a large right pleural effusion, interventional pulmonology placed a chest tube, which drained 800 cc of serosanguineous fluid. Pleural fluid studies revealed a lymphocytic exudative effusion, and CT imaging showed pleural nodules, all concerning for metastases of HCC. AFP was recent, and had increased from 19 prior to his hepatic lobectomy to now 31. However, cytology was negative. Given concerns for metastatic disease, a staging CT was performed, and in addition to the pleural nodules, this showed a supra-hepatic IVC thrombus, for which the patient was started on enoxaparin and transferred to medicine. He was then scheduled to follow-up in the interventional pulmonology clinic for a thoracoscopy and biopsy of the pleural nodules and with his oncologist today, ___. When he was seen by his oncologist today (Dr. ___, through an interpreter, with his wife and daughter present, he reported fever on a daily basis taking acetaminophen every 6 hours, with temperatures as high as 100.6. He also noted sweats, reportedly profuse, no chills. He noted chest discomfort in the right side and mild and intermittent cough but no shortness of breath. He was found to be tachycardic, heart rate 122, with an O2 saturation of 94%, and respirations of 16, temperature 99.3. Labs showed a white count of 13.1 and chest x-ray imaging showed "Substantial residual right pleural effusion, probably loculated, containing small collections of gas, right posterior and lower lateral hemithorax, extending into the major fissure. Persistent severe right basal atelectasis." He was then referred to the ED: There he spiked a fever to 101.8, with associated tachycardia 130s, and was found to have tachypnea ___, satting 96% on 2 L, his heart rate improved to 107. His labs showed flu swab negative, blood culture was collected, ECG showed sinus tachycardia with left anterior fascicular block. He was given acetaminophen, piperacillin-tazobactam and vancomycin. He was also seen by interventional pulmonary who recommended ___ consultation for CT-guided chest tube placement. OMED declined admission, deferring to Medicine. Seen on the floor: through an interpreter on speaker phone we discussed his situation. He felt ok, noted a bit of bilateral chest discomfort, stable from prior, but denied shortness of breath or cough. He understood the plan to remove fluid from the chest tomorrow, and to have him be NPO, get IVF, IV antibiotics, and lab studies on the fluid. He asked me to speak with his daughter-in-law or son who would then distill the details of his care and interpret them for him. I then spoke with ___, his dtr-in-law and reviewed the above history and the plan of care. ROS: [x] As per above HPI, otherwise reviewed and negative in all systems Past Medical History: PMHx: #Hepatitis B on tenofovir #HCC s/p R hepatic lobectomy, with concerns for metastases to chest (pleural nodules, mediastinal lymphadenopathy, recurrent R sided pleural effusion) #Supra-hepatic IVC thrombus, on enoxaparin #HTN #DM #BPH #Anxiety #Constipation #Diverticulosis #Osteopenia PSHx: #Cataract surgery ___ and ___ Social History: ___ Family History: ? colon cancer in father Physical ___: ADMISSION VS: T 99.0, BP 142/87, HR 108, RR 20, O2 sat 98% on 2L NC, FSBG 152 Lines/tubes: PIV Gen: older man lying in bed, alert, cooperative, NAD HEENT: anicteric, MMM Chest: equal chest rise, limited air movement bilaterally ___ effort), but with a few inspiratory crackles on the R in the mid and lower lung zones, no other adventitial sounds Cardiovasc: RRR, slightly tachyc, no m/r/g Abd: well healed R subcostal scar, injection sites consistent with enoxaparin usage, soft, mild TTP in the RUQ, otherwise NTND GU: no CVAT Extr: WWP, no pitting edema Skin: no significant rashes on limited exam Neuro: CN II-XII intact (IX and X not specifically tested), strength ___ throughout, sensation to light touch intact throughout, reflexes symmetric Psych: normal affect DISCHARGE 24hr data: Temp: 97.9 (Tm 98.9), BP: 138/83 (102-138/51-83), HR: 84 (84-104), RR: 18, O2 sat: 98% (97-99), O2 delivery: Ra Gen: No distress, pleasant and conversant HEENT:MMM, No visible blood at nares/oropharynx CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: decreased breath sounds at right base and ___ up the right posterior lung fields, otherwise clear to auscultation. no increased work of breathing CHEST: all chest tubes removed, dressing in place with minimal sanguinous drainage. No erythema, warmth surrounding dressing. ABDOMEN: no distension. RUQ surgical site from prior hepatic lobectomy well-healed. tenderness to palpation in RUQ without guarding EXTREMITIES: 2+ radial pulses. SKIN: Warm and well perfused. No rash. Pertinent Results: ADMISSION LABS: ============== ___ 01:02PM BLOOD WBC-13.1* RBC-3.77* Hgb-10.8* Hct-34.8* MCV-92 MCH-28.6 MCHC-31.0* RDW-14.2 RDWSD-48.3* Plt ___ ___ 01:02PM BLOOD UreaN-8 Creat-0.7 Na-136 K-4.1 Cl-98 HCO3-27 AnGap-11 ___ 02:43PM BLOOD ___ PTT-25.5 ___ DISCHARGE LABS: ============== ___ 06:28AM BLOOD WBC-7.8 RBC-2.88* Hgb-8.4* Hct-27.4* MCV-95 MCH-29.2 MCHC-30.7* RDW-15.1 RDWSD-51.8* Plt ___ ___ 06:28AM BLOOD ___ PTT-34.3 ___ ___ 06:28AM BLOOD Glucose-116* UreaN-11 Creat-1.0 Na-137 K-4.1 Cl-102 HCO3-25 AnGap-10 ___ 06:28AM BLOOD ALT-15 AST-25 LD(LDH)-209 AlkPhos-116 TotBili-0.3 ___ 06:28AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.3 CXR ___ Compared to chest radiographs since ___ most recently ___. Substantial residual right pleural effusion, probably loculated, containing small collections of gas, right posterior and lower lateral hemithorax, extending into the major fissure. Persistent severe right basal atelectasis. Left lung clear. Heart size normal. CT CHEST W/O CONTRAST ___ Again redemonstrated is a complex right small to moderate pleural effusion with multiple locules of gas. The overall volume of the pleural effusion has decreased in comparison to the prior examination, however, hyperattenuating areas appear to be slightly larger. Given the 8 day interval between the two CT examinations and the increase in size it is favored that these represent areas of hemothorax and blood clot (also given reported prior negative cytology results). PET/CT could be of value after acute symptoms have resolved to evaluate for the degree of possible metastatic disease. Stable small pulmonary nodules, suspicious for metastatic disease. CT INTERVENTIONAL PROCE ___ Successful CT-guided placement of ___ pigtail catheter into the collection. Samples was sent for microbiology evaluation. CT CHEST - ___ IMPRESSION: 1. Slight increase in size of moderate right loculated pleural effusion containing high-density material suggestive of blood products, and foci of air. 2. Additional small hydropneumothorax along the right upper lobe is new from prior CT. Status post chest tube removal. 3. Small simple left pleural effusion. 4. Unchanged 6 mm right upper lobe nodule and 9 mm left upper lobe nodule, indeterminate. 5. New visualization of small sub segmental pulmonary embolism of the right upper lobe. PATHOLOGY: ========== Pleural Fluid: DIAGNOSIS: PLEURAL FLUID, RIGHT: NEGATIVE FOR MALIGNANT CELLS. Many red blood cells, neutrophils, lymphocytes, and rare mesothelial cells. Pleura Biopsy/Excision: PATHOLOGIC DIAGNOSIS: 1. Exudate, right hemothorax, decortication: - METASTATIC HEPATOCELLULAR CARCINOMA, present in a background of fibrin and organizing blood clot. 2. Nodule, right pleura, excision: - METASTATIC HEPATOCELLULAR CARCINOMA, present in a background of fibrin and organizing blood clot. 3. Right pleura, decortication: - Pleural tissue with METASTATIC HEPATOCELLULAR CARCINOMA, present in a background of fibrin and organizing blood clot. Note: The tumor cells in these specimens are morphology similar to those present in the prior liver resection ___, reviewed). Brief Hospital Course: BRIEF HOSPITAL COURSE =================== ___ h/o HepB on tenofovir, ___ s/p recent R hepatic lobectomy with cholecystectomy and partial excision and repair of right hemidiaphragm, with recent readmission for R sided exudative pleural effusion of unclear etiology, also found to have pulmonary nodules and a supra-hepatic IVC thrombus prompting initiation of lovenox, readmitted ___ with sepsis and empyema, requiring operative management with course complicated by pulmonary abscess, hemoptysis and ___. # Acute hypoxic respiratory failure # Sepsis # Empyema # RLL abscess Patient with recent admission for pleural effusion of unclear etiology, status post drainage readmitted with fevers and dyspnea, imaging showing complex effusion, with fluid studies consistent with empyema. Patient started on broad spectrum antibiotics, had pleural drain placed by ___ with minimal sanguinous drainage, followed by chest tube placed by IP also with minimal sanguinous drainage. During this time patient had minimal clinical improvement, remained with loculated effusion and ongoing fevers. Patient was seen by ID consult service and thoracic surgery consult service who recommended surgical management. Patient transferred to thoracic surgery service when he underwent RLL VATS/decortication/pulmonary nodule biopsy. His surgery was complicated by transient hypotension and blood loss for which he received albumin and blood products respectively; he was subsequently transferred to the medicine service. While on the medicine service, pleural tissue pathology resulted and was consistent with metastatic hepatocellular carcinoma. Pleural fluid was without malignant cells. However, it was thought that the patient's pleural effusion was most likely malignant in nature. Placement of a PleurX was discussed with thoracic surgery given concern for recurrent pleural effusions, but deemed unnecessary, given that the decortication procedure performed during the patient's hospitalization was akin to a mechanical pleurodesis. The patient was maintained on vancomycin and zosyn for the majority of his hospitalization excepting a 2 day interruption in antibiotics which was accompanied by recurrent leukoctysis. Vancomycin was discontinued on ___ after MRSA swab resulted negative. Patient was transitioned to augmentin (D1: ___, with plan for ___ week course in the setting of concern for RLL parenchymal abscess raised by Interventional Pulmonology after re-review of patient's CT chest and bronchoscopy. Patient was discharged on augmentin with plan for follow up with Interventional Pulmonology as outpatient for monitoring of possible abscess. #Hemoptysis #Epistaxis #Bleeding around chest tube Hospital course was complicated by low volume hemoptysis in the setting of recent heparin administration which persisted for several days. Thoracic surgery was consulted and recommended Interventional Pulmonology involvement. Interventional pulmonology recommended CT chest, which did not reveal etiology. IP also recommended bronchoscopy which indicated that the RLL was the source of bleed. Per IP, no acute intervention was warranted. On re-review of chest CT, IP was concerned for intraparenchymal abscess. In line with IP recommendations, we proceeded with antibiotic treatment as above, with patient discharged on ___ week course of augmentin with planned follow up with IP. Heparin gtt was reinitiated after bronchoscopy and tolerated well with patient transitioned to lovenox prior to discharge. ___ Patient with baseline Cr ~0.7, increased to max 1.4 in the setting of blood loss, poor PO intake, nephrotoxic antibiotic regimen. Blood products and fluids were given as needed with mild improvement in creatinine. Urine lytes obtained near the end of ___ hospital course were consistent with intrarenal etiology, with improvement in creatinine after removing vancomycin and zosyn from patient's medication regimen. Patient was discharged with creatinine of 1.0 with plan for outpatient BMP. #TB rule out ID with concern that pulmonary nodules seen on patient's CT chest could represent TB. As such patient underwent TB rule out. Respiratory precautions were put in place. Acid fast smear/culture from induced sputum was negative x3 and respiratory precautions were lifted. Pulmonary nodules were biopsied and found to be consistent with metastatic hepatocellular carcinoma. # Chronic IVC thrombus Diagnosed during previous admission in ___, concerning for possible tumor thrombus. Was treated with lovenox, bridged with IV heparin periprocedurally. Reinitiated heparin gtt on ___ in s/o stable CBC which was held intermittently with concern for new onset hemoptysis. After bronchoscopy performed as above, heparin was reinitiated at weigh- based protocol. Patient was transitioned to lovenox without adverse event. # Pulmonary nodules # Hepatocellular Carcinoma Patient has known pleural nodules suspicious for metatatic HCC disease. Now pathology confirmed. See above. #Nutrition Patient has minimal appetite in the setting of metastatic disease. No associated nausea/vomiting. His meals supplements were supplemented with Glucerna shakes. Patient was initiated on mirtazapine to assist with appetite. # Chronic Hepatitis B Continued home tenofovir # Hepatocellular Carcinoma Continued prn oxycodone # Diabetes type 2 Continued insulin sliding scale # BPH Continued Finasteride, Tamsulosin TRANSITIONAL ISSUES ==================== [] Patient with hospital course complicated by ___ thought to be of mixed etiology (prerenal/intrarenal). Improved creatinine on discharge but not back to baseline of 0.7. Please obtain BMP as outpatient to monitor and ensure continued improvement. [] Patient with likely intraparenchymal abscess. Plan for outpatient follow up with IP, Dr. ___. Patient should have CT scan within ___ weeks for monitoring of abscess (to be scheduled by IP). If no response to prolonged antibiotic course, will likely need surgical intervention. [] Patient should continue with 6 week course of Augmentin (Day 1: ___ - ___ [] Patient with metastatic hepatocellular carcinoma. Will need close follow up with outpatient oncologist for treatment planning. [] Patient with decreased appetite and poor PO intake throughout hospitalization. Primary oncologist should monitor nutrition as outpatient. [] Patient has had elevated fasting blood glucose this hospitalization but has required <1u Novolog per day. Please evaluate for outpatient management of likely DM with oral medications. #CODE: Full #CONTACT: ___ (daughter-in-law) ___ ___ (son) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. Tamsulosin 0.4 mg PO QHS 3. tenofovir disoproxil fumarate 300 mg oral DAILY 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 5. Polyethylene Glycol 17 g PO DAILY 6. Acetaminophen 1000 mg PO Q8H 7. Enoxaparin Sodium 60 mg SC Q12H Start: ___, First Dose: ___ Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #80 Tablet Refills:0 2. Mirtazapine 7.5 mg PO QHS RX mirtazapine 7.5 mg 1 tablet(s) by mouth every night Disp #30 Tablet Refills:0 3. Multivitamins W/minerals 1 TAB PO DAILY RX multivitamin,tx-minerals [Vitamins and Minerals] 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 4. Acetaminophen 1000 mg PO Q8H 5. Enoxaparin Sodium 60 mg SC Q12H RX enoxaparin 60 mg/0.6 mL 60 mg SC every 12 hours Disp #60 Syringe Refills:0 6. Finasteride 5 mg PO DAILY 7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 8. Polyethylene Glycol 17 g PO DAILY 9. Tamsulosin 0.4 mg PO QHS 10. tenofovir disoproxil fumarate 300 mg oral DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: ================= METASTATIC HCC IVC THROMBUS PULMONARY ABSCESS EMPYEMA MALIGNANT PLEURAL EFFUSION HEMOPTYSIS SECONDARY DIAGNOSES: =================== HEPATITIS B ELEVATED FASTING GLUCOSE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___. Why did you come to the hospital? - You came to the hospital because you had an infection in your lungs. What did you receive in the hospital? - In the hospital, our thoracic surgeons performed a procedure to allow your lungs to better expand and minimize the risk of fluid accumulation in the lungs. - You also received antibiotics to treat a pulmonary abscess (an area of infection). You were discharged on these antibiotics as this type of infection requires a long course of treatment. - You were started on a medication to increase your appetite as our nutritionists feel you would greatly benefit from more food intake. - You were reinitiated on your anticoagulation therapy (blood thinners) which you are on for your increased risk of blood clots. You currently have blood clots in one of your large blood vessels and in your lungs. The anticoagulation therapy should stabalize these clots. What should you do once you leave the hospital? - Make sure to continue to take your medications as prescribed and follow up with your outpatient providers. - If you develop any fevers, lethargy, shortness of breath, please go to the emergency room immediately We wish you all the best! - Your ___ Care Team Followup Instructions: ___	[ "A419", "J852", "J9601", "I82221", "J910", "R042", "C220", "N179", "B181", "C7989", "D6832", "C782", "N400", "I444", "I10", "E8339", "K5900", "K5790", "M8580", "Z7901", "F419", "Z87891", "Z800", "Z79891", "Z79899", "R040", "T45515A", "Y92230", "Z9049", "J479", "R7301" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: fever Major Surgical or Invasive Procedure: [MASKED] - [MASKED] pleural drain [MASKED] - IP bedside chest tube placement VATs/Decortication/Pulmonary Nodule Biopsy Bronchoscopy History of Present Illness: HPI: The patient is a [MASKED] male w/PMHx including hepatitis B (on tenofovir) complicated by hepatocellular carcinoma, and a 6mm solid right lower lobe nodule lung, s/p right hepatic lobectomy (at which time it was found the tumor infiltrated the diaphragmatic muscle, but did not extend to the inked margin of the diaphragm), who was admitted [MASKED] with right-sided pleural effusion and negative cytology. Now presenting with subjective fevers, shortness of breath, and tachycardia. The patient started to have subjective fevers ~1mth ago, and then 1.5 weeks ago (around the time of his [MASKED] admission), started to have low-grade temperatures, for which he began to take standing acetaminophen. During the patient's [MASKED] admission to the transplant surgery service, he had quite a few temps in the [MASKED], up to 100.6 at most (on [MASKED]. During that admission he was found to have a large right pleural effusion, interventional pulmonology placed a chest tube, which drained 800 cc of serosanguineous fluid. Pleural fluid studies revealed a lymphocytic exudative effusion, and CT imaging showed pleural nodules, all concerning for metastases of HCC. AFP was recent, and had increased from 19 prior to his hepatic lobectomy to now 31. However, cytology was negative. Given concerns for metastatic disease, a staging CT was performed, and in addition to the pleural nodules, this showed a supra-hepatic IVC thrombus, for which the patient was started on enoxaparin and transferred to medicine. He was then scheduled to follow-up in the interventional pulmonology clinic for a thoracoscopy and biopsy of the pleural nodules and with his oncologist today, [MASKED]. When he was seen by his oncologist today (Dr. [MASKED], through an interpreter, with his wife and daughter present, he reported fever on a daily basis taking acetaminophen every 6 hours, with temperatures as high as 100.6. He also noted sweats, reportedly profuse, no chills. He noted chest discomfort in the right side and mild and intermittent cough but no shortness of breath. He was found to be tachycardic, heart rate 122, with an O2 saturation of 94%, and respirations of 16, temperature 99.3. Labs showed a white count of 13.1 and chest x-ray imaging showed "Substantial residual right pleural effusion, probably loculated, containing small collections of gas, right posterior and lower lateral hemithorax, extending into the major fissure. Persistent severe right basal atelectasis." He was then referred to the ED: There he spiked a fever to 101.8, with associated tachycardia 130s, and was found to have tachypnea [MASKED], satting 96% on 2 L, his heart rate improved to 107. His labs showed flu swab negative, blood culture was collected, ECG showed sinus tachycardia with left anterior fascicular block. He was given acetaminophen, piperacillin-tazobactam and vancomycin. He was also seen by interventional pulmonary who recommended [MASKED] consultation for CT-guided chest tube placement. OMED declined admission, deferring to Medicine. Seen on the floor: through an interpreter on speaker phone we discussed his situation. He felt ok, noted a bit of bilateral chest discomfort, stable from prior, but denied shortness of breath or cough. He understood the plan to remove fluid from the chest tomorrow, and to have him be NPO, get IVF, IV antibiotics, and lab studies on the fluid. He asked me to speak with his daughter-in-law or son who would then distill the details of his care and interpret them for him. I then spoke with [MASKED], his dtr-in-law and reviewed the above history and the plan of care. ROS: [x] As per above HPI, otherwise reviewed and negative in all systems Past Medical History: PMHx: #Hepatitis B on tenofovir #HCC s/p R hepatic lobectomy, with concerns for metastases to chest (pleural nodules, mediastinal lymphadenopathy, recurrent R sided pleural effusion) #Supra-hepatic IVC thrombus, on enoxaparin #HTN #DM #BPH #Anxiety #Constipation #Diverticulosis #Osteopenia PSHx: #Cataract surgery [MASKED] and [MASKED] Social History: [MASKED] Family History: ? colon cancer in father Physical [MASKED]: ADMISSION VS: T 99.0, BP 142/87, HR 108, RR 20, O2 sat 98% on 2L NC, FSBG 152 Lines/tubes: PIV Gen: older man lying in bed, alert, cooperative, NAD HEENT: anicteric, MMM Chest: equal chest rise, limited air movement bilaterally [MASKED] effort), but with a few inspiratory crackles on the R in the mid and lower lung zones, no other adventitial sounds Cardiovasc: RRR, slightly tachyc, no m/r/g Abd: well healed R subcostal scar, injection sites consistent with enoxaparin usage, soft, mild TTP in the RUQ, otherwise NTND GU: no CVAT Extr: WWP, no pitting edema Skin: no significant rashes on limited exam Neuro: CN II-XII intact (IX and X not specifically tested), strength [MASKED] throughout, sensation to light touch intact throughout, reflexes symmetric Psych: normal affect DISCHARGE 24hr data: Temp: 97.9 (Tm 98.9), BP: 138/83 (102-138/51-83), HR: 84 (84-104), RR: 18, O2 sat: 98% (97-99), O2 delivery: Ra Gen: No distress, pleasant and conversant HEENT:MMM, No visible blood at nares/oropharynx CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: decreased breath sounds at right base and [MASKED] up the right posterior lung fields, otherwise clear to auscultation. no increased work of breathing CHEST: all chest tubes removed, dressing in place with minimal sanguinous drainage. No erythema, warmth surrounding dressing. ABDOMEN: no distension. RUQ surgical site from prior hepatic lobectomy well-healed. tenderness to palpation in RUQ without guarding EXTREMITIES: 2+ radial pulses. SKIN: Warm and well perfused. No rash. Pertinent Results: ADMISSION LABS: ============== [MASKED] 01:02PM BLOOD WBC-13.1* RBC-3.77* Hgb-10.8* Hct-34.8* MCV-92 MCH-28.6 MCHC-31.0* RDW-14.2 RDWSD-48.3* Plt [MASKED] [MASKED] 01:02PM BLOOD UreaN-8 Creat-0.7 Na-136 K-4.1 Cl-98 HCO3-27 AnGap-11 [MASKED] 02:43PM BLOOD [MASKED] PTT-25.5 [MASKED] DISCHARGE LABS: ============== [MASKED] 06:28AM BLOOD WBC-7.8 RBC-2.88* Hgb-8.4* Hct-27.4* MCV-95 MCH-29.2 MCHC-30.7* RDW-15.1 RDWSD-51.8* Plt [MASKED] [MASKED] 06:28AM BLOOD [MASKED] PTT-34.3 [MASKED] [MASKED] 06:28AM BLOOD Glucose-116* UreaN-11 Creat-1.0 Na-137 K-4.1 Cl-102 HCO3-25 AnGap-10 [MASKED] 06:28AM BLOOD ALT-15 AST-25 LD(LDH)-209 AlkPhos-116 TotBili-0.3 [MASKED] 06:28AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.3 CXR [MASKED] Compared to chest radiographs since [MASKED] most recently [MASKED]. Substantial residual right pleural effusion, probably loculated, containing small collections of gas, right posterior and lower lateral hemithorax, extending into the major fissure. Persistent severe right basal atelectasis. Left lung clear. Heart size normal. CT CHEST W/O CONTRAST [MASKED] Again redemonstrated is a complex right small to moderate pleural effusion with multiple locules of gas. The overall volume of the pleural effusion has decreased in comparison to the prior examination, however, hyperattenuating areas appear to be slightly larger. Given the 8 day interval between the two CT examinations and the increase in size it is favored that these represent areas of hemothorax and blood clot (also given reported prior negative cytology results). PET/CT could be of value after acute symptoms have resolved to evaluate for the degree of possible metastatic disease. Stable small pulmonary nodules, suspicious for metastatic disease. CT INTERVENTIONAL PROCE [MASKED] Successful CT-guided placement of [MASKED] pigtail catheter into the collection. Samples was sent for microbiology evaluation. CT CHEST - [MASKED] IMPRESSION: 1. Slight increase in size of moderate right loculated pleural effusion containing high-density material suggestive of blood products, and foci of air. 2. Additional small hydropneumothorax along the right upper lobe is new from prior CT. Status post chest tube removal. 3. Small simple left pleural effusion. 4. Unchanged 6 mm right upper lobe nodule and 9 mm left upper lobe nodule, indeterminate. 5. New visualization of small sub segmental pulmonary embolism of the right upper lobe. PATHOLOGY: ========== Pleural Fluid: DIAGNOSIS: PLEURAL FLUID, RIGHT: NEGATIVE FOR MALIGNANT CELLS. Many red blood cells, neutrophils, lymphocytes, and rare mesothelial cells. Pleura Biopsy/Excision: PATHOLOGIC DIAGNOSIS: 1. Exudate, right hemothorax, decortication: - METASTATIC HEPATOCELLULAR CARCINOMA, present in a background of fibrin and organizing blood clot. 2. Nodule, right pleura, excision: - METASTATIC HEPATOCELLULAR CARCINOMA, present in a background of fibrin and organizing blood clot. 3. Right pleura, decortication: - Pleural tissue with METASTATIC HEPATOCELLULAR CARCINOMA, present in a background of fibrin and organizing blood clot. Note: The tumor cells in these specimens are morphology similar to those present in the prior liver resection [MASKED], reviewed). Brief Hospital Course: BRIEF HOSPITAL COURSE =================== [MASKED] h/o HepB on tenofovir, [MASKED] s/p recent R hepatic lobectomy with cholecystectomy and partial excision and repair of right hemidiaphragm, with recent readmission for R sided exudative pleural effusion of unclear etiology, also found to have pulmonary nodules and a supra-hepatic IVC thrombus prompting initiation of lovenox, readmitted [MASKED] with sepsis and empyema, requiring operative management with course complicated by pulmonary abscess, hemoptysis and [MASKED]. # Acute hypoxic respiratory failure # Sepsis # Empyema # RLL abscess Patient with recent admission for pleural effusion of unclear etiology, status post drainage readmitted with fevers and dyspnea, imaging showing complex effusion, with fluid studies consistent with empyema. Patient started on broad spectrum antibiotics, had pleural drain placed by [MASKED] with minimal sanguinous drainage, followed by chest tube placed by IP also with minimal sanguinous drainage. During this time patient had minimal clinical improvement, remained with loculated effusion and ongoing fevers. Patient was seen by ID consult service and thoracic surgery consult service who recommended surgical management. Patient transferred to thoracic surgery service when he underwent RLL VATS/decortication/pulmonary nodule biopsy. His surgery was complicated by transient hypotension and blood loss for which he received albumin and blood products respectively; he was subsequently transferred to the medicine service. While on the medicine service, pleural tissue pathology resulted and was consistent with metastatic hepatocellular carcinoma. Pleural fluid was without malignant cells. However, it was thought that the patient's pleural effusion was most likely malignant in nature. Placement of a PleurX was discussed with thoracic surgery given concern for recurrent pleural effusions, but deemed unnecessary, given that the decortication procedure performed during the patient's hospitalization was akin to a mechanical pleurodesis. The patient was maintained on vancomycin and zosyn for the majority of his hospitalization excepting a 2 day interruption in antibiotics which was accompanied by recurrent leukoctysis. Vancomycin was discontinued on [MASKED] after MRSA swab resulted negative. Patient was transitioned to augmentin (D1: [MASKED], with plan for [MASKED] week course in the setting of concern for RLL parenchymal abscess raised by Interventional Pulmonology after re-review of patient's CT chest and bronchoscopy. Patient was discharged on augmentin with plan for follow up with Interventional Pulmonology as outpatient for monitoring of possible abscess. #Hemoptysis #Epistaxis #Bleeding around chest tube Hospital course was complicated by low volume hemoptysis in the setting of recent heparin administration which persisted for several days. Thoracic surgery was consulted and recommended Interventional Pulmonology involvement. Interventional pulmonology recommended CT chest, which did not reveal etiology. IP also recommended bronchoscopy which indicated that the RLL was the source of bleed. Per IP, no acute intervention was warranted. On re-review of chest CT, IP was concerned for intraparenchymal abscess. In line with IP recommendations, we proceeded with antibiotic treatment as above, with patient discharged on [MASKED] week course of augmentin with planned follow up with IP. Heparin gtt was reinitiated after bronchoscopy and tolerated well with patient transitioned to lovenox prior to discharge. [MASKED] Patient with baseline Cr ~0.7, increased to max 1.4 in the setting of blood loss, poor PO intake, nephrotoxic antibiotic regimen. Blood products and fluids were given as needed with mild improvement in creatinine. Urine lytes obtained near the end of [MASKED] hospital course were consistent with intrarenal etiology, with improvement in creatinine after removing vancomycin and zosyn from patient's medication regimen. Patient was discharged with creatinine of 1.0 with plan for outpatient BMP. #TB rule out ID with concern that pulmonary nodules seen on patient's CT chest could represent TB. As such patient underwent TB rule out. Respiratory precautions were put in place. Acid fast smear/culture from induced sputum was negative x3 and respiratory precautions were lifted. Pulmonary nodules were biopsied and found to be consistent with metastatic hepatocellular carcinoma. # Chronic IVC thrombus Diagnosed during previous admission in [MASKED], concerning for possible tumor thrombus. Was treated with lovenox, bridged with IV heparin periprocedurally. Reinitiated heparin gtt on [MASKED] in s/o stable CBC which was held intermittently with concern for new onset hemoptysis. After bronchoscopy performed as above, heparin was reinitiated at weigh- based protocol. Patient was transitioned to lovenox without adverse event. # Pulmonary nodules # Hepatocellular Carcinoma Patient has known pleural nodules suspicious for metatatic HCC disease. Now pathology confirmed. See above. #Nutrition Patient has minimal appetite in the setting of metastatic disease. No associated nausea/vomiting. His meals supplements were supplemented with Glucerna shakes. Patient was initiated on mirtazapine to assist with appetite. # Chronic Hepatitis B Continued home tenofovir # Hepatocellular Carcinoma Continued prn oxycodone # Diabetes type 2 Continued insulin sliding scale # BPH Continued Finasteride, Tamsulosin TRANSITIONAL ISSUES ==================== [] Patient with hospital course complicated by [MASKED] thought to be of mixed etiology (prerenal/intrarenal). Improved creatinine on discharge but not back to baseline of 0.7. Please obtain BMP as outpatient to monitor and ensure continued improvement. [] Patient with likely intraparenchymal abscess. Plan for outpatient follow up with IP, Dr. [MASKED]. Patient should have CT scan within [MASKED] weeks for monitoring of abscess (to be scheduled by IP). If no response to prolonged antibiotic course, will likely need surgical intervention. [] Patient should continue with 6 week course of Augmentin (Day 1: [MASKED] - [MASKED] [] Patient with metastatic hepatocellular carcinoma. Will need close follow up with outpatient oncologist for treatment planning. [] Patient with decreased appetite and poor PO intake throughout hospitalization. Primary oncologist should monitor nutrition as outpatient. [] Patient has had elevated fasting blood glucose this hospitalization but has required <1u Novolog per day. Please evaluate for outpatient management of likely DM with oral medications. #CODE: Full #CONTACT: [MASKED] (daughter-in-law) [MASKED] [MASKED] (son) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. Tamsulosin 0.4 mg PO QHS 3. tenofovir disoproxil fumarate 300 mg oral DAILY 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 5. Polyethylene Glycol 17 g PO DAILY 6. Acetaminophen 1000 mg PO Q8H 7. Enoxaparin Sodium 60 mg SC Q12H Start: [MASKED], First Dose: [MASKED] 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 Disp #80 Tablet Refills:0 2. Mirtazapine 7.5 mg PO QHS RX mirtazapine 7.5 mg 1 tablet(s) by mouth every night Disp #30 Tablet Refills:0 3. Multivitamins W/minerals 1 TAB PO DAILY RX multivitamin,tx-minerals [Vitamins and Minerals] 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 4. Acetaminophen 1000 mg PO Q8H 5. Enoxaparin Sodium 60 mg SC Q12H RX enoxaparin 60 mg/0.6 mL 60 mg SC every 12 hours Disp #60 Syringe Refills:0 6. Finasteride 5 mg PO DAILY 7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 8. Polyethylene Glycol 17 g PO DAILY 9. Tamsulosin 0.4 mg PO QHS 10. tenofovir disoproxil fumarate 300 mg oral DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSES: ================= METASTATIC HCC IVC THROMBUS PULMONARY ABSCESS EMPYEMA MALIGNANT PLEURAL EFFUSION HEMOPTYSIS SECONDARY DIAGNOSES: =================== HEPATITIS B ELEVATED FASTING GLUCOSE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]. Why did you come to the hospital? - You came to the hospital because you had an infection in your lungs. What did you receive in the hospital? - In the hospital, our thoracic surgeons performed a procedure to allow your lungs to better expand and minimize the risk of fluid accumulation in the lungs. - You also received antibiotics to treat a pulmonary abscess (an area of infection). You were discharged on these antibiotics as this type of infection requires a long course of treatment. - You were started on a medication to increase your appetite as our nutritionists feel you would greatly benefit from more food intake. - You were reinitiated on your anticoagulation therapy (blood thinners) which you are on for your increased risk of blood clots. You currently have blood clots in one of your large blood vessels and in your lungs. The anticoagulation therapy should stabalize these clots. What should you do once you leave the hospital? - Make sure to continue to take your medications as prescribed and follow up with your outpatient providers. - If you develop any fevers, lethargy, shortness of breath, please go to the emergency room immediately We wish you all the best! - Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "J9601", "N179", "N400", "I10", "K5900", "Z7901", "F419", "Z87891", "Y92230" ]	[ "A419: Sepsis, unspecified organism", "J852: Abscess of lung without pneumonia", "J9601: Acute respiratory failure with hypoxia", "I82221: Chronic embolism and thrombosis of inferior vena cava", "J910: Malignant pleural effusion", "R042: Hemoptysis", "C220: Liver cell carcinoma", "N179: Acute kidney failure, unspecified", "B181: Chronic viral hepatitis B without delta-agent", "C7989: Secondary malignant neoplasm of other specified sites", "D6832: Hemorrhagic disorder due to extrinsic circulating anticoagulants", "C782: Secondary malignant neoplasm of pleura", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I444: Left anterior fascicular block", "I10: Essential (primary) hypertension", "E8339: Other disorders of phosphorus metabolism", "K5900: Constipation, unspecified", "K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding", "M8580: Other specified disorders of bone density and structure, unspecified site", "Z7901: Long term (current) use of anticoagulants", "F419: Anxiety disorder, unspecified", "Z87891: Personal history of nicotine dependence", "Z800: Family history of malignant neoplasm of digestive organs", "Z79891: Long term (current) use of opiate analgesic", "Z79899: Other long term (current) drug therapy", "R040: Epistaxis", "T45515A: Adverse effect of anticoagulants, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Z9049: Acquired absence of other specified parts of digestive tract", "J479: Bronchiectasis, uncomplicated", "R7301: Impaired fasting glucose" ]
10,090,755	23,765,179	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right pleural effusion Major Surgical or Invasive Procedure: ___ right chest tube placed History of Present Illness: In brief, ___ is a ___ year old man w/PMH HBV on tenofovir c/b HCC s/p R hepatic lobectomy ___, HTN, and BPH who presented on ___ with two weeks of chest pain/tightness and subjective fevers with increased sputum production. He was admitted to the transplant surgery service. CTA showed large R pleural effusion w/associated RML and RLL collapse and pleural nodules suggestive of metastatic HCC. IP was consulted and placed pigtail catheter. 800cc of serosanguinous fluid was removed and fluid studies were consistent with transudative effusion (LDH 669, cholesterol 66). Cytology returned negative for malignancy and cultures are no growth to date. IP is considering MT/pleurodesis/TPC for definitive diagnosis and management. On surveillance staging imaging ___, patient was found to have pleural nodules suspicious for metastases, a new nonocclusive filling defect in the suprahepatic IVC which could represent thrombus or tumor thrombus, and multiple new small pulmonary nodules with mediastinal LAD concerning for metastases. On evaluation this evening, Mr. ___ is feeing well and is without complaint. He states that his pain medication is adequately controlling his pain from the chest tube. Denies cough, fever, chills, chest pain, shortness of breath. He denies personal or family history of blood clots. Past Medical History: PMH: HCC Hepatitis B HTN BPH Diverticulosis PSH: cataract surgery R hepatic lobectomy, diaphragmatic resection for ___ Social History: ___ Family History: Family History: Possible colon cancer in father Physical ___ Physical Exam: GENERAL: [x]NAD [x]A/O x 3 [ ]intubated/sedated [ ]abnormal CARDIAC: [x]RRR [ ]no MRG [ ]Nl S1S2 [ ]abnormal LUNGS: [x] CTA in RUL, diminished/absent breath sounds in RML and RLL lung fields. L lung CTA [x]no respiratory distress [ ]abnormal ABDOMEN: [ ]NBS [x]soft [x]Nontender [ ]appropriately tender [x]nondistended [ ]no rebound/guarding [ ]abnormal WOUND: [x]CD&I [x]no erythema/induration [ ]JP [ ]abnormal EXTREMITIES: [x]no CCE [ ]Pulse [ ]abnormal Discharge Physical Exam: GENERAL: Primarily ___ speaking. Alert and interactive. In no acute distress. CARDIAC: Regular rhythm, normal rate. No murmurs/rubs/gallops. LUNGS: Decreased breath sounds throughout, absent in RLL ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. Surgical incision in midline and RUQ from hepatic lobectomy EXTREMITIES: No clubbing, cyanosis, or edema. WWP. NEUROLOGIC: Face symmetric, moving all extremities spontaneously. AOx3 Pertinent Results: ___ Chest CT: The previously large right pleural effusion drained by a basal pigtail catheter, is much smaller and contains small air collections incidental to drain placement. High attenuation pleural nodules are likely metastases, but some could be clot. Image guided transthoracic needle aspiration should be feasible. A nonocclusive filling defect is new or newly apparent in the supra hepatic IVC and could be thrombus or tumor thrombus. Doppler ultrasound evaluation could better differentiate these. Small pulmonary nodules are new since ___ and more prominent though small mediastinal lymphadenopathy are likely metastases. ___ CT A/P: 1. Moderately-sized nonocclusive filling defect in the suprahepatic inferior vena cava approximately at the bifurcation of the middle and left hepatic veins. The middle and left hepatic veins are widely patent. 2. The patient is status post right hepatectomy with expected postsurgical changes. 3. There are no hepatic lesions that meet OPTN 5 criteria for hepatocellular carcinoma. 4. Moderate right pleural effusion with subcutaneous drainage catheter in place. 5. Fusiform dilatation of the right renal artery at the bifurcation in the right hilum measuring 2.2 x 1.5 x 1.1 cm. ___ AP radiograph of the chest. COMPARISON: Chest radiograph ___. IMPRESSION: The right basilar chest tube has been removed. The small to moderate right pleural effusion with locules of air and compressive atelectasis of the right middle lobe and right lower lobe are not significantly changed compared to prior study, allowing for differences in patient's respiratory effort. There is no new consolidation. No pneumothorax is identified. The cardiomediastinal silhouette is stable in appearance. There are no acute osseous abnormalities. Brief Hospital Course: Mr ___ was admitted to the Transplant Surgery service on ___ with a large right sided pleural effusion. Interventional Pulmonology was consulted and a ___ chest tube was placed, draining 800 of serosanguinous fluid. This was sent for pleural studies. Pleural studies revealed a lymphocytic exudative effusion. Upon further review of the CT chest obtained on admission, pleural nodules were noted, concerning for metastasis of hepatocellular carcinoma. An AFP was sent; this was 31, increased from 19 prior to his hepatic lobectomy. Cytology from the pleural fluid did not show any malignant cells. Nonetheless, given concerns for metastatic disease, a staging CT scan (already previously scheduled as an outpatient) was performed. This demonstrated pleural nodules, again concerning for metastasis, as well as a suprahepatic IVC thrombus (bland). The patient was started on therapeutic Lovenox for this. Given these findings, the patient was therefore transferred to Medicine for further oncologic workup. Pt had the chest tube removed by IP and continued to have mild right sided chest pain and low grade fevers without any N/V/D or urinary symptoms. Repeat CXR was stable and pt was eager to get home for Christmas with his family. We spoke at length with patient and family (daughter who is a ___) about our concerns for recurrent cancer. We also explained the lack of diagnostic certainly and need for close follow up as outlined below. We emailed his primary oncologist who was able to get him in for follow-up right after ___. Pt was given teaching and was discharged on lovenox 60mg SubQ BID. Lovenox was chosen because he will likely need additional procedures with IP in the next ___ weeks and wouldn't want them delayed by the washout time required of a DOAC. Follow Up: - Interventional pulmonology: Follow up in ___ clinic w/ Dr. ___ in 2 weeks for thoracoscopyand biopsy of pleural nodules - Oncologist: Dr. ___ on ___ at 11:30 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. Tamsulosin 0.4 mg PO QHS 3. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 4. Aspirin EC 81 mg PO DAILY 5. tenofovir disoproxil fumarate 300 mg oral DAILY Discharge Medications: 1. Enoxaparin Sodium 60 mg SC Q12H RX enoxaparin 60 mg/0.6 mL 0.6 mL SubQ twice a day Disp #30 Syringe Refills:0 2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed Disp #12 Tablet Refills:0 3. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 [Miralax] 17 gram/dose 17g powder(s) by mouth daily Refills:0 4. Acetaminophen 1000 mg PO Q8H 5. Finasteride 5 mg PO DAILY 6. Tamsulosin 0.4 mg PO QHS 7. tenofovir disoproxil fumarate 300 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: Pleural effusion h/o ___ s/p right hepatic lobectomy Pulmonary nodules Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: WHY WERE YOU ADMITTED: Chest pains and cough WHAT HAPPENED WHEN YOU WERE HERE: We discovered that you had fluid around your right lung, which we drained by placing a catheter. We also did a CT scan that showed some nodules/masses in your lungs most concerning for spread of cancer, although no diagnosis can be made until the lung doctors ___ the ___, which they are planning on doing in a few weeks. We have scheduled you an appointment with your oncologist on ___ and the lung doctors ___ to schedule an appointment very soon. You were also noted to have a small dilation in the artery going to your kidneys, we recommend that you follow up with vascular surgery in the next few months. (you can contact their office at ___ WHAT SHOULD YOU DO WHEN YOU GO HOME: - You should take your medications as prescribed. - You will inject 60mg enoxaparin under the skin twice daily - We will also give you some oxycodone for the chest pain you are having REASONS TO COME BACK TO THE HOSPITAL: Please come back to the hospital if you experience worsening chest pain, shortness of breath, fevers, chills, confusion, or any other concerning symptoms. It was a pleasure meeting you and providing care for you during your hospital stay. Sincerely, Your ___ Healthcare Team Followup Instructions: ___	[ "A419", "J852", "J9601", "I82221", "J910", "R042", "C220", "C771", "C7800", "N179", "B181", "C7989", "D6832", "C782", "N400", "I444", "E8339", "K5900", "K5790", "M8580", "Z7901", "F419", "Z87891", "Z800", "Z79891", "Z79899", "R040", "T45515A", "Y92230", "Z9049", "J479", "R7301", "R918" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: right pleural effusion Major Surgical or Invasive Procedure: [MASKED] right chest tube placed History of Present Illness: In brief, [MASKED] is a [MASKED] year old man w/PMH HBV on tenofovir c/b HCC s/p R hepatic lobectomy [MASKED], HTN, and BPH who presented on [MASKED] with two weeks of chest pain/tightness and subjective fevers with increased sputum production. He was admitted to the transplant surgery service. CTA showed large R pleural effusion w/associated RML and RLL collapse and pleural nodules suggestive of metastatic HCC. IP was consulted and placed pigtail catheter. 800cc of serosanguinous fluid was removed and fluid studies were consistent with transudative effusion (LDH 669, cholesterol 66). Cytology returned negative for malignancy and cultures are no growth to date. IP is considering MT/pleurodesis/TPC for definitive diagnosis and management. On surveillance staging imaging [MASKED], patient was found to have pleural nodules suspicious for metastases, a new nonocclusive filling defect in the suprahepatic IVC which could represent thrombus or tumor thrombus, and multiple new small pulmonary nodules with mediastinal LAD concerning for metastases. On evaluation this evening, Mr. [MASKED] is feeing well and is without complaint. He states that his pain medication is adequately controlling his pain from the chest tube. Denies cough, fever, chills, chest pain, shortness of breath. He denies personal or family history of blood clots. Past Medical History: PMH: HCC Hepatitis B HTN BPH Diverticulosis PSH: cataract surgery R hepatic lobectomy, diaphragmatic resection for [MASKED] Social History: [MASKED] Family History: Family History: Possible colon cancer in father Physical [MASKED] Physical Exam: GENERAL: [x]NAD [x]A/O x 3 [ ]intubated/sedated [ ]abnormal CARDIAC: [x]RRR [ ]no MRG [ ]Nl S1S2 [ ]abnormal LUNGS: [x] CTA in RUL, diminished/absent breath sounds in RML and RLL lung fields. L lung CTA [x]no respiratory distress [ ]abnormal ABDOMEN: [ ]NBS [x]soft [x]Nontender [ ]appropriately tender [x]nondistended [ ]no rebound/guarding [ ]abnormal WOUND: [x]CD&I [x]no erythema/induration [ ]JP [ ]abnormal EXTREMITIES: [x]no CCE [ ]Pulse [ ]abnormal Discharge Physical Exam: GENERAL: Primarily [MASKED] speaking. Alert and interactive. In no acute distress. CARDIAC: Regular rhythm, normal rate. No murmurs/rubs/gallops. LUNGS: Decreased breath sounds throughout, absent in RLL ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. Surgical incision in midline and RUQ from hepatic lobectomy EXTREMITIES: No clubbing, cyanosis, or edema. WWP. NEUROLOGIC: Face symmetric, moving all extremities spontaneously. AOx3 Pertinent Results: [MASKED] Chest CT: The previously large right pleural effusion drained by a basal pigtail catheter, is much smaller and contains small air collections incidental to drain placement. High attenuation pleural nodules are likely metastases, but some could be clot. Image guided transthoracic needle aspiration should be feasible. A nonocclusive filling defect is new or newly apparent in the supra hepatic IVC and could be thrombus or tumor thrombus. Doppler ultrasound evaluation could better differentiate these. Small pulmonary nodules are new since [MASKED] and more prominent though small mediastinal lymphadenopathy are likely metastases. [MASKED] CT A/P: 1. Moderately-sized nonocclusive filling defect in the suprahepatic inferior vena cava approximately at the bifurcation of the middle and left hepatic veins. The middle and left hepatic veins are widely patent. 2. The patient is status post right hepatectomy with expected postsurgical changes. 3. There are no hepatic lesions that meet OPTN 5 criteria for hepatocellular carcinoma. 4. Moderate right pleural effusion with subcutaneous drainage catheter in place. 5. Fusiform dilatation of the right renal artery at the bifurcation in the right hilum measuring 2.2 x 1.5 x 1.1 cm. [MASKED] AP radiograph of the chest. COMPARISON: Chest radiograph [MASKED]. IMPRESSION: The right basilar chest tube has been removed. The small to moderate right pleural effusion with locules of air and compressive atelectasis of the right middle lobe and right lower lobe are not significantly changed compared to prior study, allowing for differences in patient's respiratory effort. There is no new consolidation. No pneumothorax is identified. The cardiomediastinal silhouette is stable in appearance. There are no acute osseous abnormalities. Brief Hospital Course: Mr [MASKED] was admitted to the Transplant Surgery service on [MASKED] with a large right sided pleural effusion. Interventional Pulmonology was consulted and a [MASKED] chest tube was placed, draining 800 of serosanguinous fluid. This was sent for pleural studies. Pleural studies revealed a lymphocytic exudative effusion. Upon further review of the CT chest obtained on admission, pleural nodules were noted, concerning for metastasis of hepatocellular carcinoma. An AFP was sent; this was 31, increased from 19 prior to his hepatic lobectomy. Cytology from the pleural fluid did not show any malignant cells. Nonetheless, given concerns for metastatic disease, a staging CT scan (already previously scheduled as an outpatient) was performed. This demonstrated pleural nodules, again concerning for metastasis, as well as a suprahepatic IVC thrombus (bland). The patient was started on therapeutic Lovenox for this. Given these findings, the patient was therefore transferred to Medicine for further oncologic workup. Pt had the chest tube removed by IP and continued to have mild right sided chest pain and low grade fevers without any N/V/D or urinary symptoms. Repeat CXR was stable and pt was eager to get home for Christmas with his family. We spoke at length with patient and family (daughter who is a [MASKED]) about our concerns for recurrent cancer. We also explained the lack of diagnostic certainly and need for close follow up as outlined below. We emailed his primary oncologist who was able to get him in for follow-up right after [MASKED]. Pt was given teaching and was discharged on lovenox 60mg SubQ BID. Lovenox was chosen because he will likely need additional procedures with IP in the next [MASKED] weeks and wouldn't want them delayed by the washout time required of a DOAC. Follow Up: - Interventional pulmonology: Follow up in [MASKED] clinic w/ Dr. [MASKED] in 2 weeks for thoracoscopyand biopsy of pleural nodules - Oncologist: Dr. [MASKED] on [MASKED] at 11:30 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. Tamsulosin 0.4 mg PO QHS 3. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 4. Aspirin EC 81 mg PO DAILY 5. tenofovir disoproxil fumarate 300 mg oral DAILY Discharge Medications: 1. Enoxaparin Sodium 60 mg SC Q12H RX enoxaparin 60 mg/0.6 mL 0.6 mL SubQ twice a day Disp #30 Syringe Refills:0 2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed Disp #12 Tablet Refills:0 3. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 [Miralax] 17 gram/dose 17g powder(s) by mouth daily Refills:0 4. Acetaminophen 1000 mg PO Q8H 5. Finasteride 5 mg PO DAILY 6. Tamsulosin 0.4 mg PO QHS 7. tenofovir disoproxil fumarate 300 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: Pleural effusion h/o [MASKED] s/p right hepatic lobectomy Pulmonary nodules Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: WHY WERE YOU ADMITTED: Chest pains and cough WHAT HAPPENED WHEN YOU WERE HERE: We discovered that you had fluid around your right lung, which we drained by placing a catheter. We also did a CT scan that showed some nodules/masses in your lungs most concerning for spread of cancer, although no diagnosis can be made until the lung doctors [MASKED] the [MASKED], which they are planning on doing in a few weeks. We have scheduled you an appointment with your oncologist on [MASKED] and the lung doctors [MASKED] to schedule an appointment very soon. You were also noted to have a small dilation in the artery going to your kidneys, we recommend that you follow up with vascular surgery in the next few months. (you can contact their office at [MASKED] WHAT SHOULD YOU DO WHEN YOU GO HOME: - You should take your medications as prescribed. - You will inject 60mg enoxaparin under the skin twice daily - We will also give you some oxycodone for the chest pain you are having REASONS TO COME BACK TO THE HOSPITAL: Please come back to the hospital if you experience worsening chest pain, shortness of breath, fevers, chills, confusion, or any other concerning symptoms. It was a pleasure meeting you and providing care for you during your hospital stay. Sincerely, Your [MASKED] Healthcare Team Followup Instructions: [MASKED]	[]	[ "J9601", "N179", "N400", "K5900", "Z7901", "F419", "Z87891", "Y92230" ]	[ "A419: Sepsis, unspecified organism", "J852: Abscess of lung without pneumonia", "J9601: Acute respiratory failure with hypoxia", "I82221: Chronic embolism and thrombosis of inferior vena cava", "J910: Malignant pleural effusion", "R042: Hemoptysis", "C220: Liver cell carcinoma", "C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes", "C7800: Secondary malignant neoplasm of unspecified lung", "N179: Acute kidney failure, unspecified", "B181: Chronic viral hepatitis B without delta-agent", "C7989: Secondary malignant neoplasm of other specified sites", "D6832: Hemorrhagic disorder due to extrinsic circulating anticoagulants", "C782: Secondary malignant neoplasm of pleura", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I444: Left anterior fascicular block", "E8339: Other disorders of phosphorus metabolism", "K5900: Constipation, unspecified", "K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding", "M8580: Other specified disorders of bone density and structure, unspecified site", "Z7901: Long term (current) use of anticoagulants", "F419: Anxiety disorder, unspecified", "Z87891: Personal history of nicotine dependence", "Z800: Family history of malignant neoplasm of digestive organs", "Z79891: Long term (current) use of opiate analgesic", "Z79899: Other long term (current) drug therapy", "R040: Epistaxis", "T45515A: Adverse effect of anticoagulants, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Z9049: Acquired absence of other specified parts of digestive tract", "J479: Bronchiectasis, uncomplicated", "R7301: Impaired fasting glucose", "R918: Other nonspecific abnormal finding of lung field" ]
10,090,755	24,299,267	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ___ Major Surgical or Invasive Procedure: ___ 1. Diagnostic laparoscopy. 2. Right hepatic lobectomy with cholecystectomy. 3. Partial excision and repair of right hemidiaphragm . Brief Hospital Course: ___ hx HPV, biopsy-confirmed HCC scheduled for R posterior section ectomy w/Dr. ___ presented to the ED with a 2 week history of abdominal pain in RUQ which worsened on ___ along with a fever of ~101 at home. CT abd/pelvis concerning for abscess, tumor necrosis and RHV thrombus. Chest CTA was negative for PE. He was admitted to transplant surgery service and started on IV fluid, cefepime/Flagyl. On ___, Cefepime was changed to Ceftriaxone for blood cultures with GPCs in clusters on blood cx x1. Vancomycin was added for coag neg staph. He remained afebrile and serum WBC decreased from 20.8 to 17.5. Blood cultures from ___, and ___ were negative. On ___, he underwent diagnostic laparoscopy, right hepatic lobectomy with cholecystectomy and partial excision and repair of right hemidiaphragm for HCC. Surgeon was Dr. ___. Please refer to operative note for complete details. Postop, he was hypotensive and IV fluid bolus was administered with improvement. The foley was removed the next day and he was voiding well. Diet was started slowly. He was passing flatus and had a small BM on ___. Abdomen felt bloated to the patient and dietary intake was low. He needed encouragement to drink more fluids especially since JP output was high. JP drain output was non-bilious. Output averaged 500cc, but increased to 860cc per day on ___. Fluid appeared somewhat cloudy and fluid triglyceride was check, but was low therefore chyle leak was less likely. He was encouraged to eat high protein foods like fish/chicken. He was also encouraged to drink more fluid. IV albumin was administered on ___ for poor po intake. Incision was intact without redness/drainage. He was oob and ambulating. He felt well enough to go home on postop day 7. Of note, LFTs were decreasing except for increase in alk phos over the last 3 days of hospital stay from 108 to 683. AST increased from 898 to 121 to 141. Scheduled Tylenol for pain relief was decreased. He was not using narcotic pain medication. On, ___, liver duplex showed patent hepatic vasculature; no intrahepatic biliary dilation. ___ was arranged to assess JP drain management at home as the JP remained in place. He will f/u with Dr. ___ on ___ and JP drain will likely be removed on that day. Home Tenofovir was continued. Anti-htn meds and HCTZ were held as sbp was in the low 100s. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Finasteride 5 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Lisinopril 5 mg PO DAILY 5. Tamsulosin 0.4 mg PO QHS 6. tenofovir disoproxil fumarate 300 mg oral DAILY 7. Aspirin EC 81 mg PO DAILY 8. calcium carbonate-vit D3-min 600 mg calcium- 400 unit oral DAILY Discharge Medications: 1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild do not take more than 2000mg per day RX acetaminophen 325 mg 1 tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 2. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram/dose 17 grams by mouth once a day Refills:0 3. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #60 Tablet Refills:0 4. Aspirin EC 81 mg PO DAILY 5. Finasteride 5 mg PO DAILY 6. Tamsulosin 0.4 mg PO QHS 7. tenofovir disoproxil fumarate 300 mg oral DAILY hepatitis B treatment 8. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do not restart amLODIPine until blood pressures were on the low side. 9. HELD- calcium carbonate-vit D3-min 600 mg calcium- 400 unit oral DAILY This medication was held. Do not restart calcium carbonate-vit D3-min until follow up with Dr. ___ 10. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until follow up appointment with Dr. ___ 11. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do not restart Lisinopril until discussed with Dr ___ in follow up appointment Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ___ Home ___ and ___, ___. Address 1: ___ Phone Number: ___ Address 2: Fax Number: ___ Please call Dr. ___ office at ___ for fever of 101 or higher, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, pain not controlled by your pain medication, swelling of the abdomen or ankles, yellowing of the skin or eyes, inability to tolerate food, fluids or medications, the incision or JP drain sites have redness, drainage or bleeding, or any other concerning symptoms. *Empty JP drain and record all output** if you go home with the JP drain. You may shower. Allow water to run over the incision sites. Do not apply lotions or powders to the incision areas. Leave incisions open to the air. No lifting more than 10 pounds No driving if taking narcotic pain medication Followup Instructions: ___	[ "C220", "I820", "B181", "R7881", "I9581", "I10", "E119", "N400", "Z87891", "Z5331" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: [MASKED] Major Surgical or Invasive Procedure: [MASKED] 1. Diagnostic laparoscopy. 2. Right hepatic lobectomy with cholecystectomy. 3. Partial excision and repair of right hemidiaphragm . Brief Hospital Course: [MASKED] hx HPV, biopsy-confirmed HCC scheduled for R posterior section ectomy w/Dr. [MASKED] presented to the ED with a 2 week history of abdominal pain in RUQ which worsened on [MASKED] along with a fever of ~101 at home. CT abd/pelvis concerning for abscess, tumor necrosis and RHV thrombus. Chest CTA was negative for PE. He was admitted to transplant surgery service and started on IV fluid, cefepime/Flagyl. On [MASKED], Cefepime was changed to Ceftriaxone for blood cultures with GPCs in clusters on blood cx x1. Vancomycin was added for coag neg staph. He remained afebrile and serum WBC decreased from 20.8 to 17.5. Blood cultures from [MASKED], and [MASKED] were negative. On [MASKED], he underwent diagnostic laparoscopy, right hepatic lobectomy with cholecystectomy and partial excision and repair of right hemidiaphragm for HCC. Surgeon was Dr. [MASKED]. Please refer to operative note for complete details. Postop, he was hypotensive and IV fluid bolus was administered with improvement. The foley was removed the next day and he was voiding well. Diet was started slowly. He was passing flatus and had a small BM on [MASKED]. Abdomen felt bloated to the patient and dietary intake was low. He needed encouragement to drink more fluids especially since JP output was high. JP drain output was non-bilious. Output averaged 500cc, but increased to 860cc per day on [MASKED]. Fluid appeared somewhat cloudy and fluid triglyceride was check, but was low therefore chyle leak was less likely. He was encouraged to eat high protein foods like fish/chicken. He was also encouraged to drink more fluid. IV albumin was administered on [MASKED] for poor po intake. Incision was intact without redness/drainage. He was oob and ambulating. He felt well enough to go home on postop day 7. Of note, LFTs were decreasing except for increase in alk phos over the last 3 days of hospital stay from 108 to 683. AST increased from 898 to 121 to 141. Scheduled Tylenol for pain relief was decreased. He was not using narcotic pain medication. On, [MASKED], liver duplex showed patent hepatic vasculature; no intrahepatic biliary dilation. [MASKED] was arranged to assess JP drain management at home as the JP remained in place. He will f/u with Dr. [MASKED] on [MASKED] and JP drain will likely be removed on that day. Home Tenofovir was continued. Anti-htn meds and HCTZ were held as sbp was in the low 100s. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Finasteride 5 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Lisinopril 5 mg PO DAILY 5. Tamsulosin 0.4 mg PO QHS 6. tenofovir disoproxil fumarate 300 mg oral DAILY 7. Aspirin EC 81 mg PO DAILY 8. calcium carbonate-vit D3-min 600 mg calcium- 400 unit oral DAILY Discharge Medications: 1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild do not take more than 2000mg per day RX acetaminophen 325 mg 1 tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 2. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram/dose 17 grams by mouth once a day Refills:0 3. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #60 Tablet Refills:0 4. Aspirin EC 81 mg PO DAILY 5. Finasteride 5 mg PO DAILY 6. Tamsulosin 0.4 mg PO QHS 7. tenofovir disoproxil fumarate 300 mg oral DAILY hepatitis B treatment 8. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do not restart amLODIPine until blood pressures were on the low side. 9. HELD- calcium carbonate-vit D3-min 600 mg calcium- 400 unit oral DAILY This medication was held. Do not restart calcium carbonate-vit D3-min until follow up with Dr. [MASKED] 10. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until follow up appointment with Dr. [MASKED] 11. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do not restart Lisinopril until discussed with Dr [MASKED] in follow up appointment Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: [MASKED] Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: [MASKED] Home [MASKED] and [MASKED], [MASKED]. Address 1: [MASKED] Phone Number: [MASKED] Address 2: Fax Number: [MASKED] Please call Dr. [MASKED] office at [MASKED] for fever of 101 or higher, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, pain not controlled by your pain medication, swelling of the abdomen or ankles, yellowing of the skin or eyes, inability to tolerate food, fluids or medications, the incision or JP drain sites have redness, drainage or bleeding, or any other concerning symptoms. *Empty JP drain and record all output** if you go home with the JP drain. You may shower. Allow water to run over the incision sites. Do not apply lotions or powders to the incision areas. Leave incisions open to the air. No lifting more than 10 pounds No driving if taking narcotic pain medication Followup Instructions: [MASKED]	[]	[ "I10", "E119", "N400", "Z87891" ]	[ "C220: Liver cell carcinoma", "I820: Budd-Chiari syndrome", "B181: Chronic viral hepatitis B without delta-agent", "R7881: Bacteremia", "I9581: Postprocedural hypotension", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z87891: Personal history of nicotine dependence", "Z5331: Laparoscopic surgical procedure converted to open procedure" ]
10,090,768	23,141,956	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Compazine Attending: ___. Chief Complaint: Diverticulitis Major Surgical or Invasive Procedure: None History of Present Illness: HPI: ___ with history of multiple episodes of diverticulitis. She is scheduled for an elective lap sigmoid colectomy with Dr. ___ on ___. However, she presents today with abdominal pain since ___ that feels like her previous episodes of diverticulitis. She denies nausea, but had one episode of small volume bilious emesis. She had a normal bowel movement yesterday and continues to pass flatus. She had a prescription for PO cipro/flagyl at home, and has been taking this since ___, however her pain continues to worsen. She has been able to hold down water, but hasn't eaten food since ___. She denies fevers but reports chills last night. The only difference between this and her previous episodes of diverticulitis is that she does not have diarrhea currently. Past Medical History: HTN, undifferentiated spondyloarthropathy, Hx diverticulitis Social History: ___ Family History: non-conbtributory Physical Exam: General: Doing well, tolerating a regular diet, pain controlled with pain medications by mouth. VSS Neuro: A&OX3 Cardio/Pulm: RRR, CTAB Abd: non distended, soft, non tender ___: ambulating Pertinent Results: ___ 07:21AM BLOOD WBC-9.1 RBC-3.99 Hgb-12.0 Hct-36.0 MCV-90 MCH-30.1 MCHC-33.3 RDW-12.7 RDWSD-42.1 Plt ___ ___ 08:31AM BLOOD WBC-13.6# RBC-4.35 Hgb-12.9 Hct-38.4 MCV-88 MCH-29.7 MCHC-33.6 RDW-12.8 RDWSD-41.7 Plt ___ ___ 08:31AM BLOOD WBC-13.6# RBC-4.35 Hgb-12.9 Hct-38.4 MCV-88 MCH-29.7 MCHC-33.6 RDW-12.8 RDWSD-41.7 Plt ___ ___ 07:21AM BLOOD Glucose-81 UreaN-9 Creat-0.9 Na-137 K-4.1 Cl-102 HCO3-25 AnGap-14 ___ 08:31AM BLOOD Glucose-113* UreaN-9 Creat-1.0 Na-135 K-4.8 Cl-98 HCO3-22 AnGap-20 Study Date of ___ 12:46 ___ IMPRESSION: 1. Sigmoid diverticulitis with inflammatory changes similar in distribution to the patient's prior episode on CT abdomen pelvis ___. There is a 1.7 x 0.8 cm early subserosal fluid collection in the region of the sigmoid colon. 2. Bibasilar atelectasis. Brief Hospital Course: Mrs. ___ known patient of Dr. ___, was admitted to the inpatient colorectal surgery service with diverticulitis. Her white blood cell count was 13.6 at the time of admission and she was having abdominal pain. Please see HPI. She was admitted, made NPO, and given intravenous cipro and flagyl. She improved greatly overnight and her white blood cell count returned to normal. She tolerated a regular diet. On ___ she was seen by Dr. ___ well on antibiotics by mouth. She was discharged home and will present for surgery next week as previously arranged. Medications on Admission: Folic Acid 1mg daily, lisinopril 30mg daily, vitamins Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain do not take more than 3000mg of Tylenol in 24 hours or drink alcohol while taking this medication 2. Ciprofloxacin HCl 500 mg PO Q12H please take until your surgery RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #9 Tablet Refills:0 3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H please take until your time of surgery RX metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #13 Tablet Refills:0 4. FoLIC Acid 1 mg PO DAILY 5. Lisinopril 30 mg PO DAILY 6. Multivitamins 1 TAB 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 with Diverticulitis. You are to have surgery with Dr. ___ week on ___ to remove the diseased part of your colon. Your abdominal pain has improved and you have tolerated a regular diet. You will continue to take the antibiotics Ciprofloxacin and Flagyl (metrodiazole) until the time of surgery. It is very important that you do not drink alcohol while taking the antibiotic flagyl because this can cause nausea and vomiting. Please take the bowel prep next week prior to your surgery as you were instructed by our office. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. Followup Instructions: ___	[ "K5720", "I10", "M069" ]	Allergies: Compazine Chief Complaint: Diverticulitis Major Surgical or Invasive Procedure: None History of Present Illness: HPI: [MASKED] with history of multiple episodes of diverticulitis. She is scheduled for an elective lap sigmoid colectomy with Dr. [MASKED] on [MASKED]. However, she presents today with abdominal pain since [MASKED] that feels like her previous episodes of diverticulitis. She denies nausea, but had one episode of small volume bilious emesis. She had a normal bowel movement yesterday and continues to pass flatus. She had a prescription for PO cipro/flagyl at home, and has been taking this since [MASKED], however her pain continues to worsen. She has been able to hold down water, but hasn't eaten food since [MASKED]. She denies fevers but reports chills last night. The only difference between this and her previous episodes of diverticulitis is that she does not have diarrhea currently. Past Medical History: HTN, undifferentiated spondyloarthropathy, Hx diverticulitis Social History: [MASKED] Family History: non-conbtributory Physical Exam: General: Doing well, tolerating a regular diet, pain controlled with pain medications by mouth. VSS Neuro: A&OX3 Cardio/Pulm: RRR, CTAB Abd: non distended, soft, non tender [MASKED]: ambulating Pertinent Results: [MASKED] 07:21AM BLOOD WBC-9.1 RBC-3.99 Hgb-12.0 Hct-36.0 MCV-90 MCH-30.1 MCHC-33.3 RDW-12.7 RDWSD-42.1 Plt [MASKED] [MASKED] 08:31AM BLOOD WBC-13.6# RBC-4.35 Hgb-12.9 Hct-38.4 MCV-88 MCH-29.7 MCHC-33.6 RDW-12.8 RDWSD-41.7 Plt [MASKED] [MASKED] 08:31AM BLOOD WBC-13.6# RBC-4.35 Hgb-12.9 Hct-38.4 MCV-88 MCH-29.7 MCHC-33.6 RDW-12.8 RDWSD-41.7 Plt [MASKED] [MASKED] 07:21AM BLOOD Glucose-81 UreaN-9 Creat-0.9 Na-137 K-4.1 Cl-102 HCO3-25 AnGap-14 [MASKED] 08:31AM BLOOD Glucose-113* UreaN-9 Creat-1.0 Na-135 K-4.8 Cl-98 HCO3-22 AnGap-20 Study Date of [MASKED] 12:46 [MASKED] IMPRESSION: 1. Sigmoid diverticulitis with inflammatory changes similar in distribution to the patient's prior episode on CT abdomen pelvis [MASKED]. There is a 1.7 x 0.8 cm early subserosal fluid collection in the region of the sigmoid colon. 2. Bibasilar atelectasis. Brief Hospital Course: Mrs. [MASKED] known patient of Dr. [MASKED], was admitted to the inpatient colorectal surgery service with diverticulitis. Her white blood cell count was 13.6 at the time of admission and she was having abdominal pain. Please see HPI. She was admitted, made NPO, and given intravenous cipro and flagyl. She improved greatly overnight and her white blood cell count returned to normal. She tolerated a regular diet. On [MASKED] she was seen by Dr. [MASKED] well on antibiotics by mouth. She was discharged home and will present for surgery next week as previously arranged. Medications on Admission: Folic Acid 1mg daily, lisinopril 30mg daily, vitamins Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain do not take more than 3000mg of Tylenol in 24 hours or drink alcohol while taking this medication 2. Ciprofloxacin HCl 500 mg PO Q12H please take until your surgery RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #9 Tablet Refills:0 3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H please take until your time of surgery RX metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #13 Tablet Refills:0 4. FoLIC Acid 1 mg PO DAILY 5. Lisinopril 30 mg PO DAILY 6. Multivitamins 1 TAB 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 with Diverticulitis. You are to have surgery with Dr. [MASKED] week on [MASKED] to remove the diseased part of your colon. Your abdominal pain has improved and you have tolerated a regular diet. You will continue to take the antibiotics Ciprofloxacin and Flagyl (metrodiazole) until the time of surgery. It is very important that you do not drink alcohol while taking the antibiotic flagyl because this can cause nausea and vomiting. Please take the bowel prep next week prior to your surgery as you were instructed by our office. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. Followup Instructions: [MASKED]	[]	[ "I10" ]	[ "K5720: Diverticulitis of large intestine with perforation and abscess without bleeding", "I10: Essential (primary) hypertension", "M069: Rheumatoid arthritis, unspecified" ]
10,090,768	28,756,926	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Compazine Attending: ___. Chief Complaint: Diverticulitis Major Surgical or Invasive Procedure: Laparoscopic partial left colectomy with takedown splenic flexure and stapled #31 coloproctostomy. History of Present Illness: Mrs. ___ has chronic diverticulitis referred to Dr. ___. Readmitted for Diverticulitis the week prior to surgery and improved with antibiotics. Presented for surgery as previously arranged. Past Medical History: HTN, undifferentiated spondyloarthropathy, Hx diverticulitis Social History: ___ Family History: non-conbtributory Physical Exam: General: Doing well, tolerating a regular diet, pain controlled, ambulating without issue, drain removed without issues. VSS Neuro: A&OX3 Cardio/Pulm: heart rate stable, no respiratory distress, no chest pain Abdomen: flat, soft, minimally tender, lap sites intact, left lower quadrant drain removed and steristrips in place. ___: no lower extremity edema Pertinent Results: ___ 10:50AM BLOOD WBC-9.5 RBC-3.84* Hgb-11.2 Hct-33.7* MCV-88 MCH-29.2 MCHC-33.2 RDW-12.7 RDWSD-40.6 Plt ___ ___ 07:35AM BLOOD Hct-34.2 ___ 11:22AM BLOOD Hct-30.4* ___ 07:21AM BLOOD WBC-9.7 RBC-3.42* Hgb-10.0* Hct-29.9* MCV-87 MCH-29.2 MCHC-33.4 RDW-12.6 RDWSD-40.1 Plt ___ ___ 10:45AM BLOOD Hct-34.2 ___ 10:50AM BLOOD Glucose-122* UreaN-8 Creat-0.8 Na-137 K-4.0 Cl-106 HCO3-24 AnGap-11 ___ 07:21AM BLOOD Glucose-88 UreaN-10 Creat-0.9 Na-136 K-4.2 Cl-105 HCO3-22 AnGap-13 ___ 10:45AM BLOOD Na-137 K-3.5 Cl-105 ___ 10:50AM BLOOD Calcium-9.3 Phos-2.7 Mg-2.1 ___ 07:21AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.2 ___ 10:45AM BLOOD Mg-2.1 Brief Hospital Course: Mrs. ___ was admitted to the inpatient colorectal surgery service after laparoscopic sigmoid colectomy. She did well post-operatively. On post-operative day one she was advanced to clear liquids and when she passed flatus into post-operative day two she was advanced to a regular diet which was tolerated without issue. She tolerated pain medications by mouth and intravenous fluids were stopped. She was ambulating without issue. The JP drain was removed without issue and closed with steri-strips. She was ___ well, tolerating a regular diet, and passing gas. Medications on Admission: acetaminophen 650mg po q6 prn, folic acid 1mg PO qd, lisinopril 30mg PO qd, multivitamins 1tab PO qd Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain do not take more than 3000mg of Tylenol in 2 hours or drink alcohol while taking RX acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #50 Tablet Refills:0 2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain do not drink alcohol or drive a car while taking this medication RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #50 Tablet Refills:0 3. Lisinopril 30 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Acute on chronic sigmoid 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 after a Laparoscopic Partial Left Colectomy for surgical management of your Diverticulitis. You have recovered from this procedure well and you are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. You will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact you regarding these results they will contact you before this time. You have tolerated a regular diet, are passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next ___ days. After anesthesia it is not uncommon for patients to have some decrease in bowel function but you should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected. However, if you notice that you are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms do not improve call the office. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. You have ___ laparoscopic surgical incisions on your abdomen which are closed with internal sutures and a skin glue called Dermabond. These are healing well however it is important that you monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/malodorous drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. Please call the office if you develop any of these symptoms or a fever. You may go to the emergency room if your symptoms are severe. You may shower; pat the incisions dry with a towel, do not rub. The small incisions may be left open to the air. If closed with steri-strips (little white adhesive strips) instead of Dermabond, these will fall off over time, please do not remove them. Please no baths or swimming for 6 weeks after surgery unless told otherwise by your surgical team. You will be prescribed narcotic pain medication Oxycodone. This medication should be taken when you have pain and as needed as written on the bottle. This is not a standing medication. You should continue to take Tylenol for pain around the clock and you can also take Advil. Please do not take more than 3000mg of Tylenol in 24 hours. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. No heavy lifting greater than 6 lbs for until your first post-operative visit after surgery. Please no strenuous activity until this time unless instructed otherwise by Dr. ___ Dr. ___. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: ___	[ "K5720", "I10", "M069" ]	Allergies: Compazine Chief Complaint: Diverticulitis Major Surgical or Invasive Procedure: Laparoscopic partial left colectomy with takedown splenic flexure and stapled #31 coloproctostomy. History of Present Illness: Mrs. [MASKED] has chronic diverticulitis referred to Dr. [MASKED]. Readmitted for Diverticulitis the week prior to surgery and improved with antibiotics. Presented for surgery as previously arranged. Past Medical History: HTN, undifferentiated spondyloarthropathy, Hx diverticulitis Social History: [MASKED] Family History: non-conbtributory Physical Exam: General: Doing well, tolerating a regular diet, pain controlled, ambulating without issue, drain removed without issues. VSS Neuro: A&OX3 Cardio/Pulm: heart rate stable, no respiratory distress, no chest pain Abdomen: flat, soft, minimally tender, lap sites intact, left lower quadrant drain removed and steristrips in place. [MASKED]: no lower extremity edema Pertinent Results: [MASKED] 10:50AM BLOOD WBC-9.5 RBC-3.84* Hgb-11.2 Hct-33.7* MCV-88 MCH-29.2 MCHC-33.2 RDW-12.7 RDWSD-40.6 Plt [MASKED] [MASKED] 07:35AM BLOOD Hct-34.2 [MASKED] 11:22AM BLOOD Hct-30.4* [MASKED] 07:21AM BLOOD WBC-9.7 RBC-3.42* Hgb-10.0* Hct-29.9* MCV-87 MCH-29.2 MCHC-33.4 RDW-12.6 RDWSD-40.1 Plt [MASKED] [MASKED] 10:45AM BLOOD Hct-34.2 [MASKED] 10:50AM BLOOD Glucose-122* UreaN-8 Creat-0.8 Na-137 K-4.0 Cl-106 HCO3-24 AnGap-11 [MASKED] 07:21AM BLOOD Glucose-88 UreaN-10 Creat-0.9 Na-136 K-4.2 Cl-105 HCO3-22 AnGap-13 [MASKED] 10:45AM BLOOD Na-137 K-3.5 Cl-105 [MASKED] 10:50AM BLOOD Calcium-9.3 Phos-2.7 Mg-2.1 [MASKED] 07:21AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.2 [MASKED] 10:45AM BLOOD Mg-2.1 Brief Hospital Course: Mrs. [MASKED] was admitted to the inpatient colorectal surgery service after laparoscopic sigmoid colectomy. She did well post-operatively. On post-operative day one she was advanced to clear liquids and when she passed flatus into post-operative day two she was advanced to a regular diet which was tolerated without issue. She tolerated pain medications by mouth and intravenous fluids were stopped. She was ambulating without issue. The JP drain was removed without issue and closed with steri-strips. She was [MASKED] well, tolerating a regular diet, and passing gas. Medications on Admission: acetaminophen 650mg po q6 prn, folic acid 1mg PO qd, lisinopril 30mg PO qd, multivitamins 1tab PO qd Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain do not take more than 3000mg of Tylenol in 2 hours or drink alcohol while taking RX acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #50 Tablet Refills:0 2. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain do not drink alcohol or drive a car while taking this medication RX oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #50 Tablet Refills:0 3. Lisinopril 30 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Acute on chronic sigmoid 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 after a Laparoscopic Partial Left Colectomy for surgical management of your Diverticulitis. You have recovered from this procedure well and you are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. You will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact you regarding these results they will contact you before this time. You have tolerated a regular diet, are passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next [MASKED] days. After anesthesia it is not uncommon for patients to have some decrease in bowel function but you should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected. However, if you notice that you are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms do not improve call the office. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. You have [MASKED] laparoscopic surgical incisions on your abdomen which are closed with internal sutures and a skin glue called Dermabond. These are healing well however it is important that you monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/malodorous drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. Please call the office if you develop any of these symptoms or a fever. You may go to the emergency room if your symptoms are severe. You may shower; pat the incisions dry with a towel, do not rub. The small incisions may be left open to the air. If closed with steri-strips (little white adhesive strips) instead of Dermabond, these will fall off over time, please do not remove them. Please no baths or swimming for 6 weeks after surgery unless told otherwise by your surgical team. You will be prescribed narcotic pain medication Oxycodone. This medication should be taken when you have pain and as needed as written on the bottle. This is not a standing medication. You should continue to take Tylenol for pain around the clock and you can also take Advil. Please do not take more than 3000mg of Tylenol in 24 hours. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. No heavy lifting greater than 6 lbs for until your first post-operative visit after surgery. Please no strenuous activity until this time unless instructed otherwise by Dr. [MASKED] Dr. [MASKED]. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: [MASKED]	[]	[ "I10" ]	[ "K5720: Diverticulitis of large intestine with perforation and abscess without bleeding", "I10: Essential (primary) hypertension", "M069: Rheumatoid arthritis, unspecified" ]
10,090,787	20,628,099	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain/palpitations Major Surgical or Invasive Procedure: None History of Present Illness: ___ with h/o CAD s/p CABG in ___, Cath with stent placement ___ presenting from ___ with anterior chest pressure similar to prior MI. He reports that the pain was constant after lifting a heavy toilet yesterday. On arrival to the ___ the patient was noted to be in SVT. The patient has prior episodes of SVT that have occurred during various presentations to the hospital. Most notably in ___ when the patient received his last ___. There was also report of ST elevation changes in II, aVL. The patient was given aspirin, Plavix, heparin and morphine and sent for evaluation at ___ for emergent cardiac evaluation. On arrival patient denies any chest pain, sob. States it resolved after receiving the medication at ___. The patient's EKG was reviewed by the cardiology fellow and determined to be ECG w/ non-specific changes. No evidence of STEMI. In the ED initial vitals 0 97.7 60 129/42 22 100% RA. The patient had normal troponin and was back into sinus rhythm. He was well appearing and breathing comfortably on RA. The patient's heparin gtt was held and he was admitted to the ___ service. On the floor the patient's vitals were 99.1 151/58 73 18 96 on RA. The patient was NAD with no active complaints. On further review of his history the patient reports that since ___ his exercise capacity has increased. He is able to walk ___ miles with his dog without significant symptoms. He also reports that he is able to walk up the stairs without stopping and without symptoms. REVIEW OF SYSTEMS: Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope, or presyncope. On further review of systems, denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, 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: - palpitations w/ chest pain episodes for last ___ years. States these have gotten better since his CABG in ___ lasting only up to 1 hr as opposed to up to 2 hrs prior to surgery. - s/p ___ LIMA to left anterior descending, SVG to obtuse marginal. Post op course complicated by SVT's requiring cardioversionx2. Cardiac Cath ___ with angiplasty and stenting of LMCA with 3.05 Cypher DES. - Prostate ca- Diagnosed ___, s/p Prostatectomy - HTN - Hyperlipidemia - GERD - S/P appendectomy - MVA ___- pt states this resulted in temporary back pain. -GIB- ? source stomach after CABG in ___ Social History: ___ Family History: Brother died at ___ of MI. Mother and father had coronary artery disease at ages ___ and ___, respectively, passed away. Physical Exam: Admission Physical ================== VS: 99.1 151/58 73 18 96 on RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. Lying flat in bed HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 9 cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. regular rhythm with premature beats, 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. Decreased breath sounds in the right lower lobe 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 ================== VS: 98.2 115-153 64-69 18 96-99\|RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. Lying flat in bed HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. regular rhythm with premature beats, normal S1, S2. No murmurs/rubs/gallops. LUNGS: 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 Pertinent Results: Admission Labs ============== ___ 11:58AM BLOOD WBC-8.9 RBC-4.58* Hgb-13.6* Hct-41.4 MCV-90 MCH-29.7 MCHC-32.9 RDW-12.8 RDWSD-42.2 Plt Ct-75* ___ 11:58AM BLOOD Neuts-86.3* Lymphs-8.1* Monos-4.5* Eos-0.0* Baso-0.4 Im ___ AbsNeut-7.68* AbsLymp-0.72* AbsMono-0.40 AbsEos-0.00* AbsBaso-0.04 ___ 11:58AM BLOOD Plt Smr-VERY LOW Plt Ct-75* ___ 11:58AM BLOOD Glucose-106* UreaN-20 Creat-1.2 Na-134 K-3.8 Cl-95* HCO3-24 AnGap-19 ___ 11:58AM BLOOD cTropnT-<0.01 ___ 04:55PM BLOOD Calcium-9.2 Phos-2.8 Mg-1.8 ___ 04:55PM BLOOD TSH-0.40 Pertinent Interval Labs ======================= ___ 04:55PM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 07:11AM BLOOD CK-MB-<1 cTropnT-<0.01 Discharge Labs ============== ___ 05:35AM BLOOD WBC-7.4 RBC-4.48* Hgb-13.2* Hct-40.1 MCV-90 MCH-29.5 MCHC-32.9 RDW-13.2 RDWSD-43.8 Plt Ct-77* ___ 05:35AM BLOOD Plt Ct-77* ___ 05:35AM BLOOD Glucose-98 UreaN-24* Creat-1.1 Na-134 K-3.9 Cl-97 HCO3-26 AnGap-15 ___ 05:35AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.0 Imaging & Studies ================= CXR ___ FINDINGS: Sternotomy. Mildly tortuous thoracic aorta. Aortic calcification. Normal heart size, pulmonary vascularity Suggestion of tiny pleural effusion or thickening posterior costophrenic angle. IMPRESSION: Tiny pleural effusion or thickening TTE ___ The left atrium is mildly dilated. Mild symmetric left ventricular hypertrophy with normal cavity size, and regional/global systolic function (3D LVEF = 58%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. 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 mild pulmonary artery systolic hypertension. IMPRESSION: Symmetric LVH with normal global and regional biventricular systolic function. Dilated ascending aorta. Mild pulmonary hypertension. Stress ___ INTERPRETATION: ___ yo man with HL and HTN; s/p CABG in ___ with PCI to LM in ___ was referred to evaluate an atypical chest discomfort in the presence of SVT. The patient completed 13.25 minutes of a Gervino protocol representing an average exercise tolerance; ~ ___ METS. The exercise test was stopped due to fatigue. No chest, back, neck or arm discomforts were reported. No significant ST segment changes were noted. The rhythm was sinus with frequent isolated APBs noted early in exercise. With increasing levels of exercise only rare isolated APBs were noted. The blood pressure response to exercise was appropriate. In the presence of beta blocker therapy, the peak exercise heart rate was blunted. IMPRESSION: Average exercise tolerance for age. No anginal symptoms or ischemic ST segment changes. No exercise-induced arrhthmia. Appropriate blood pressure response to exercise. Blunted heart rate response. Nuclear report sent separately. Cardiac Perfusion ___ Exercise protocol: Gervino Exercise duration: 13.25 minutes Reason exercise terminated: Fatigue. Resting heart rate: 71 bpm Resting blood pressure: 84/50 Peak heart rate: 89 bpm Peak blood pressure: 150/60 Percent maximum predicted HR: 63% Symptoms during exercise: Fatigue otherwise no symptoms. ECG findings: No ST segment changes or exercise-induced arrhythmia. Resting perfusion images were obtained with Tc-99m sestamibi. Tracer was injected approximately 45 minutes prior to obtaining the resting images. At peak exercise, approximately three times the resting dose of Tc-99m sestamibi was administered IV. Stress images were obtained approximately 45 minutes following tracer injection. Imaging Protocol: Gated SPECT FINDINGS: Left ventricular cavity size is normal with end-diastolic volume of 85 mL. Resting and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 55%. IMPRESSION: 1. Normal cardiac perfusion for local stress achieved. 2. Normal left ventricular cavity size an ejection fraction Microbiology ============ None Brief Hospital Course: Mr. ___ is a ___ male with PMH significant for CAD s/p CABG in ___, PCI with placement ___ 1 to ___ in ___ and symptomatic supraventricular tachycardia who presents with palpitations and anterior chest pressure similar in nature to prior MI. # CAD s/p CABG (___) ___ 1 to ___: Patient noted pain after lifting a heavy object and was noted to be in SVT upon arrival to ED, concerning given prior h/o SVT when patient received cardiac cath. Patient was transferred from ___ to ___ on aspirin, plavix, heparin ggt, and morphine. At ___, EKG demonstrated non-specific changes with negative troponins x 2. Heparin ggt was stopped in setting of resolution of chest pain and normal findings. Patient had last had coronary angiogram in ___ during PCI that demonstrated LAD small and patent, patent LIMA, and SVG-OM widely patent. He received a ___ 1 to ___ with no residual stenosis. Exercise stress test and P-MIBI were performed that were normal. Chest pain felt to more likely related to SVT as opposed to CAD. Patient was continued on ASA 81, atorvastatin 80mg. Metoprolol and diltiazem were increased for improved nodal blockade in the setting of SVT with angina. His clopidogrel was discontinued in the setting of thrombocytopenia. # SVT with angina: Patient had SVT consistent with prior episodes extending back ___ years or so. Episode was initiated by lifting a heavy object and lasted until he arrived at the hospital. Patient spontaneously returned to ___ and chest pain improved. Patient had several similar episodes of SVT captured on telemetry that lasted ___ - ___. Episode was initiated by PAC. At this point differential diagnosis is AVNRT, AVRT, sinus tachycardia. Given onset with PAC and initiation during sleep and during lifting, AVNRT seems likely. Retrograde P wave not visualized although may be embedded in T wave. Patient's nodal blockage was increased to metoprolol succinate 150mg daily and diltiazem ER 240mg daily. He was discharged with ___ of Hearts for follow up with Dr. ___ in 2 weeks. If patient does not have adequate improvement, may require electrophysiology follow up and possible ablation. # Thrombocytopenia. Patient with thrombocytopenia during this admission with PC from ___ to ___ verified by smear. No evidence of bleeding or other complications with last platelet count 221 in ___. Plavix was discontinued. Other cell lines constant so infiltrative process less likely. ITP possible. If no improvement after discontinuing Plavix, patient will need HCV, HIV, H. Pylori testing and referral to Hem/Onc. # HTN: Patient continued on metop/dilt with doses increased per above # HLD: Patient continued on atorvastatin 80mg daily TRANSITIONAL ISSUES: - Patient discharged with ___ Monitor, with results monitored by outpatient cardiologist Dr. ___. - Medication changes: metoprolol increased to 150mg ; diltiazem increased to 240mg. STOPPED Plavix due to thrombocytopenia and no current indication. - Noted to have thrombocytopenia on admission, stable on discharged at 77K. Please continue to monitor as outpatient and work up as indicated clinically. # CODE: Full # CONTACT: ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 100 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Aspirin 81 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Diltiazem Extended-Release 180 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY Discharge Medications: 1. Diltiazem Extended-Release 240 mg PO DAILY RX diltiazem HCl [Cardizem CD] 240 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 2. Metoprolol Succinate XL 150 mg PO DAILY RX metoprolol succinate 50 mg 3 tablet(s) by mouth daily Disp #90 Tablet Refills:0 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. FoLIC Acid 1 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - Intermittent supraventricular Tachycardia - Angina Secondary issues: - thrombocytopenia - HTN - HLD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a privilege to care for you at the ___ ___. You were admitted for evaluation of your chest pain. You underwent two studies, an exercise stress test and a pMIBI scan, both of which were NOT concerning for significant underlying blocked vessels. You were noted to have an intermittent fast heart rate that can cause the symptoms you experienced. In order to treat this, we increased your medications metoprolol and diltiazem. You will need to follow up with Dr. ___ further management of your heart. You were also noted to have a low platelet count and so we stopped your Plavix. Please follow up with your PCP and cardiologist for ongoing management of this issue. Please continue to take all medications as prescribed in this discharge summary and follow up with all scheduled appointments. If you develop any of the danger signs listed below, please contact your doctors ___ return the hospital immediately. We wish you the best. Sincerely, Your ___ Care Team Followup Instructions: ___	[ "I471", "I25110", "D696", "N183", "I129", "E780", "K219", "I252", "Z951", "Z87891", "Z9861", "Z8249" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest pain/palpitations Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with h/o CAD s/p CABG in [MASKED], Cath with stent placement [MASKED] presenting from [MASKED] with anterior chest pressure similar to prior MI. He reports that the pain was constant after lifting a heavy toilet yesterday. On arrival to the [MASKED] the patient was noted to be in SVT. The patient has prior episodes of SVT that have occurred during various presentations to the hospital. Most notably in [MASKED] when the patient received his last [MASKED]. There was also report of ST elevation changes in II, aVL. The patient was given aspirin, Plavix, heparin and morphine and sent for evaluation at [MASKED] for emergent cardiac evaluation. On arrival patient denies any chest pain, sob. States it resolved after receiving the medication at [MASKED]. The patient's EKG was reviewed by the cardiology fellow and determined to be ECG w/ non-specific changes. No evidence of STEMI. In the ED initial vitals 0 97.7 60 129/42 22 100% RA. The patient had normal troponin and was back into sinus rhythm. He was well appearing and breathing comfortably on RA. The patient's heparin gtt was held and he was admitted to the [MASKED] service. On the floor the patient's vitals were 99.1 151/58 73 18 96 on RA. The patient was NAD with no active complaints. On further review of his history the patient reports that since [MASKED] his exercise capacity has increased. He is able to walk [MASKED] miles with his dog without significant symptoms. He also reports that he is able to walk up the stairs without stopping and without symptoms. REVIEW OF SYSTEMS: Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope, or presyncope. On further review of systems, denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, 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: - palpitations w/ chest pain episodes for last [MASKED] years. States these have gotten better since his CABG in [MASKED] lasting only up to 1 hr as opposed to up to 2 hrs prior to surgery. - s/p [MASKED] LIMA to left anterior descending, SVG to obtuse marginal. Post op course complicated by SVT's requiring cardioversionx2. Cardiac Cath [MASKED] with angiplasty and stenting of LMCA with 3.05 Cypher DES. - Prostate ca- Diagnosed [MASKED], s/p Prostatectomy - HTN - Hyperlipidemia - GERD - S/P appendectomy - MVA [MASKED]- pt states this resulted in temporary back pain. -GIB- ? source stomach after CABG in [MASKED] Social History: [MASKED] Family History: Brother died at [MASKED] of MI. Mother and father had coronary artery disease at ages [MASKED] and [MASKED], respectively, passed away. Physical Exam: Admission Physical ================== VS: 99.1 151/58 73 18 96 on RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. Lying flat in bed HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 9 cm. CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. regular rhythm with premature beats, 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. Decreased breath sounds in the right lower lobe 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 ================== VS: 98.2 115-153 64-69 18 96-99\|RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. Lying flat in bed HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. regular rhythm with premature beats, normal S1, S2. No murmurs/rubs/gallops. LUNGS: 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 Pertinent Results: Admission Labs ============== [MASKED] 11:58AM BLOOD WBC-8.9 RBC-4.58* Hgb-13.6* Hct-41.4 MCV-90 MCH-29.7 MCHC-32.9 RDW-12.8 RDWSD-42.2 Plt Ct-75* [MASKED] 11:58AM BLOOD Neuts-86.3* Lymphs-8.1* Monos-4.5* Eos-0.0* Baso-0.4 Im [MASKED] AbsNeut-7.68* AbsLymp-0.72* AbsMono-0.40 AbsEos-0.00* AbsBaso-0.04 [MASKED] 11:58AM BLOOD Plt Smr-VERY LOW Plt Ct-75* [MASKED] 11:58AM BLOOD Glucose-106* UreaN-20 Creat-1.2 Na-134 K-3.8 Cl-95* HCO3-24 AnGap-19 [MASKED] 11:58AM BLOOD cTropnT-<0.01 [MASKED] 04:55PM BLOOD Calcium-9.2 Phos-2.8 Mg-1.8 [MASKED] 04:55PM BLOOD TSH-0.40 Pertinent Interval Labs ======================= [MASKED] 04:55PM BLOOD CK-MB-<1 cTropnT-<0.01 [MASKED] 07:11AM BLOOD CK-MB-<1 cTropnT-<0.01 Discharge Labs ============== [MASKED] 05:35AM BLOOD WBC-7.4 RBC-4.48* Hgb-13.2* Hct-40.1 MCV-90 MCH-29.5 MCHC-32.9 RDW-13.2 RDWSD-43.8 Plt Ct-77* [MASKED] 05:35AM BLOOD Plt Ct-77* [MASKED] 05:35AM BLOOD Glucose-98 UreaN-24* Creat-1.1 Na-134 K-3.9 Cl-97 HCO3-26 AnGap-15 [MASKED] 05:35AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.0 Imaging & Studies ================= CXR [MASKED] FINDINGS: Sternotomy. Mildly tortuous thoracic aorta. Aortic calcification. Normal heart size, pulmonary vascularity Suggestion of tiny pleural effusion or thickening posterior costophrenic angle. IMPRESSION: Tiny pleural effusion or thickening TTE [MASKED] The left atrium is mildly dilated. Mild symmetric left ventricular hypertrophy with normal cavity size, and regional/global systolic function (3D LVEF = 58%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. 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 mild pulmonary artery systolic hypertension. IMPRESSION: Symmetric LVH with normal global and regional biventricular systolic function. Dilated ascending aorta. Mild pulmonary hypertension. Stress [MASKED] INTERPRETATION: [MASKED] yo man with HL and HTN; s/p CABG in [MASKED] with PCI to LM in [MASKED] was referred to evaluate an atypical chest discomfort in the presence of SVT. The patient completed 13.25 minutes of a Gervino protocol representing an average exercise tolerance; ~ [MASKED] METS. The exercise test was stopped due to fatigue. No chest, back, neck or arm discomforts were reported. No significant ST segment changes were noted. The rhythm was sinus with frequent isolated APBs noted early in exercise. With increasing levels of exercise only rare isolated APBs were noted. The blood pressure response to exercise was appropriate. In the presence of beta blocker therapy, the peak exercise heart rate was blunted. IMPRESSION: Average exercise tolerance for age. No anginal symptoms or ischemic ST segment changes. No exercise-induced arrhthmia. Appropriate blood pressure response to exercise. Blunted heart rate response. Nuclear report sent separately. Cardiac Perfusion [MASKED] Exercise protocol: Gervino Exercise duration: 13.25 minutes Reason exercise terminated: Fatigue. Resting heart rate: 71 bpm Resting blood pressure: 84/50 Peak heart rate: 89 bpm Peak blood pressure: 150/60 Percent maximum predicted HR: 63% Symptoms during exercise: Fatigue otherwise no symptoms. ECG findings: No ST segment changes or exercise-induced arrhythmia. Resting perfusion images were obtained with Tc-99m sestamibi. Tracer was injected approximately 45 minutes prior to obtaining the resting images. At peak exercise, approximately three times the resting dose of Tc-99m sestamibi was administered IV. Stress images were obtained approximately 45 minutes following tracer injection. Imaging Protocol: Gated SPECT FINDINGS: Left ventricular cavity size is normal with end-diastolic volume of 85 mL. Resting and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 55%. IMPRESSION: 1. Normal cardiac perfusion for local stress achieved. 2. Normal left ventricular cavity size an ejection fraction Microbiology ============ None Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with PMH significant for CAD s/p CABG in [MASKED], PCI with placement [MASKED] 1 to [MASKED] in [MASKED] and symptomatic supraventricular tachycardia who presents with palpitations and anterior chest pressure similar in nature to prior MI. # CAD s/p CABG ([MASKED]) [MASKED] 1 to [MASKED]: Patient noted pain after lifting a heavy object and was noted to be in SVT upon arrival to ED, concerning given prior h/o SVT when patient received cardiac cath. Patient was transferred from [MASKED] to [MASKED] on aspirin, plavix, heparin ggt, and morphine. At [MASKED], EKG demonstrated non-specific changes with negative troponins x 2. Heparin ggt was stopped in setting of resolution of chest pain and normal findings. Patient had last had coronary angiogram in [MASKED] during PCI that demonstrated LAD small and patent, patent LIMA, and SVG-OM widely patent. He received a [MASKED] 1 to [MASKED] with no residual stenosis. Exercise stress test and P-MIBI were performed that were normal. Chest pain felt to more likely related to SVT as opposed to CAD. Patient was continued on ASA 81, atorvastatin 80mg. Metoprolol and diltiazem were increased for improved nodal blockade in the setting of SVT with angina. His clopidogrel was discontinued in the setting of thrombocytopenia. # SVT with angina: Patient had SVT consistent with prior episodes extending back [MASKED] years or so. Episode was initiated by lifting a heavy object and lasted until he arrived at the hospital. Patient spontaneously returned to [MASKED] and chest pain improved. Patient had several similar episodes of SVT captured on telemetry that lasted [MASKED] - [MASKED]. Episode was initiated by PAC. At this point differential diagnosis is AVNRT, AVRT, sinus tachycardia. Given onset with PAC and initiation during sleep and during lifting, AVNRT seems likely. Retrograde P wave not visualized although may be embedded in T wave. Patient's nodal blockage was increased to metoprolol succinate 150mg daily and diltiazem ER 240mg daily. He was discharged with [MASKED] of Hearts for follow up with Dr. [MASKED] in 2 weeks. If patient does not have adequate improvement, may require electrophysiology follow up and possible ablation. # Thrombocytopenia. Patient with thrombocytopenia during this admission with PC from [MASKED] to [MASKED] verified by smear. No evidence of bleeding or other complications with last platelet count 221 in [MASKED]. Plavix was discontinued. Other cell lines constant so infiltrative process less likely. ITP possible. If no improvement after discontinuing Plavix, patient will need HCV, HIV, H. Pylori testing and referral to Hem/Onc. # HTN: Patient continued on metop/dilt with doses increased per above # HLD: Patient continued on atorvastatin 80mg daily TRANSITIONAL ISSUES: - Patient discharged with [MASKED] Monitor, with results monitored by outpatient cardiologist Dr. [MASKED]. - Medication changes: metoprolol increased to 150mg ; diltiazem increased to 240mg. STOPPED Plavix due to thrombocytopenia and no current indication. - Noted to have thrombocytopenia on admission, stable on discharged at 77K. Please continue to monitor as outpatient and work up as indicated clinically. # CODE: Full # CONTACT: [MASKED] [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 100 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Aspirin 81 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Diltiazem Extended-Release 180 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY Discharge Medications: 1. Diltiazem Extended-Release 240 mg PO DAILY RX diltiazem HCl [Cardizem CD] 240 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 2. Metoprolol Succinate XL 150 mg PO DAILY RX metoprolol succinate 50 mg 3 tablet(s) by mouth daily Disp #90 Tablet Refills:0 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. FoLIC Acid 1 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - Intermittent supraventricular Tachycardia - Angina Secondary issues: - thrombocytopenia - HTN - HLD 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 privilege to care for you at the [MASKED] [MASKED]. You were admitted for evaluation of your chest pain. You underwent two studies, an exercise stress test and a pMIBI scan, both of which were NOT concerning for significant underlying blocked vessels. You were noted to have an intermittent fast heart rate that can cause the symptoms you experienced. In order to treat this, we increased your medications metoprolol and diltiazem. You will need to follow up with Dr. [MASKED] further management of your heart. You were also noted to have a low platelet count and so we stopped your Plavix. Please follow up with your PCP and cardiologist for ongoing management of this issue. Please continue to take all medications as prescribed in this discharge summary and follow up with all scheduled appointments. If you develop any of the danger signs listed below, please contact your doctors [MASKED] return the hospital immediately. We wish you the best. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "D696", "I129", "K219", "I252", "Z951", "Z87891" ]	[ "I471: Supraventricular tachycardia", "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "D696: Thrombocytopenia, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E780: Pure hypercholesterolemia", "K219: Gastro-esophageal reflux disease without esophagitis", "I252: Old myocardial infarction", "Z951: Presence of aortocoronary bypass graft", "Z87891: Personal history of nicotine dependence", "Z9861: Coronary angioplasty status", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]
10,090,787	27,982,098	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Tachycardia and chest pain Major Surgical or Invasive Procedure: AVNRT ablation ___ History of Present Illness: ___ with history of CABG in ___, who presents with a complaint of palpitations and chest pain. Patient endorsed chest pain for one day duration, waxing and waning. Earlier today, patient had more sustained chest pain and went to see his PCP. An ECG was performed and revealed tachycardia. PCP referred the patient to the ED. Upon arrival to the ED, patient endorsed nonradiating chest pain. He triggered for tachycardia >130; ECG revealed SVT. Vagal maneuvers were unsuccessful. He was given 6mg adenosine followed by 12mg adenosine and converted to sinus rhythm. His chest pain dissipated after conversion of his rhythm. In the ED initial vitals were: Temp 96, HR 145, BP 120/77, RR 18, 100% Ra EKG: Initial ECG with narrow complex regular tachycardia consistent with SVT. Repeat ECG after conversion with adenosine NSR with borderline 1st degree block, TWI in V1 and V2, no ST segment changes. Labs/studies notable for: 144 104 20 --------------< 118 4.5 23 1.4 11.8 > 14.2/44.7 < 171 ___: 11.2 PTT: 26.4 INR: 1.0 Ca: 10.1 Mg: 1.9 P: 3.3 CK: 82 MB: 2 Trop-T: <0.___lood and 30 protein Patient was given: Adenosine 6mg followed by 12mg ASA 243mg (for full 325 load) 500mL NS Vitals on transfer: HR 55 \| BP 144/69 \| RR 17 \| SpO2 97% RA On the floor he endorses story above, not having any current chest pain or shortness of breath or palpitations. REVIEW OF SYSTEMS: Positive per HPI. Cardiac review of systems is notable for absence, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope, or presyncope. On further review of systems, denies fevers or chills. Denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: - Hypertension - Dyslipidemia - CABG in ___ for LMCA stenosis with a LIMA to LAD and SVG to OM - PCI with DES to LCMA in ___ -Prostate cancer -GERD Social History: ___ Family History: Brother died at ___ of MI. Mother and father had coronary artery disease at ages ___ and ___, respectively, passed away. Physical Exam: Admission PE: VS: 99.1 151/58 73 18 96 on RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. Lying flat in bed HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP not elevated CARDIAC: PMI located in ___ intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. no thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. ============================================== Discharge PE: VS: Temp 98, BP 115-163/69-75, HR 61, RR 16, O2 sat 95% on room air Tele: rate 59-66, SR, prolonged PR Discharge weight: 186.29 lbs/ 84.5 kg ================ GENERAL: NAD. Oriented x3. Mood, affect appropriate. NECK: Supple. JVP not elevated CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Access sites: B/L groin sites C/D/I. No ooze or hematoma. B/L ___ palpable. Pertinent Results: Admission Labs: ___ 03:00PM BLOOD WBC-11.8* RBC-4.91 Hgb-14.2 Hct-44.7 MCV-91 MCH-28.9 MCHC-31.8* RDW-14.6 RDWSD-48.8* Plt ___ ___ 03:00PM BLOOD Neuts-57.1 ___ Monos-7.3 Eos-2.4 Baso-0.5 Im ___ AbsNeut-6.74* AbsLymp-3.82* AbsMono-0.86* AbsEos-0.28 AbsBaso-0.06 ___ 03:00PM BLOOD ___ PTT-26.4 ___ ___ 03:00PM BLOOD Glucose-118* UreaN-20 Creat-1.4* Na-144 K-4.5 Cl-104 HCO3-23 AnGap-17 ___ 03:00PM BLOOD CK(CPK)-82 ___ 03:00PM BLOOD CK-MB-2 ___ 03:00PM BLOOD Calcium-10.1 Phos-3.3 Mg-1.9 ========================================================= Discharge Labs: ___ 08:26AM BLOOD UreaN-27* Creat-1.1 K-4.1 ___ 08:26AM BLOOD Mg-2.0 ============================== Results: CXR PA/Lat ___: IMPRESSION: Lower lung opacities likely atelectasis though difficult to exclude a developing pneumonia especially at the left lung base. ============================================================ TTE ___: CONCLUSION: The left atrial volume index is moderately increased. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. The visually estimated left ventricular ejection fraction is 60%. There is no resting left ventricular outflow tract gradient. 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 is mildly dilated with mildly dilated ascending aorta. The aortic arch diameter is normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is a centrally directed jet of moderate [2+] aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is mild [1+] mitral regurgitation. There is mild pulmonic regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. The end-diastolic PR velocity is elevated suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Moderate functional aortic regurgitation. Mild pulmonary hypertension. Dilated ascending aorta. Compared with the prior TTE (images not available for review) of ___, the severity of aortic regurgitation is now increased. = ================================================================ EP Brief Procedure Note ___: Findings ___ with frequent SVT referred for EPS. Incessant AVNRT induced. Ablation performed in slow pathway region with junctional beats noted. Conduction intact afterwards, noninducible with and without isuprel and 20 minute wait period. No complications. Brief Hospital Course: Assessment/Plan: Mr ___ is an ___ man with hx of CABG in ___, PCI s/p DES to LCMA in ___, HTN, who presented with SVT and chest pain, converted with adenosine, admitted to cardiology floor in NSR and remained bradycardic to 40-50's on the floor. # SVT with angina: Patient had SVT consistent with prior episodes. Was bradycardic 47-52 at rest on the floor. HR increases to 56-69 with ambulation. EP consulted for SVT management. EP recommended AVNRT ablation after reviewing ekg's and strips. -s/p successful AVNRT ablation - stop dilt - Start metop tartrate 25 mg bid - Home with ___ - F/U with Dr. ___ on ___ AT 11:30 AM and PCP on ___ AT 10:00 AM # CAD s/p CABG (___) ___ 1 to ___ in ___, presented initially with chest pain in the setting of SVT which resolved in the ED. trop/MB negative x3, no ischemic changes on EKG. - continue atorvastatin, ASA - start metop tartrate 25 mg bid - plavix had previously been stopped at prior admission because of thrombocytopenia # HTN: - Stop dilt - Resume ibesartan 300 mg daily # HLD: - continue atorvastatin 80mg daily # DISPO: discharge home today Medications on Admission: The Preadmission Medication list is accurate and complete. 1. irbesartan 150 mg oral DAILY 2. Metoprolol Succinate XL 100 mg PO QAM 3. Diltiazem Extended-Release 240 mg PO DAILY 4. Rosuvastatin Calcium 40 mg PO QPM 5. Pantoprazole 40 mg PO Q24H 6. Aspirin 81 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Metoprolol Succinate XL 50 mg PO QHS Discharge Medications: 1. Metoprolol Tartrate 25 mg PO BID 2. Aspirin 81 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. irbesartan 300 mg oral DAILY 5. Pantoprazole 40 mg PO Q24H 6. Rosuvastatin Calcium 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: AVNRT CAD HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because of chest pain and tachycardia. Your rhythm was converted to normal sinus rhythm with use of medication in the Emergency room. EP was consulted and you were found to have AV nodal re-entry tachycardia (AVNRT). You had an ablation to treat AVNRT. Activity restrictions and information regarding care of the procedure site on your groin are included in your discharge instructions. Please continue your current medications with the following change: - Stop metoprolol succinate. Instead, start metoprolol succinate 25 mg twice a day. This dose change will help in preventing your heart rate from going too low. - Stop diltiazem. You do not need this medication after ablation. - Continue irbesartan at 300 mg without any changes. You will be wearing a heart monitor for the next ___ will be able to monitor your heart rate and rhythm. If you have any urgent questions that are related to your recovery from your medical issues 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! Your ___ Cardiac Care Team Followup Instructions: ___	[ "I471", "I10", "E785", "K219", "Z8546", "Z923", "Z87891", "I25119", "Z951", "Z955" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Tachycardia and chest pain Major Surgical or Invasive Procedure: AVNRT ablation [MASKED] History of Present Illness: [MASKED] with history of CABG in [MASKED], who presents with a complaint of palpitations and chest pain. Patient endorsed chest pain for one day duration, waxing and waning. Earlier today, patient had more sustained chest pain and went to see his PCP. An ECG was performed and revealed tachycardia. PCP referred the patient to the ED. Upon arrival to the ED, patient endorsed nonradiating chest pain. He triggered for tachycardia >130; ECG revealed SVT. Vagal maneuvers were unsuccessful. He was given 6mg adenosine followed by 12mg adenosine and converted to sinus rhythm. His chest pain dissipated after conversion of his rhythm. In the ED initial vitals were: Temp 96, HR 145, BP 120/77, RR 18, 100% Ra EKG: Initial ECG with narrow complex regular tachycardia consistent with SVT. Repeat ECG after conversion with adenosine NSR with borderline 1st degree block, TWI in V1 and V2, no ST segment changes. Labs/studies notable for: 144 104 20 --------------< 118 4.5 23 1.4 11.8 > 14.2/44.7 < 171 [MASKED]: 11.2 PTT: 26.4 INR: 1.0 Ca: 10.1 Mg: 1.9 P: 3.3 CK: 82 MB: 2 Trop-T: <0. lood and 30 protein Patient was given: Adenosine 6mg followed by 12mg ASA 243mg (for full 325 load) 500mL NS Vitals on transfer: HR 55 \| BP 144/69 \| RR 17 \| SpO2 97% RA On the floor he endorses story above, not having any current chest pain or shortness of breath or palpitations. REVIEW OF SYSTEMS: Positive per HPI. Cardiac review of systems is notable for absence, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope, or presyncope. On further review of systems, denies fevers or chills. Denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: - Hypertension - Dyslipidemia - CABG in [MASKED] for LMCA stenosis with a LIMA to LAD and SVG to OM - PCI with DES to LCMA in [MASKED] -Prostate cancer -GERD Social History: [MASKED] Family History: Brother died at [MASKED] of MI. Mother and father had coronary artery disease at ages [MASKED] and [MASKED], respectively, passed away. Physical Exam: Admission PE: VS: 99.1 151/58 73 18 96 on RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. Lying flat in bed HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP not elevated CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. no thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. ============================================== Discharge PE: VS: Temp 98, BP 115-163/69-75, HR 61, RR 16, O2 sat 95% on room air Tele: rate 59-66, SR, prolonged PR Discharge weight: 186.29 lbs/ 84.5 kg ================ GENERAL: NAD. Oriented x3. Mood, affect appropriate. NECK: Supple. JVP not elevated CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Access sites: B/L groin sites C/D/I. No ooze or hematoma. B/L [MASKED] palpable. Pertinent Results: Admission Labs: [MASKED] 03:00PM BLOOD WBC-11.8* RBC-4.91 Hgb-14.2 Hct-44.7 MCV-91 MCH-28.9 MCHC-31.8* RDW-14.6 RDWSD-48.8* Plt [MASKED] [MASKED] 03:00PM BLOOD Neuts-57.1 [MASKED] Monos-7.3 Eos-2.4 Baso-0.5 Im [MASKED] AbsNeut-6.74* AbsLymp-3.82* AbsMono-0.86* AbsEos-0.28 AbsBaso-0.06 [MASKED] 03:00PM BLOOD [MASKED] PTT-26.4 [MASKED] [MASKED] 03:00PM BLOOD Glucose-118* UreaN-20 Creat-1.4* Na-144 K-4.5 Cl-104 HCO3-23 AnGap-17 [MASKED] 03:00PM BLOOD CK(CPK)-82 [MASKED] 03:00PM BLOOD CK-MB-2 [MASKED] 03:00PM BLOOD Calcium-10.1 Phos-3.3 Mg-1.9 ========================================================= Discharge Labs: [MASKED] 08:26AM BLOOD UreaN-27* Creat-1.1 K-4.1 [MASKED] 08:26AM BLOOD Mg-2.0 ============================== Results: CXR PA/Lat [MASKED]: IMPRESSION: Lower lung opacities likely atelectasis though difficult to exclude a developing pneumonia especially at the left lung base. ============================================================ TTE [MASKED]: CONCLUSION: The left atrial volume index is moderately increased. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. The visually estimated left ventricular ejection fraction is 60%. There is no resting left ventricular outflow tract gradient. 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 is mildly dilated with mildly dilated ascending aorta. The aortic arch diameter is normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is a centrally directed jet of moderate [2+] aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is mild [1+] mitral regurgitation. There is mild pulmonic regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. The end-diastolic PR velocity is elevated suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Moderate functional aortic regurgitation. Mild pulmonary hypertension. Dilated ascending aorta. Compared with the prior TTE (images not available for review) of [MASKED], the severity of aortic regurgitation is now increased. = ================================================================ EP Brief Procedure Note [MASKED]: Findings [MASKED] with frequent SVT referred for EPS. Incessant AVNRT induced. Ablation performed in slow pathway region with junctional beats noted. Conduction intact afterwards, noninducible with and without isuprel and 20 minute wait period. No complications. Brief Hospital Course: Assessment/Plan: Mr [MASKED] is an [MASKED] man with hx of CABG in [MASKED], PCI s/p DES to LCMA in [MASKED], HTN, who presented with SVT and chest pain, converted with adenosine, admitted to cardiology floor in NSR and remained bradycardic to 40-50's on the floor. # SVT with angina: Patient had SVT consistent with prior episodes. Was bradycardic 47-52 at rest on the floor. HR increases to 56-69 with ambulation. EP consulted for SVT management. EP recommended AVNRT ablation after reviewing ekg's and strips. -s/p successful AVNRT ablation - stop dilt - Start metop tartrate 25 mg bid - Home with [MASKED] - F/U with Dr. [MASKED] on [MASKED] AT 11:30 AM and PCP on [MASKED] AT 10:00 AM # CAD s/p CABG ([MASKED]) [MASKED] 1 to [MASKED] in [MASKED], presented initially with chest pain in the setting of SVT which resolved in the ED. trop/MB negative x3, no ischemic changes on EKG. - continue atorvastatin, ASA - start metop tartrate 25 mg bid - plavix had previously been stopped at prior admission because of thrombocytopenia # HTN: - Stop dilt - Resume ibesartan 300 mg daily # HLD: - continue atorvastatin 80mg daily # DISPO: discharge home today Medications on Admission: The Preadmission Medication list is accurate and complete. 1. irbesartan 150 mg oral DAILY 2. Metoprolol Succinate XL 100 mg PO QAM 3. Diltiazem Extended-Release 240 mg PO DAILY 4. Rosuvastatin Calcium 40 mg PO QPM 5. Pantoprazole 40 mg PO Q24H 6. Aspirin 81 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Metoprolol Succinate XL 50 mg PO QHS Discharge Medications: 1. Metoprolol Tartrate 25 mg PO BID 2. Aspirin 81 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. irbesartan 300 mg oral DAILY 5. Pantoprazole 40 mg PO Q24H 6. Rosuvastatin Calcium 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: AVNRT CAD HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because of chest pain and tachycardia. Your rhythm was converted to normal sinus rhythm with use of medication in the Emergency room. EP was consulted and you were found to have AV nodal re-entry tachycardia (AVNRT). You had an ablation to treat AVNRT. Activity restrictions and information regarding care of the procedure site on your groin are included in your discharge instructions. Please continue your current medications with the following change: - Stop metoprolol succinate. Instead, start metoprolol succinate 25 mg twice a day. This dose change will help in preventing your heart rate from going too low. - Stop diltiazem. You do not need this medication after ablation. - Continue irbesartan at 300 mg without any changes. You will be wearing a heart monitor for the next [MASKED] will be able to monitor your heart rate and rhythm. If you have any urgent questions that are related to your recovery from your medical issues 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! Your [MASKED] Cardiac Care Team Followup Instructions: [MASKED]	[]	[ "I10", "E785", "K219", "Z87891", "Z951", "Z955" ]	[ "I471: Supraventricular tachycardia", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z8546: Personal history of malignant neoplasm of prostate", "Z923: Personal history of irradiation", "Z87891: Personal history of nicotine dependence", "I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft" ]
10,091,225	21,238,636	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dyspnea on exertion; symptomatic anemia Major Surgical or Invasive Procedure: None History of Present Illness: Mrs ___ is ___ speaking ___ with DM2 (diet controlled), HL, multiple hernias s/p repair (one involving small bowel resection), likely inflammatory arthritis, and recurrent iron deficiency anemia (thought due to slow crytpogenic GI bleeding) previously on iron infusions via hematology, who presents with dyspnea on exertion and bilateral shoulder pain. She tells me that she has been having increased joint pain recently -- review of records confirms this, as she has seen Rheumatology recently for arthralgias. It is thought she may have an inflammatory arthritis. She was given an RX for Diclofenac for pain which she has used intermittently. Her joint pain has worsened in spite of medication, with development of bilateral shoulder pain, worse with range of motion. About two weeks ago, she began to experience shortness of breath with exertion. This slowly but progressively worsened. She became concerned she may be anemic, and she decided to come to the ED. In the ED, VSS. EKG reportedly nonischemic. Labs notable for anemia with Hb of 7.2, Hct of 24.4; LDH WNL. Troponin negative. DRE with guaiac negative brown stool. CXR reportedly negative. No type and screen ordered. No blood or other medications administered. Admission was requested for symptomatic anemia. ROS is negative in 10 points except as noted. Past Medical History: Iron deficiency anemia --Presented in ___ with Hgb 9.9 g/dl with microcytic hypochromic indices, and ferritin 6.6 ng/ml. Iron deficiency thought to be secondary to occult blood loss from GI tract and menorrhagia. Ferrous gluconate tablets were prescribed. negative vWD workup, positive H. pylori antibody testing. Triple antibiotic therapy prescribed. --On ___, colonoscopy performed was normal to cecum, but prep was fair. EGD reported slightly irregular salmon colored mucosa distributed in a localized pattern, suggestive of ___ esophagus, but otherwise was normal to third part of duodenum. Biopsies of GE junction reported no intestinal metaplasia; duondenal biopsy reported normal villous architecture but focal increased interepithelial lymphocytes that raise the possibility of celiac disease. Immunostain for H. pylori was negative with adequate controls. --Presented to ___ ER ___ with DOE and hemoglobin 6.4 g/dl and ferritin 3.6 ng/ml in the context of taking naproxen for 6 months for joint pain. Transfused PRBC; given IV Ferrlecit. EGD ___ reported abnormal esophagus suspicious for ___ esophagus, but otherwise normal with no sites of bleeding. Colonoscopy did not identify a bleeding source, though prep was suboptimal. Capsule endoscopy in ___ found a small ulceration in the proximal jejunum at the surgical anastomosis with adjacent staple in the jejenum. No bleeding observed. Per gastroenterology, ulcer thought to be ischemic in nature. H. pylori antibody testing was positive; she was prescribed in triple therapy in ___. Diabetes Mellitus Type 2 HL Obesity Urinary incontinence Multiple abdominal hernias s/p repair, one of them involving SB resection Uterine fibroids s/p embo Social History: ___ Family History: Significant for death of her mother at age ___ from a stroke. Her father is still alive. She has 12 full biological siblings and two children who are alive and well. There is no family history of cancer, colon polyps, or blood disorders. Physical Exam: Vitals AVSS Gen NAD, quite pleasant Abd soft, NT, ND, bs+ CV RRR, no MRG Lungs CTA ___ Ext WWP, no edema Skin no rash, anicteric GU no foley Eyes EOMI HENT MMM, OP clear Neuro nonfocal, moves all extremities, steady gait Psych normal affect Pertinent Results: Labs on admission: Heme ___ 01:25PM BLOOD WBC-6.1 RBC-2.98# Hgb-7.2# Hct-24.4# MCV-82# MCH-24.2# MCHC-29.5* RDW-15.8* RDWSD-47.4* Plt ___ ___ 07:47PM BLOOD WBC-5.5 RBC-2.89* Hgb-7.0* Hct-23.8* MCV-82 MCH-24.2* MCHC-29.4* RDW-15.9* RDWSD-48.6* Plt ___ ___ 01:25PM BLOOD Neuts-68.2 Lymphs-18.1* Monos-9.4 Eos-3.1 Baso-0.7 NRBC-0.3* Im ___ AbsNeut-4.16 AbsLymp-1.10* AbsMono-0.57 AbsEos-0.19 AbsBaso-0.04 ___ 01:25PM BLOOD ___ PTT-29.2 ___ Chem ___ 01:25PM BLOOD Glucose-157* UreaN-22* Creat-0.7 Na-141 K-4.1 Cl-105 HCO3-26 AnGap-14 ___ 01:25PM BLOOD LD(LDH)-152 ___ 01:25PM BLOOD cTropnT-<0.01 ___ 07:47PM BLOOD cTropnT-PND ___ 01:25PM BLOOD Hapto-PND Ferritn-PND Imaging on admission: CXR - Negative for acute process EKG on admission: NSR Brief Hospital Course: She was transfused with one unit of PRBC with Hgb increased to 8 and improvement in overall fatigue and achy feeling. Unfortunately, Feraheme\ - which provides 510 mg of iron is not on the inpatient formulary, and the benefit of keeping her for a single dose of ferrilicit (150) is minimal. Given that she was symptomatically improved, and otherwise stable, she was discharged to home with plan for early outpatient follow-up for ongoing iron infusion and potential GI evaluation. Because of the holiday weekend, this will have to be arranged by the patient in concert with her PCP. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 25 mg PO DAILY 2. melatonin 1 mg oral QPM 3. Ferrous Sulfate 325 mg PO BID 4. Atorvastatin 10 mg PO QPM 5. diclofenac sodium 75 mg oral BID:PRN pain 6. Omeprazole 20 mg PO DAILY 7. MetFORMIN (Glucophage) 500 mg PO BID Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. diclofenac sodium 75 mg oral BID:PRN pain 3. Ferrous Sulfate 325 mg PO BID 4. Losartan Potassium 25 mg PO DAILY 5. melatonin 1 mg oral QPM 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: - Symptomatic acute on chronic iron and blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___ - you were admitted with fatigue and joint aches and we found the your blood level was low. You were treated with a blood transfusion with improvement in your symptoms.\ Please call Dr. ___ on ___ to arrange for outpatient iron infusion therapy Please discuss with your Primary Care Doctor whether you should be seen by a Gastroenterologist for another evaluation. Followup Instructions: ___	[ "D500", "E669", "Z87891", "Z6833", "R0600", "M25512", "M25511", "E119", "E785" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Dyspnea on exertion; symptomatic anemia Major Surgical or Invasive Procedure: None History of Present Illness: Mrs [MASKED] is [MASKED] speaking [MASKED] with DM2 (diet controlled), HL, multiple hernias s/p repair (one involving small bowel resection), likely inflammatory arthritis, and recurrent iron deficiency anemia (thought due to slow crytpogenic GI bleeding) previously on iron infusions via hematology, who presents with dyspnea on exertion and bilateral shoulder pain. She tells me that she has been having increased joint pain recently -- review of records confirms this, as she has seen Rheumatology recently for arthralgias. It is thought she may have an inflammatory arthritis. She was given an RX for Diclofenac for pain which she has used intermittently. Her joint pain has worsened in spite of medication, with development of bilateral shoulder pain, worse with range of motion. About two weeks ago, she began to experience shortness of breath with exertion. This slowly but progressively worsened. She became concerned she may be anemic, and she decided to come to the ED. In the ED, VSS. EKG reportedly nonischemic. Labs notable for anemia with Hb of 7.2, Hct of 24.4; LDH WNL. Troponin negative. DRE with guaiac negative brown stool. CXR reportedly negative. No type and screen ordered. No blood or other medications administered. Admission was requested for symptomatic anemia. ROS is negative in 10 points except as noted. Past Medical History: Iron deficiency anemia --Presented in [MASKED] with Hgb 9.9 g/dl with microcytic hypochromic indices, and ferritin 6.6 ng/ml. Iron deficiency thought to be secondary to occult blood loss from GI tract and menorrhagia. Ferrous gluconate tablets were prescribed. negative vWD workup, positive H. pylori antibody testing. Triple antibiotic therapy prescribed. --On [MASKED], colonoscopy performed was normal to cecum, but prep was fair. EGD reported slightly irregular salmon colored mucosa distributed in a localized pattern, suggestive of [MASKED] esophagus, but otherwise was normal to third part of duodenum. Biopsies of GE junction reported no intestinal metaplasia; duondenal biopsy reported normal villous architecture but focal increased interepithelial lymphocytes that raise the possibility of celiac disease. Immunostain for H. pylori was negative with adequate controls. --Presented to [MASKED] ER [MASKED] with DOE and hemoglobin 6.4 g/dl and ferritin 3.6 ng/ml in the context of taking naproxen for 6 months for joint pain. Transfused PRBC; given IV Ferrlecit. EGD [MASKED] reported abnormal esophagus suspicious for [MASKED] esophagus, but otherwise normal with no sites of bleeding. Colonoscopy did not identify a bleeding source, though prep was suboptimal. Capsule endoscopy in [MASKED] found a small ulceration in the proximal jejunum at the surgical anastomosis with adjacent staple in the jejenum. No bleeding observed. Per gastroenterology, ulcer thought to be ischemic in nature. H. pylori antibody testing was positive; she was prescribed in triple therapy in [MASKED]. Diabetes Mellitus Type 2 HL Obesity Urinary incontinence Multiple abdominal hernias s/p repair, one of them involving SB resection Uterine fibroids s/p embo Social History: [MASKED] Family History: Significant for death of her mother at age [MASKED] from a stroke. Her father is still alive. She has 12 full biological siblings and two children who are alive and well. There is no family history of cancer, colon polyps, or blood disorders. Physical Exam: Vitals AVSS Gen NAD, quite pleasant Abd soft, NT, ND, bs+ CV RRR, no MRG Lungs CTA [MASKED] Ext WWP, no edema Skin no rash, anicteric GU no foley Eyes EOMI HENT MMM, OP clear Neuro nonfocal, moves all extremities, steady gait Psych normal affect Pertinent Results: Labs on admission: Heme [MASKED] 01:25PM BLOOD WBC-6.1 RBC-2.98# Hgb-7.2# Hct-24.4# MCV-82# MCH-24.2# MCHC-29.5* RDW-15.8* RDWSD-47.4* Plt [MASKED] [MASKED] 07:47PM BLOOD WBC-5.5 RBC-2.89* Hgb-7.0* Hct-23.8* MCV-82 MCH-24.2* MCHC-29.4* RDW-15.9* RDWSD-48.6* Plt [MASKED] [MASKED] 01:25PM BLOOD Neuts-68.2 Lymphs-18.1* Monos-9.4 Eos-3.1 Baso-0.7 NRBC-0.3* Im [MASKED] AbsNeut-4.16 AbsLymp-1.10* AbsMono-0.57 AbsEos-0.19 AbsBaso-0.04 [MASKED] 01:25PM BLOOD [MASKED] PTT-29.2 [MASKED] Chem [MASKED] 01:25PM BLOOD Glucose-157* UreaN-22* Creat-0.7 Na-141 K-4.1 Cl-105 HCO3-26 AnGap-14 [MASKED] 01:25PM BLOOD LD(LDH)-152 [MASKED] 01:25PM BLOOD cTropnT-<0.01 [MASKED] 07:47PM BLOOD cTropnT-PND [MASKED] 01:25PM BLOOD Hapto-PND Ferritn-PND Imaging on admission: CXR - Negative for acute process EKG on admission: NSR Brief Hospital Course: She was transfused with one unit of PRBC with Hgb increased to 8 and improvement in overall fatigue and achy feeling. Unfortunately, Feraheme\ - which provides 510 mg of iron is not on the inpatient formulary, and the benefit of keeping her for a single dose of ferrilicit (150) is minimal. Given that she was symptomatically improved, and otherwise stable, she was discharged to home with plan for early outpatient follow-up for ongoing iron infusion and potential GI evaluation. Because of the holiday weekend, this will have to be arranged by the patient in concert with her PCP. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 25 mg PO DAILY 2. melatonin 1 mg oral QPM 3. Ferrous Sulfate 325 mg PO BID 4. Atorvastatin 10 mg PO QPM 5. diclofenac sodium 75 mg oral BID:PRN pain 6. Omeprazole 20 mg PO DAILY 7. MetFORMIN (Glucophage) 500 mg PO BID Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. diclofenac sodium 75 mg oral BID:PRN pain 3. Ferrous Sulfate 325 mg PO BID 4. Losartan Potassium 25 mg PO DAILY 5. melatonin 1 mg oral QPM 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: - Symptomatic acute on chronic iron and blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [MASKED] - you were admitted with fatigue and joint aches and we found the your blood level was low. You were treated with a blood transfusion with improvement in your symptoms.\ Please call Dr. [MASKED] on [MASKED] to arrange for outpatient iron infusion therapy Please discuss with your Primary Care Doctor whether you should be seen by a Gastroenterologist for another evaluation. Followup Instructions: [MASKED]	[]	[ "E669", "Z87891", "E119", "E785" ]	[ "D500: Iron deficiency anemia secondary to blood loss (chronic)", "E669: Obesity, unspecified", "Z87891: Personal history of nicotine dependence", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "R0600: Dyspnea, unspecified", "M25512: Pain in left shoulder", "M25511: Pain in right shoulder", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified" ]
10,091,225	23,357,228	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: EGD Colonoscopy attach Pertinent Results: Discharge Physical Exam: GENERAL: Alert female, lying in bed, in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. MMM CV: Heart regular, +systolic flow 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 MSK: Neck supple, moves all extremities, no edema noted SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: Very pleasant, appropriate affect Labs: ___ 06:00AM BLOOD WBC-6.8 RBC-3.38* Hgb-9.7* Hct-31.6* MCV-94 MCH-28.7 MCHC-30.7* RDW-13.6 RDWSD-45.8 Plt ___ ___ 06:00AM BLOOD Glucose-111* UreaN-11 Creat-0.7 Na-141 K-4.2 Cl-102 HCO3-24 AnGap-15 ___ 06:20AM BLOOD ALT-18 AST-18 AlkPhos-69 TotBili-0.2 ___ 06:00AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.9 - L-Spine plain films (___): IMPRESSION: No previous images. The vertebra and intervertebral disc spaces are within normal limits except for minimal narrowing and slight anterolisthesis of L4 with respect L5. No evidence of compression fracture. EGD w/ push enteroscopy ___: completely normal esophagus, stomach, duodenum, and jejunum to the extent of the study. Colonoscopy ___: normal Brief Hospital Course: Ms. ___ is a ___ woman with history of HTN, HLD, DMII, uterine fibroids with menorrhagia s/p embolization, H. pylori ___ s/p treatment, upper GIB with jejunal ulcerations noted on last capsule endoscopy now presenting with melena. ACUTE/ACTIVE PROBLEMS: # Acute on chronic anemia: # Suspected upper gastrointestinal bleeding: Patient with multiple prior admissions for iron deficiency anemia, now presented with several days of melena and found to have hemodynamically stable acute on chronic anemia. Last colonoscopy within normal limits; last EGD with esophagitis and duodenitis; last capsule endoscopy with jejunal ulcerations. The patient had no further melanotic BMs following admission. Her EGD on ___ was normal w/ push enteroscopy. Colonoscopy on ___ was also normal. GI discussed option of capsule endoscopy inpt vs outpt with the patient and she opted for outpt. She was on IV pantoprazole BID in house, but can resume her home omeprazole on discharge. Will continue oral iron supplementation. # Acute kidney injury: Baseline creatinine 0.7, and 1.0 on admission. Likely pre-renal azotemia in setting of GIB as above. S/p 1L IVF in ED. Cr at time of discharge was 0.7. RESOLVED # Back pain: Patient reported about 3 weeks of lumbar pain that is relieved with lying down on admission. Lumbar plain films without acute process. Patient pain free since she arrived to the floor and remained so. This was likely musculoskeletal pain, now RESOLVED. - Tylenol as needed for pain CHRONIC/STABLE PROBLEMS: # HTN: - Held losartan in setting of GIB as above but can resume on discharge # HLD: - Continue statin # DMII: - Held metformin in house but can resume on discharge. Transitional Issues: ( )capsule endoscopy as outpt ( )monitoring for further GIB Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Losartan Potassium 25 mg PO DAILY 3. MetFORMIN (Glucophage) 500 mg PO BID 4. Omeprazole 20 mg PO DAILY 5. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. Ferrous Sulfate 325 mg PO DAILY 3. Losartan Potassium 25 mg PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO BID 5. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You were admitted due to concern that you were having a GI bleed since you had black stools. You had a colonoscopy and and an upper endoscopy without evidence of bleeding. You did not have any further bleeding in your stool while here. The GI team has recommended you have a capsule study which you will need to follow up with as an outpatient. Please avoid taking any NSAIDs. Thank you for letting us participate in your care. Followup Instructions: ___	[ "K921", "D509", "K635", "K219", "N179", "M545", "Z8719", "Z8619", "E1142", "I10", "E785", "E669", "Z6833", "Z87891" ]	Allergies: No Known Allergies / Adverse Drug Reactions Major Surgical or Invasive Procedure: EGD Colonoscopy attach Pertinent Results: Discharge Physical Exam: GENERAL: Alert female, lying in bed, in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. MMM CV: Heart regular, +systolic flow 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 MSK: Neck supple, moves all extremities, no edema noted SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: Very pleasant, appropriate affect Labs: [MASKED] 06:00AM BLOOD WBC-6.8 RBC-3.38* Hgb-9.7* Hct-31.6* MCV-94 MCH-28.7 MCHC-30.7* RDW-13.6 RDWSD-45.8 Plt [MASKED] [MASKED] 06:00AM BLOOD Glucose-111* UreaN-11 Creat-0.7 Na-141 K-4.2 Cl-102 HCO3-24 AnGap-15 [MASKED] 06:20AM BLOOD ALT-18 AST-18 AlkPhos-69 TotBili-0.2 [MASKED] 06:00AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.9 - L-Spine plain films ([MASKED]): IMPRESSION: No previous images. The vertebra and intervertebral disc spaces are within normal limits except for minimal narrowing and slight anterolisthesis of L4 with respect L5. No evidence of compression fracture. EGD w/ push enteroscopy [MASKED]: completely normal esophagus, stomach, duodenum, and jejunum to the extent of the study. Colonoscopy [MASKED]: normal Brief Hospital Course: Ms. [MASKED] is a [MASKED] woman with history of HTN, HLD, DMII, uterine fibroids with menorrhagia s/p embolization, H. pylori [MASKED] s/p treatment, upper GIB with jejunal ulcerations noted on last capsule endoscopy now presenting with melena. ACUTE/ACTIVE PROBLEMS: # Acute on chronic anemia: # Suspected upper gastrointestinal bleeding: Patient with multiple prior admissions for iron deficiency anemia, now presented with several days of melena and found to have hemodynamically stable acute on chronic anemia. Last colonoscopy within normal limits; last EGD with esophagitis and duodenitis; last capsule endoscopy with jejunal ulcerations. The patient had no further melanotic BMs following admission. Her EGD on [MASKED] was normal w/ push enteroscopy. Colonoscopy on [MASKED] was also normal. GI discussed option of capsule endoscopy inpt vs outpt with the patient and she opted for outpt. She was on IV pantoprazole BID in house, but can resume her home omeprazole on discharge. Will continue oral iron supplementation. # Acute kidney injury: Baseline creatinine 0.7, and 1.0 on admission. Likely pre-renal azotemia in setting of GIB as above. S/p 1L IVF in ED. Cr at time of discharge was 0.7. RESOLVED # Back pain: Patient reported about 3 weeks of lumbar pain that is relieved with lying down on admission. Lumbar plain films without acute process. Patient pain free since she arrived to the floor and remained so. This was likely musculoskeletal pain, now RESOLVED. - Tylenol as needed for pain CHRONIC/STABLE PROBLEMS: # HTN: - Held losartan in setting of GIB as above but can resume on discharge # HLD: - Continue statin # DMII: - Held metformin in house but can resume on discharge. Transitional Issues: ( )capsule endoscopy as outpt ( )monitoring for further GIB Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Losartan Potassium 25 mg PO DAILY 3. MetFORMIN (Glucophage) 500 mg PO BID 4. Omeprazole 20 mg PO DAILY 5. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. Ferrous Sulfate 325 mg PO DAILY 3. Losartan Potassium 25 mg PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO BID 5. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [MASKED], You were admitted due to concern that you were having a GI bleed since you had black stools. You had a colonoscopy and and an upper endoscopy without evidence of bleeding. You did not have any further bleeding in your stool while here. The GI team has recommended you have a capsule study which you will need to follow up with as an outpatient. Please avoid taking any NSAIDs. Thank you for letting us participate in your care. Followup Instructions: [MASKED]	[]	[ "D509", "K219", "N179", "I10", "E785", "E669", "Z87891" ]	[ "K921: Melena", "D509: Iron deficiency anemia, unspecified", "K635: Polyp of colon", "K219: Gastro-esophageal reflux disease without esophagitis", "N179: Acute kidney failure, unspecified", "M545: Low back pain", "Z8719: Personal history of other diseases of the digestive system", "Z8619: Personal history of other infectious and parasitic diseases", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E669: Obesity, unspecified", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "Z87891: Personal history of nicotine dependence" ]
10,091,535	23,107,691	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: back pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ previously healthy male s/p MVC with C6/7 disc disruption and ALL injury. Now s/p ACDF C6/7 on ___ with Dr. ___. Presents with back pain and hematoma. The patient had a recent cervical fusion on ___ by Dr. ___ for vertebral fractures sustained in MVC on ___ patient was discharged from the hospital on ___, and has had progressively worsening pain across his upper back over the past 24 hours. The pain is localized to this area and has been constant. It has been associated with moderate redness and swelling. It is not associated with fevers or lightheadedness. Movement of any kind exacerbates the pain. He has had minimal relief at home with oxycodone, Tylenol, and ibuprofen. In the ED, CT neck and torso shows 9 x 2 x 14 cm fluid collection, without rim enhancement, extending from C5-T5 in the posterior subcutaneous tissue. WBC 9.7, lactate 1.5, hematocrit 38. The ED discussed the case with the spine team, the collection seen on CT likely represents a hematoma, for which no urgent operative intervention is planned, and for which the patient does not require hospitalization. Pain control with PO medications in the ED was inadequate prompting admission. Past Medical History: No PMH prior to aforementioned MVC and previous MVC requiring facial surgery Social History: ___ Family History: No family history of DM or heart disease Physical Exam: ADMISSION PHYSICAL EXAM: ========================== VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert, appears uncomfortable EYES: Anicteric, pupils equally round ENT: 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, non-tender to palpation. Bowel sounds present. No HSM MSK: Back pain with movement SKIN: Slight erythema and induration from scapula to scapula across the upper back, which is tender to palpation, with no crepitus appreciated. No injuries to this area. NEURO: Sensation intact, motor function intact, no hyperreflexia. PSYCH: pleasant, appropriate affect DISCHARGE PHYSICAL EXAM: ========================= Vitals: 97.6PO 116/73 53 18 97 RA GENERAL: Alert, appears uncomfortable EYES: Anicteric, pupils equally round ENT: 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, non-tender to palpation. Bowel sounds present. No HSM MSK: Back pain with movement SKIN: Slight erythema and induration from scapula to scapula across the upper back, which is tender to palpation, with no crepitus appreciated. Continues to improve from prior and significantly regressed from prior skin marking/outline. NEURO: Sensation intact, motor function intact. PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS: =============== ___ 12:15AM BLOOD WBC-9.7 RBC-4.43* Hgb-13.2* Hct-38.3* MCV-87 MCH-29.8 MCHC-34.5 RDW-11.7 RDWSD-36.9 Plt ___ ___ 12:15AM BLOOD Glucose-98 UreaN-14 Creat-0.7 Na-139 K-4.1 Cl-99 HCO3-27 AnGap-13 ___ 12:15AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.0 IMAGING: ======== ___. Status post ACDF at C6-C7. While this exam is not technically optimized for evaluation of the osseous structures, there is no evidence for hardware related complications or fracture. 2. Small amount of prevertebral fluid without rim enhancement from C6-C7 through T1-T2, extending anteriorly to the right sternocleidomastoid with mild sternocleidomastoid edema, compatible with postsurgical change. 3. Partially visualized fluid without rim enhancement in the posterior paravertebral muscles extending from C5-C6 inferiorly at least to T3 and beyond the inferior margin of the field of view, also compatible with postsurgical change. 4. The spinal canal is not well assessed, particularly at the level of the hardware, but could be better assessed by MRI if clinically warranted. ___ CT Chest: 1. Low density fluid collection in the posterior interfascial layers measuring at least 9.1 x 2.1 x 13.8 cm extending from the cervical spine at C5 to T5 thoracic level. No rim enhancement. Please clinically correlate. 2. Likely postsurgical changes at the base of neck from anterior fixation at C6-7 with residual prevertebral edema. 3. Mild compression fractures from C7 through T1, overall unchanged when compared to MRI from ___. ___ CXR: No acute cardiopulmonary abnormalities aside from very small pleural effusions or pleural thickening. Compression fractures of thoracic spine are better seen on the MRI from ___. DISCHARGE LABS: ================= ___ 07:16AM BLOOD WBC-7.2 RBC-4.35* Hgb-13.0* Hct-38.0* MCV-87 MCH-29.9 MCHC-34.2 RDW-11.6 RDWSD-37.1 Plt ___ Brief Hospital Course: Mr. ___ is a ___ year-old-male with a history of a recent motor vehicle accident complicated by vertebral fractures with recent cervical fusion who presented with back pain with associated swelling and erythema. CT scan showed likely hematoma and pt was seen by spine, without indication for surgical management and pt was admitted for pain control requiring IV morphine and PO oxycodone. He remained neurologically intact with improvement of hematoma on exam and stable H/H. He was weaned to home oxycodone prior to discharge. TRANSITIONAL ISSUES: ==================== []F/U with spine clinic on ___, C collar to stay in place until until follow up []pt set up with new PCP []pt states he does not need oxycodone rx as he has not filled one recently given by spine surgery []plan for surgery with ortho on ___ for facial fracture repair Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Bacitracin Ointment 1 Appl TP BID 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 4. Docusate Sodium 100 mg PO BID 5. Senna 8.6 mg PO BID constipation Discharge Medications: 1. Bisacodyl 10 mg PO DAILY constipation RX bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #20 Tablet Refills:0 2. Lidocaine 5% Patch 1 PTCH TD QPM RX lidocaine 5 % apply one patch every monirng Disp #30 Patch Refills:0 3. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram/dose 17 g by mouth daily Refills:0 4. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 5. Bacitracin Ointment 1 Appl TP BID 6. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #20 Capsule Refills:0 7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 8. Senna 8.6 mg PO BID constipation RX sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp #20 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: hematoma SECONDARY: recent vertebral fracture s/p cervical fusion facial fracture constipation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ with back pain. You were found to have a blood collection, called a hematoma, that is causing your pain. Your hematoma improved and your pain also improved with oxycodone. You can continue to take this medication as prescribed. Please also use ice packs as needed for the pain and swelling. Please do not drive or drink while taking oxycodone. You can also use the lidocaine patch for 12 hours at a time for pain control. Please take stool softeners or laxatives as needed to prevent and treat constipation while on oxycodone. Please continue to keep your C collar in place until your follow up with spine on ___ (see the appointment below). You also have surgery for your facial fractures on ___. We have also set you up with a primary care doctor, please see the appointment below. We wish you the best, Your ___ Care Team Followup Instructions: ___	[ "G8918", "L7632", "H532", "K5903", "T40605A", "S12600D", "S22019D", "V4940XD", "Y929", "Z981", "S0232XD", "S0231XD" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: back pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [MASKED] is a [MASKED] previously healthy male s/p MVC with C6/7 disc disruption and ALL injury. Now s/p ACDF C6/7 on [MASKED] with Dr. [MASKED]. Presents with back pain and hematoma. The patient had a recent cervical fusion on [MASKED] by Dr. [MASKED] for vertebral fractures sustained in MVC on [MASKED] patient was discharged from the hospital on [MASKED], and has had progressively worsening pain across his upper back over the past 24 hours. The pain is localized to this area and has been constant. It has been associated with moderate redness and swelling. It is not associated with fevers or lightheadedness. Movement of any kind exacerbates the pain. He has had minimal relief at home with oxycodone, Tylenol, and ibuprofen. In the ED, CT neck and torso shows 9 x 2 x 14 cm fluid collection, without rim enhancement, extending from C5-T5 in the posterior subcutaneous tissue. WBC 9.7, lactate 1.5, hematocrit 38. The ED discussed the case with the spine team, the collection seen on CT likely represents a hematoma, for which no urgent operative intervention is planned, and for which the patient does not require hospitalization. Pain control with PO medications in the ED was inadequate prompting admission. Past Medical History: No PMH prior to aforementioned MVC and previous MVC requiring facial surgery Social History: [MASKED] Family History: No family history of DM or heart disease Physical Exam: ADMISSION PHYSICAL EXAM: ========================== VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert, appears uncomfortable EYES: Anicteric, pupils equally round ENT: 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, non-tender to palpation. Bowel sounds present. No HSM MSK: Back pain with movement SKIN: Slight erythema and induration from scapula to scapula across the upper back, which is tender to palpation, with no crepitus appreciated. No injuries to this area. NEURO: Sensation intact, motor function intact, no hyperreflexia. PSYCH: pleasant, appropriate affect DISCHARGE PHYSICAL EXAM: ========================= Vitals: 97.6PO 116/73 53 18 97 RA GENERAL: Alert, appears uncomfortable EYES: Anicteric, pupils equally round ENT: 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, non-tender to palpation. Bowel sounds present. No HSM MSK: Back pain with movement SKIN: Slight erythema and induration from scapula to scapula across the upper back, which is tender to palpation, with no crepitus appreciated. Continues to improve from prior and significantly regressed from prior skin marking/outline. NEURO: Sensation intact, motor function intact. PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS: =============== [MASKED] 12:15AM BLOOD WBC-9.7 RBC-4.43* Hgb-13.2* Hct-38.3* MCV-87 MCH-29.8 MCHC-34.5 RDW-11.7 RDWSD-36.9 Plt [MASKED] [MASKED] 12:15AM BLOOD Glucose-98 UreaN-14 Creat-0.7 Na-139 K-4.1 Cl-99 HCO3-27 AnGap-13 [MASKED] 12:15AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.0 IMAGING: ======== [MASKED]. Status post ACDF at C6-C7. While this exam is not technically optimized for evaluation of the osseous structures, there is no evidence for hardware related complications or fracture. 2. Small amount of prevertebral fluid without rim enhancement from C6-C7 through T1-T2, extending anteriorly to the right sternocleidomastoid with mild sternocleidomastoid edema, compatible with postsurgical change. 3. Partially visualized fluid without rim enhancement in the posterior paravertebral muscles extending from C5-C6 inferiorly at least to T3 and beyond the inferior margin of the field of view, also compatible with postsurgical change. 4. The spinal canal is not well assessed, particularly at the level of the hardware, but could be better assessed by MRI if clinically warranted. [MASKED] CT Chest: 1. Low density fluid collection in the posterior interfascial layers measuring at least 9.1 x 2.1 x 13.8 cm extending from the cervical spine at C5 to T5 thoracic level. No rim enhancement. Please clinically correlate. 2. Likely postsurgical changes at the base of neck from anterior fixation at C6-7 with residual prevertebral edema. 3. Mild compression fractures from C7 through T1, overall unchanged when compared to MRI from [MASKED]. [MASKED] CXR: No acute cardiopulmonary abnormalities aside from very small pleural effusions or pleural thickening. Compression fractures of thoracic spine are better seen on the MRI from [MASKED]. DISCHARGE LABS: ================= [MASKED] 07:16AM BLOOD WBC-7.2 RBC-4.35* Hgb-13.0* Hct-38.0* MCV-87 MCH-29.9 MCHC-34.2 RDW-11.6 RDWSD-37.1 Plt [MASKED] Brief Hospital Course: Mr. [MASKED] is a [MASKED] year-old-male with a history of a recent motor vehicle accident complicated by vertebral fractures with recent cervical fusion who presented with back pain with associated swelling and erythema. CT scan showed likely hematoma and pt was seen by spine, without indication for surgical management and pt was admitted for pain control requiring IV morphine and PO oxycodone. He remained neurologically intact with improvement of hematoma on exam and stable H/H. He was weaned to home oxycodone prior to discharge. TRANSITIONAL ISSUES: ==================== []F/U with spine clinic on [MASKED], C collar to stay in place until until follow up []pt set up with new PCP []pt states he does not need oxycodone rx as he has not filled one recently given by spine surgery []plan for surgery with ortho on [MASKED] for facial fracture repair Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Bacitracin Ointment 1 Appl TP BID 3. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate 4. Docusate Sodium 100 mg PO BID 5. Senna 8.6 mg PO BID constipation Discharge Medications: 1. Bisacodyl 10 mg PO DAILY constipation RX bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #20 Tablet Refills:0 2. Lidocaine 5% Patch 1 PTCH TD QPM RX lidocaine 5 % apply one patch every monirng Disp #30 Patch Refills:0 3. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram/dose 17 g by mouth daily Refills:0 4. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 5. Bacitracin Ointment 1 Appl TP BID 6. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #20 Capsule Refills:0 7. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate 8. Senna 8.6 mg PO BID constipation RX sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp #20 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: hematoma SECONDARY: recent vertebral fracture s/p cervical fusion facial fracture constipation 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] with back pain. You were found to have a blood collection, called a hematoma, that is causing your pain. Your hematoma improved and your pain also improved with oxycodone. You can continue to take this medication as prescribed. Please also use ice packs as needed for the pain and swelling. Please do not drive or drink while taking oxycodone. You can also use the lidocaine patch for 12 hours at a time for pain control. Please take stool softeners or laxatives as needed to prevent and treat constipation while on oxycodone. Please continue to keep your C collar in place until your follow up with spine on [MASKED] (see the appointment below). You also have surgery for your facial fractures on [MASKED]. We have also set you up with a primary care doctor, please see the appointment below. We wish you the best, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "Y929" ]	[ "G8918: Other acute postprocedural pain", "L7632: Postprocedural hematoma of skin and subcutaneous tissue following other procedure", "H532: Diplopia", "K5903: Drug induced constipation", "T40605A: Adverse effect of unspecified narcotics, initial encounter", "S12600D: Unspecified displaced fracture of seventh cervical vertebra, subsequent encounter for fracture with routine healing", "S22019D: Unspecified fracture of first thoracic vertebra, subsequent encounter for fracture with routine healing", "V4940XD: Driver injured in collision with unspecified motor vehicles in traffic accident, subsequent encounter", "Y929: Unspecified place or not applicable", "Z981: Arthrodesis status", "S0232XD: Fracture of orbital floor, left side, subsequent encounter for fracture with routine healing", "S0231XD: Fracture of orbital floor, right side, subsequent encounter for fracture with routine healing" ]
10,091,535	24,897,993	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Orbital floor fracture and right nasal bone fracture. Major Surgical or Invasive Procedure: ___ @ 15:43 Procedure Description:orif right orbital floor, closed nasal reduction Surgical Staff: ___ MD - STAFF Past Medical History: No PMH prior to aforementioned MVC and previous MVC requiring facial surgery Social History: ___ Family History: No family history of DM or heart disease Physical Exam: GEN: No acute distress, resting comfortably watching TV HEENT: NCAT, C-collar in place. Left eye conjunctival hemorrhage. bilateral extraocular motor function intact without pain with movement. Able to see TV. CV: Regular rate PULM: Easy work of breathing MSK: Warm, well perfused, moving spontaneously Brief Hospital Course: ___ year old male who was admitted for elective fixation of orbital floor and nasal bone fracture. The orbital floor was repaired transconjunctival with a preformed plate. The nose was treated with closed reduction and splinting. The patient tolerated the procedure without intra-operative complications. Please refer to the operative note for full operative detail. The patient was extubated in the OR and transferred to the PACU in stable condition. * N: The patient's pain was initially well controlled with iv narcotics and then was transitioned to PO pain meds when tolerating a diet. At time of discharge, pain was well controlled on PO medication without the need for iv breakthrough. HENT: Post-operative max/face CT demonstrated plate in good position with no herniation of orbital contents. CV: stable without issues throughout admission * P: The patient was weaned to RA postoperatively. At time of discharge was ambulating independently without supplement oxygen. * GI: The patient was initially on clears and advanced to a regular diet on POD1. * GU: The patient was voiding without difficulty throughout the admission.. * HEME: The patient was offered pneumoboots throughout admission for DVT prophylaxis. No sch was given due to increased risk of post-operative bleeding. * ID: The patient received perioperative antibiotics. The remainder of the hospital course was uncomplicated and pt was discharged in stable condition, ambulating and voiding independently, and with adequate pain control. Pt should follow-up with both their surgeon and PCP ___ ___ weeks. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days RX amoxicillin-pot clavulanate 500 mg-125 mg 1 tab by mouth twice a day Disp #14 Tablet Refills:0 3. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 4. Tobramycin 0.3% Ophth Soln 1 DROP RIGHT EYE QID RX tobramycin [Tobrex] 0.3 % 1 drop right eye four times a day Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Orbital floor fracture, nasal bone fracture. Discharge Condition: Mental Status: Clear and coherent. Discharge Instructions: MEDICATION: 1) Take your pain medication as needed, as prescribed. Use only as directed. Do not combine with alcoholic beverages. Do not drive, operate machinery, or make important decisions while taking narcotics. Please wean the dose and/or frequency as your pain improves over the next ___ weeks. 2) You may also take Tylenol (acetaminophen) for pain. Do not take more than 4000mg of Tylenol (acetaminophen) in a 24 hour period. You may find the contents of the pain medication on the bottle of your prescription. Ask your doctor before taking over the counter medications 3) It is not uncommon to have some stomach upset with use of narcotic medication. For this reason, take your medication with food. 4) In order to avoid constipation, you may need to take a stool softener and/or laxative if you are taking pain medication. Increasing your fluid intake may also be helpful. 5) Please avoid taking NSAIDs (Ibuprofen, Advil, Aleve, Motrin) for at least 2 weeks after your surgery. These medications could increase your risk of post-operative bleeding. 6) You should follow-up with your primary care provider regarding new prescriptions and refills of your home medications and to update them on your recent hospital admission. 7) Antibiotics: Please complete entire course of antibiotics as directed DIET: 1) Please continue a clear diet for 48 hours post-operatively, then you may advance to a mechanical soft diet. When eating, do not suck or use straws. 2) High protein nutritional supplements are encouraged as they promote wound healing. ACTIVITIES: 1) You may shower, but keep your nasal splint dry at all times. 2) Please keep your head elevated on ___ pillows when lying down to decrease swelling. 3) You are on sinus precautions: No smoking, no bending over to lift, sneeze with your mouth open, no nose blowing, no drinking through straws, no swimming, or diving until seen at your follow up appointment. 4) Do not drive until approved by your doctor. Do not drive if you are taking narcotics, other controlled medications, or muscle relaxants as they can make you drowsy and slow your reaction time. 5) Return to work depends on your type of employment and can be discussed at your post-op appointment. 6) It is important for you to walk around once home. Please avoid any activity that raises your heart rate or causes you to break a sweat until you have been cleared to resume your normal activities. Please avoid bending over, lifting, or strenuous activity until cleared by your surgeon. WOUND CARE/DRESSINGS: 1) Please keep iced gauze over area of operation for 48-72 hours post-operatively to help decrease swelling. Do not place ice directly on your skin. Followup Instructions: ___	[ "S0231XA", "S022XXA", "V892XXA", "Y92410", "H11421", "Z87891", "S0240CA" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Orbital floor fracture and right nasal bone fracture. Major Surgical or Invasive Procedure: [MASKED] @ 15:43 Procedure Description:orif right orbital floor, closed nasal reduction Surgical Staff: [MASKED] MD - STAFF Past Medical History: No PMH prior to aforementioned MVC and previous MVC requiring facial surgery Social History: [MASKED] Family History: No family history of DM or heart disease Physical Exam: GEN: No acute distress, resting comfortably watching TV HEENT: NCAT, C-collar in place. Left eye conjunctival hemorrhage. bilateral extraocular motor function intact without pain with movement. Able to see TV. CV: Regular rate PULM: Easy work of breathing MSK: Warm, well perfused, moving spontaneously Brief Hospital Course: [MASKED] year old male who was admitted for elective fixation of orbital floor and nasal bone fracture. The orbital floor was repaired transconjunctival with a preformed plate. The nose was treated with closed reduction and splinting. The patient tolerated the procedure without intra-operative complications. Please refer to the operative note for full operative detail. The patient was extubated in the OR and transferred to the PACU in stable condition. * N: The patient's pain was initially well controlled with iv narcotics and then was transitioned to PO pain meds when tolerating a diet. At time of discharge, pain was well controlled on PO medication without the need for iv breakthrough. HENT: Post-operative max/face CT demonstrated plate in good position with no herniation of orbital contents. CV: stable without issues throughout admission * P: The patient was weaned to RA postoperatively. At time of discharge was ambulating independently without supplement oxygen. * GI: The patient was initially on clears and advanced to a regular diet on POD1. * GU: The patient was voiding without difficulty throughout the admission.. * HEME: The patient was offered pneumoboots throughout admission for DVT prophylaxis. No sch was given due to increased risk of post-operative bleeding. * ID: The patient received perioperative antibiotics. The remainder of the hospital course was uncomplicated and pt was discharged in stable condition, ambulating and voiding independently, and with adequate pain control. Pt should follow-up with both their surgeon and PCP [MASKED] [MASKED] weeks. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H Duration: 7 Days RX amoxicillin-pot clavulanate 500 mg-125 mg 1 tab by mouth twice a day Disp #14 Tablet Refills:0 3. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 4. Tobramycin 0.3% Ophth Soln 1 DROP RIGHT EYE QID RX tobramycin [Tobrex] 0.3 % 1 drop right eye four times a day Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Orbital floor fracture, nasal bone fracture. Discharge Condition: Mental Status: Clear and coherent. Discharge Instructions: MEDICATION: 1) Take your pain medication as needed, as prescribed. Use only as directed. Do not combine with alcoholic beverages. Do not drive, operate machinery, or make important decisions while taking narcotics. Please wean the dose and/or frequency as your pain improves over the next [MASKED] weeks. 2) You may also take Tylenol (acetaminophen) for pain. Do not take more than 4000mg of Tylenol (acetaminophen) in a 24 hour period. You may find the contents of the pain medication on the bottle of your prescription. Ask your doctor before taking over the counter medications 3) It is not uncommon to have some stomach upset with use of narcotic medication. For this reason, take your medication with food. 4) In order to avoid constipation, you may need to take a stool softener and/or laxative if you are taking pain medication. Increasing your fluid intake may also be helpful. 5) Please avoid taking NSAIDs (Ibuprofen, Advil, Aleve, Motrin) for at least 2 weeks after your surgery. These medications could increase your risk of post-operative bleeding. 6) You should follow-up with your primary care provider regarding new prescriptions and refills of your home medications and to update them on your recent hospital admission. 7) Antibiotics: Please complete entire course of antibiotics as directed DIET: 1) Please continue a clear diet for 48 hours post-operatively, then you may advance to a mechanical soft diet. When eating, do not suck or use straws. 2) High protein nutritional supplements are encouraged as they promote wound healing. ACTIVITIES: 1) You may shower, but keep your nasal splint dry at all times. 2) Please keep your head elevated on [MASKED] pillows when lying down to decrease swelling. 3) You are on sinus precautions: No smoking, no bending over to lift, sneeze with your mouth open, no nose blowing, no drinking through straws, no swimming, or diving until seen at your follow up appointment. 4) Do not drive until approved by your doctor. Do not drive if you are taking narcotics, other controlled medications, or muscle relaxants as they can make you drowsy and slow your reaction time. 5) Return to work depends on your type of employment and can be discussed at your post-op appointment. 6) It is important for you to walk around once home. Please avoid any activity that raises your heart rate or causes you to break a sweat until you have been cleared to resume your normal activities. Please avoid bending over, lifting, or strenuous activity until cleared by your surgeon. WOUND CARE/DRESSINGS: 1) Please keep iced gauze over area of operation for 48-72 hours post-operatively to help decrease swelling. Do not place ice directly on your skin. Followup Instructions: [MASKED]	[]	[ "Z87891" ]	[ "S0231XA: Fracture of orbital floor, right side, initial encounter for closed fracture", "S022XXA: Fracture of nasal bones, initial encounter for closed fracture", "V892XXA: Person injured in unspecified motor-vehicle accident, traffic, initial encounter", "Y92410: Unspecified street and highway as the place of occurrence of the external cause", "H11421: Conjunctival edema, right eye", "Z87891: Personal history of nicotine dependence", "S0240CA: Maxillary fracture, right side, initial encounter for closed fracture" ]
10,091,535	26,594,423	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 - Motor vehicle collision Neck pain Major Surgical or Invasive Procedure: ___ 1. Anterior cervical discectomy with interbody fusion, C6-C7. 2. Interbody reconstruction with biomedical device, C6-C7. 3. Anterior plate instrumentation, C6, C7. 4. Autograft, same incision. 5. Open treatment, cervical fracture. History of Present Illness: ___ year-old male with history of substance abuse came to ___ ___ as a Trauma patient after a motor vehicle collision. Patient reports he was not restrained by seat belt and allegedly was rear-ended. LOC+. At scene GCS 15 per EMT, went to OSH, where he was pan-scanned, showing fractures on C-spine, T-spine and right orbital fx. C-collar on arrival at ___. Past Medical History: Substance abuse Social History: ___ Family History: No known family history to patient Physical Exam: In trauma bay: Vitals: HR 73 BP 133/76 RR 18 O2 94%RA, GCS 15 General: in distress, in c-collar HEENT: bilateral periorbital ecchymosis, blood in nares, left chin laceration, TTP nose CV: RRR Resp: CTAB GI: soft, non-distended, TTP RUQ, Back: tenderness to palpation c-spine and t-spine Skin: bilateral thigh abrasions Pertinent Results: ___ 06:32AM BLOOD WBC-12.7* RBC-4.33* Hgb-12.9* Hct-38.8* MCV-90 MCH-29.8 MCHC-33.2 RDW-12.4 RDWSD-40.5 Plt ___ ___ 04:49PM BLOOD WBC-22.6# RBC-5.00 Hgb-14.8 Hct-44.3 MCV-89 MCH-29.6 MCHC-33.4 RDW-12.3 RDWSD-39.8 Plt ___ ___ 04:49PM BLOOD ___ PTT-23.1 ___ ___ 06:32AM BLOOD Glucose-117* UreaN-8 Creat-0.8 Na-140 K-4.2 Cl-102 HCO3-25 AnGap-13 ___ 06:32AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.2 ___ 04:49PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 07:02PM BLOOD Glucose-220* Lactate-3.4* Na-134 K-4.5 Cl-101 ___ 07:02PM BLOOD Hgb-15.4 calcHCT-46 O2 Sat-88 COHgb-3 MetHgb-0 ___ 07:02PM BLOOD freeCa-1.00* Brief Hospital Course: The patient was transferred from an outside hospital after a motor vehicle collision and found to have had multiple fractures including C6-7 spine and anterior longitudinal ligament disruption with interspinous ligament injury, T7-10 spine, and multiple facial fractures including right orbital floor blow-out fracture, comminuted fractures of the nasal bones, anterior nasal septum, and right maxilla nasal process on ___. He was admitted to the Acute Care Surgery for multiple fractures and pain management. He underwent anterior cervical disectomy with interbody fusion on ___, performed by Dr. ___. 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. He was seen and followed by plastics surgery and ophthalmology while he was hospitalized. Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with IV morphine, acetaminphen and toradol, and then transitioned to oral acetaminophen and oxycodone 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: Initially patient was placed on NPO and IV fluids for surgery. On POD1 he was placed on soft diet given facial fractures, 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, 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 starting 48 hours after surgery. ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Bacitracin Ointment 1 Appl TP BID 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4) hours Disp #48 Tablet Refills:0 5. Senna 8.6 mg PO BID constipation Discharge Disposition: Home Discharge Diagnosis: 1. Right orbital floor blow-out fracture 2. Comminuted fractures of the nasal bones, anterior nasal septum, and right maxilla nasal process, mildly displaced to the left 3. Anterior longitudinal ligament disruption at C6-C7 4. Interspinous ligament injury at C6-C7 5. C6-7 disc dislocation 6. Hyperextension inferior corner fracture at the C6 vertebral body 7. Acute compression fractures of the T7 through T10 vertebral bodies 8. Concussion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ after a motor vehicle collision and underwent a cervical spine surgery with orthopedic spine service. You are recovering well and are now ready for discharge. Please follow the instructions below to continue your recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Difficulty with concentration, headache, or dizziness. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. Facial fractures/Neck fractures Please continue to wear c-collar When lying down, please be at a 30 degree angle ___ use ice compression 10 minutes every hour to reduce eye swelling ___ use over the counter motrin for eye swelling *please sneeze with your mouth open Please follow up with Plastics surgery and ortho spine surgery, appointment dates are listed below. Please make an appointment with Cognitive Neurology by calling ___. It was a pleasure taking care of you, Your ___ Team Followup Instructions: ___	[ "S12500A", "S22069A", "S0231XA", "S0182XA", "H1133", "S2231XA", "S12600A", "V4303XA", "S022XXA", "M532X2", "M6289", "M488X2" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Trauma - Motor vehicle collision Neck pain Major Surgical or Invasive Procedure: [MASKED] 1. Anterior cervical discectomy with interbody fusion, C6-C7. 2. Interbody reconstruction with biomedical device, C6-C7. 3. Anterior plate instrumentation, C6, C7. 4. Autograft, same incision. 5. Open treatment, cervical fracture. History of Present Illness: [MASKED] year-old male with history of substance abuse came to [MASKED] [MASKED] as a Trauma patient after a motor vehicle collision. Patient reports he was not restrained by seat belt and allegedly was rear-ended. LOC+. At scene GCS 15 per EMT, went to OSH, where he was pan-scanned, showing fractures on C-spine, T-spine and right orbital fx. C-collar on arrival at [MASKED]. Past Medical History: Substance abuse Social History: [MASKED] Family History: No known family history to patient Physical Exam: In trauma bay: Vitals: HR 73 BP 133/76 RR 18 O2 94%RA, GCS 15 General: in distress, in c-collar HEENT: bilateral periorbital ecchymosis, blood in nares, left chin laceration, TTP nose CV: RRR Resp: CTAB GI: soft, non-distended, TTP RUQ, Back: tenderness to palpation c-spine and t-spine Skin: bilateral thigh abrasions Pertinent Results: [MASKED] 06:32AM BLOOD WBC-12.7* RBC-4.33* Hgb-12.9* Hct-38.8* MCV-90 MCH-29.8 MCHC-33.2 RDW-12.4 RDWSD-40.5 Plt [MASKED] [MASKED] 04:49PM BLOOD WBC-22.6# RBC-5.00 Hgb-14.8 Hct-44.3 MCV-89 MCH-29.6 MCHC-33.4 RDW-12.3 RDWSD-39.8 Plt [MASKED] [MASKED] 04:49PM BLOOD [MASKED] PTT-23.1 [MASKED] [MASKED] 06:32AM BLOOD Glucose-117* UreaN-8 Creat-0.8 Na-140 K-4.2 Cl-102 HCO3-25 AnGap-13 [MASKED] 06:32AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.2 [MASKED] 04:49PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 07:02PM BLOOD Glucose-220* Lactate-3.4* Na-134 K-4.5 Cl-101 [MASKED] 07:02PM BLOOD Hgb-15.4 calcHCT-46 O2 Sat-88 COHgb-3 MetHgb-0 [MASKED] 07:02PM BLOOD freeCa-1.00* Brief Hospital Course: The patient was transferred from an outside hospital after a motor vehicle collision and found to have had multiple fractures including C6-7 spine and anterior longitudinal ligament disruption with interspinous ligament injury, T7-10 spine, and multiple facial fractures including right orbital floor blow-out fracture, comminuted fractures of the nasal bones, anterior nasal septum, and right maxilla nasal process on [MASKED]. He was admitted to the Acute Care Surgery for multiple fractures and pain management. He underwent anterior cervical disectomy with interbody fusion on [MASKED], performed by Dr. [MASKED]. 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. He was seen and followed by plastics surgery and ophthalmology while he was hospitalized. Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with IV morphine, acetaminphen and toradol, and then transitioned to oral acetaminophen and oxycodone 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: Initially patient was placed on NPO and IV fluids for surgery. On POD1 he was placed on soft diet given facial fractures, 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, 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 starting 48 hours after surgery. [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: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Bacitracin Ointment 1 Appl TP BID 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4) hours Disp #48 Tablet Refills:0 5. Senna 8.6 mg PO BID constipation Discharge Disposition: Home Discharge Diagnosis: 1. Right orbital floor blow-out fracture 2. Comminuted fractures of the nasal bones, anterior nasal septum, and right maxilla nasal process, mildly displaced to the left 3. Anterior longitudinal ligament disruption at C6-C7 4. Interspinous ligament injury at C6-C7 5. C6-7 disc dislocation 6. Hyperextension inferior corner fracture at the C6 vertebral body 7. Acute compression fractures of the T7 through T10 vertebral bodies 8. Concussion 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] after a motor vehicle collision and underwent a cervical spine surgery with orthopedic spine service. You are recovering well and are now ready for discharge. Please follow the instructions below to continue your recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Difficulty with concentration, headache, or dizziness. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips [MASKED] days after surgery. Facial fractures/Neck fractures Please continue to wear c-collar When lying down, please be at a 30 degree angle [MASKED] use ice compression 10 minutes every hour to reduce eye swelling [MASKED] use over the counter motrin for eye swelling *please sneeze with your mouth open Please follow up with Plastics surgery and ortho spine surgery, appointment dates are listed below. Please make an appointment with Cognitive Neurology by calling [MASKED]. It was a pleasure taking care of you, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[]	[ "S12500A: Unspecified displaced fracture of sixth cervical vertebra, initial encounter for closed fracture", "S22069A: Unspecified fracture of T7-T8 vertebra, initial encounter for closed fracture", "S0231XA: Fracture of orbital floor, right side, initial encounter for closed fracture", "S0182XA: Laceration with foreign body of other part of head, initial encounter", "H1133: Conjunctival hemorrhage, bilateral", "S2231XA: Fracture of one rib, right side, initial encounter for closed fracture", "S12600A: Unspecified displaced fracture of seventh cervical vertebra, initial encounter for closed fracture", "V4303XA: Car driver injured in collision with pick-up truck in nontraffic accident, initial encounter", "S022XXA: Fracture of nasal bones, initial encounter for closed fracture", "M532X2: Spinal instabilities, cervical region", "M6289: Other specified disorders of muscle", "M488X2: Other specified spondylopathies, cervical region" ]
10,091,570	20,164,530	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / meloxicam Attending: ___. Chief Complaint: Leg pain with standing and walking Major Surgical or Invasive Procedure: L2-S1 laminectomies ___, ___ History of Present Illness: ___ ___ and a very active man who enjoys ___, ___, etc., who presents today for a second opinion regarding his radiating left greater than right leg pain, provoked by standing and walking. He has been found to have spinal stenosis, and has undergone a prolonged and multimodal course of conservative care for that. A significant part of his care as directed by Dr. ___ in the past. Dr. ___ him through epidural steroid injections, physical therapy, boot camp and other treatments, without significant or lasting relief. For that reason, he presents now to be considered a candidate for surgical treatment. Of note, he did undergo previous surgical evaluation as well with Dr. ___ in ___ and was told by Dr. ___ he should consider undergoing a fusion including interbody cage procedure. He presents today for another evaluation given Dr. ___ recommendation in the past that he undergo laminectomy only. In summary, however, ___ ___ is a generally healthy ___ man who has pain descending into his legs, left greater than right, preventing extended walking and extended standing. On standing and walking, the two activities that reliably precipitate his pain, which does get better when he sits to get relief. He does also get the pain with static standing as well, which is characteristic of neurogenic claudication. He has had been found to have significant stenosis at L2-L3, essentially, and also L4-L5 in the lateral recess. L3-L4 is very mild lateral recess stenosis only. Past Medical History: His past medical history is high blood pressure, stomach ulcers. Surgical History: Tonsillectomy, carotid surgery in ___ and ___, parathyroid removal 96, carotid stents ___. Social History: Tobacco use: Former smoker;Packs/Day: ___ Years Smoked: 20,He works as a ___. He formerly smoked 2 pack a day for ___ years. He has one to two drinks a week. He is married. Physical Exam: AVSS Well appearing, NAD, comfortable All fingers WWP, brisk capillary refill, 2+ distal pulses BLE: SILT L1-S1 dermatomal distributions BLE: ___ ___ BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle All toes WWP, brisk capillary refill, 2+ distal pulses Pertinent Results: ___ 06:25AM BLOOD WBC-14.3* RBC-3.17* Hgb-10.3* Hct-30.6* MCV-97 MCH-32.5* MCHC-33.7 RDW-13.0 RDWSD-46.4* Plt ___ ___ 09:10AM BLOOD WBC-14.9* RBC-3.51* Hgb-11.2* Hct-34.4* MCV-98 MCH-31.9 MCHC-32.6 RDW-13.1 RDWSD-46.6* Plt ___ ___ 09:23PM BLOOD WBC-16.0* RBC-3.31* Hgb-10.8* Hct-32.3* MCV-98 MCH-32.6* MCHC-33.4 RDW-13.2 RDWSD-47.2* Plt ___ ___ 06:25AM BLOOD Plt ___ ___ 09:10AM BLOOD Plt ___ ___ 09:23PM BLOOD Plt ___ ___ 06:25AM BLOOD Glucose-101* UreaN-12 Creat-0.8 Na-138 K-3.9 Cl-102 HCO3-26 AnGap-14 ___ 09:10AM BLOOD Glucose-107* UreaN-13 Creat-0.9 Na-138 K-3.8 Cl-100 HCO3-30 AnGap-12 ___ 03:22AM BLOOD Glucose-106* UreaN-14 Creat-0.9 Na-137 K-3.7 Cl-100 HCO3-26 AnGap-15 ___ 06:25AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0 ___ 09:10AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1 ___ 03:22AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.0 ___ 08:37AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM ___ 08:37AM URINE RBC-50* WBC-10* Bacteri-NONE Yeast-NONE Epi-0 ___ 8:37 am URINE Source: Catheter. *FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. Brief Hospital Course: Patient was admitted to the ___ Spine Surgery Service and taken to the Operating Room for the above procedure.Refer to the dictated operative note for further details.The surgery was without complication and the patient was transferred to the PACU in a stable ___ were used for postoperative DVT prophylaxis.Intravenous antibiotics were continued for 24hrs postop per standard protocol.Initial postop pain was controlled with oral and IV pain medication.Diet was advanced as tolerated.Foley was removed on POD#2. Physical therapy and Occupational therapy were consulted for mobilization OOB to ambulate and ADL's. Mr. ___ continued to have serosanguinous drainage from his hemovac. His surgical incision remained clean and dry without any signs of infection. wbc's were stable and was afebrile. His hemovac drain was discontinued on ___. He was placed on oral antibiotics for broad skin infection coverage and a Prevena Wound VAC was placed given his HVAC drainage. He will be given a 7 day course of antibiotics and follow up in the spine clinic in 1 week. Hospital course was otherwise unremarkable.On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: Aggrenox, tramadol, hydrochlorothiazide, tamsulosin, Cialis, Nitrostat, valsartan, esomeprazole, atorvastatin, diltiazem, metoprolol tartrate, aspirin 325, loratadine and omeprazole. Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H may take over the counter 2. Diazepam 5 mg PO BID:PRN pain may cause drowsiness RX diazepam 5 mg 1 BID by mouth pain or spasm Disp #28 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID please take while taking narcotic pain medication RX docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:0 4. Gabapentin 200 mg PO TID RX gabapentin 100 mg 2 capsule(s) by mouth three times a day Disp #84 Capsule Refills:0 5. Levofloxacin 500 mg PO Q24H 7 days RX levofloxacin 500 mg 1 tablet(s) by mouth Q24 Disp #6 Tablet Refills:0 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Please do not operate heavy machinery,drink alcohol or drive RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #65 Tablet Refills:0 7. Atorvastatin 80 mg PO QPM 8. Diltiazem Extended-Release 300 mg PO DAILY 9. Metoprolol Tartrate 25 mg PO BID 10. Omeprazole 40 mg PO DAILY 11. Tamsulosin 0.4 mg PO QHS 12. Valsartan 160 mg PO DAILY 13. Valsartan 80 mg PO QPM 14.Rolling Walker Dx:Lumbar Stenosis Px:Good ___ Months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Lumbar spinal stenosis. 2. Radiculopathy. 3. Neurogenic claudication. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Lumbar Decompression Without Fusion You have undergone the following operation: Lumbar Decompression Without Fusion Immediately after the operation: Activity:You should not lift anything greater than 10 lbs for 2 weeks.You will be more comfortable if you do not sit or stand more than~45 minutes without moving around. Rehabilitation/ Physical ___ times a day you should go for a walk for ___ minutes as part of your recovery.You can walk as much as you can tolerate.Limit any kind of lifting. Diet:Eat a normal healthy diet.You may have some constipation after surgery.You have been given medication to help with this issue. Brace:You may have been given a brace.If you have been given a brace, this brace is to be worn when you are walking.You may take it off when sitting in a chair or lying in bed. Wound Care: Please keep the Prevena wound vac system in place until your follow up appointment. If, for any reason, the wound vac system stops working or the canister fills, please call the ___ and we can have another once placed. You should resume taking your normal home medications. You have also been given Additional Medications to control your pain.Please allow 72 hours for refill of narcotic prescriptions,so please plan ahead.You can either have them mailed to your home or pick them up at the clinic located on ___ 2.We are not allowed to call in or fax narcotic prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In addition,we are only allowed to write for pain medications for 90 days from the date of surgery. Follow up: Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. At the 2-week visit we will check your incision, take baseline X-rays and answer any questions.We may at that time start physical therapy. We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: 1)Weight bearing as tolerated.2)Gait,balance training.3)No lifting >10 lbs.4)No significant bending/twisting. Treatments Frequency: Wound Care: Please keep the Prevena wound vac system in place until your follow up appointment. If, for any reason, the wound vac system stops working or the canister fills, please call the ___ and we can have another once placed. Followup Instructions: ___	[ "M4806", "I10", "M4807", "M5417", "M5416", "I2510", "Z955", "Z87891", "E785" ]	Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / meloxicam Chief Complaint: Leg pain with standing and walking Major Surgical or Invasive Procedure: L2-S1 laminectomies [MASKED], [MASKED] History of Present Illness: [MASKED] [MASKED] and a very active man who enjoys [MASKED], [MASKED], etc., who presents today for a second opinion regarding his radiating left greater than right leg pain, provoked by standing and walking. He has been found to have spinal stenosis, and has undergone a prolonged and multimodal course of conservative care for that. A significant part of his care as directed by Dr. [MASKED] in the past. Dr. [MASKED] him through epidural steroid injections, physical therapy, boot camp and other treatments, without significant or lasting relief. For that reason, he presents now to be considered a candidate for surgical treatment. Of note, he did undergo previous surgical evaluation as well with Dr. [MASKED] in [MASKED] and was told by Dr. [MASKED] he should consider undergoing a fusion including interbody cage procedure. He presents today for another evaluation given Dr. [MASKED] recommendation in the past that he undergo laminectomy only. In summary, however, [MASKED] [MASKED] is a generally healthy [MASKED] man who has pain descending into his legs, left greater than right, preventing extended walking and extended standing. On standing and walking, the two activities that reliably precipitate his pain, which does get better when he sits to get relief. He does also get the pain with static standing as well, which is characteristic of neurogenic claudication. He has had been found to have significant stenosis at L2-L3, essentially, and also L4-L5 in the lateral recess. L3-L4 is very mild lateral recess stenosis only. Past Medical History: His past medical history is high blood pressure, stomach ulcers. Surgical History: Tonsillectomy, carotid surgery in [MASKED] and [MASKED], parathyroid removal 96, carotid stents [MASKED]. Social History: Tobacco use: Former smoker;Packs/Day: [MASKED] Years Smoked: 20,He works as a [MASKED]. He formerly smoked 2 pack a day for [MASKED] years. He has one to two drinks a week. He is married. Physical Exam: AVSS Well appearing, NAD, comfortable All fingers WWP, brisk capillary refill, 2+ distal pulses BLE: SILT L1-S1 dermatomal distributions BLE: [MASKED] [MASKED] BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle All toes WWP, brisk capillary refill, 2+ distal pulses Pertinent Results: [MASKED] 06:25AM BLOOD WBC-14.3* RBC-3.17* Hgb-10.3* Hct-30.6* MCV-97 MCH-32.5* MCHC-33.7 RDW-13.0 RDWSD-46.4* Plt [MASKED] [MASKED] 09:10AM BLOOD WBC-14.9* RBC-3.51* Hgb-11.2* Hct-34.4* MCV-98 MCH-31.9 MCHC-32.6 RDW-13.1 RDWSD-46.6* Plt [MASKED] [MASKED] 09:23PM BLOOD WBC-16.0* RBC-3.31* Hgb-10.8* Hct-32.3* MCV-98 MCH-32.6* MCHC-33.4 RDW-13.2 RDWSD-47.2* Plt [MASKED] [MASKED] 06:25AM BLOOD Plt [MASKED] [MASKED] 09:10AM BLOOD Plt [MASKED] [MASKED] 09:23PM BLOOD Plt [MASKED] [MASKED] 06:25AM BLOOD Glucose-101* UreaN-12 Creat-0.8 Na-138 K-3.9 Cl-102 HCO3-26 AnGap-14 [MASKED] 09:10AM BLOOD Glucose-107* UreaN-13 Creat-0.9 Na-138 K-3.8 Cl-100 HCO3-30 AnGap-12 [MASKED] 03:22AM BLOOD Glucose-106* UreaN-14 Creat-0.9 Na-137 K-3.7 Cl-100 HCO3-26 AnGap-15 [MASKED] 06:25AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0 [MASKED] 09:10AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1 [MASKED] 03:22AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.0 [MASKED] 08:37AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM [MASKED] 08:37AM URINE RBC-50* WBC-10* Bacteri-NONE Yeast-NONE Epi-0 [MASKED] 8:37 am URINE Source: Catheter. *FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. Brief Hospital Course: Patient was admitted to the [MASKED] Spine Surgery Service and taken to the Operating Room for the above procedure.Refer to the dictated operative note for further details.The surgery was without complication and the patient was transferred to the PACU in a stable [MASKED] were used for postoperative DVT prophylaxis.Intravenous antibiotics were continued for 24hrs postop per standard protocol.Initial postop pain was controlled with oral and IV pain medication.Diet was advanced as tolerated.Foley was removed on POD#2. Physical therapy and Occupational therapy were consulted for mobilization OOB to ambulate and ADL's. Mr. [MASKED] continued to have serosanguinous drainage from his hemovac. His surgical incision remained clean and dry without any signs of infection. wbc's were stable and was afebrile. His hemovac drain was discontinued on [MASKED]. He was placed on oral antibiotics for broad skin infection coverage and a Prevena Wound VAC was placed given his HVAC drainage. He will be given a 7 day course of antibiotics and follow up in the spine clinic in 1 week. Hospital course was otherwise unremarkable.On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: Aggrenox, tramadol, hydrochlorothiazide, tamsulosin, Cialis, Nitrostat, valsartan, esomeprazole, atorvastatin, diltiazem, metoprolol tartrate, aspirin 325, loratadine and omeprazole. Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H may take over the counter 2. Diazepam 5 mg PO BID:PRN pain may cause drowsiness RX diazepam 5 mg 1 BID by mouth pain or spasm Disp #28 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID please take while taking narcotic pain medication RX docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:0 4. Gabapentin 200 mg PO TID RX gabapentin 100 mg 2 capsule(s) by mouth three times a day Disp #84 Capsule Refills:0 5. Levofloxacin 500 mg PO Q24H 7 days RX levofloxacin 500 mg 1 tablet(s) by mouth Q24 Disp #6 Tablet Refills:0 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Please do not operate heavy machinery,drink alcohol or drive RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #65 Tablet Refills:0 7. Atorvastatin 80 mg PO QPM 8. Diltiazem Extended-Release 300 mg PO DAILY 9. Metoprolol Tartrate 25 mg PO BID 10. Omeprazole 40 mg PO DAILY 11. Tamsulosin 0.4 mg PO QHS 12. Valsartan 160 mg PO DAILY 13. Valsartan 80 mg PO QPM 14.Rolling Walker Dx:Lumbar Stenosis Px:Good [MASKED] Months Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: 1. Lumbar spinal stenosis. 2. Radiculopathy. 3. Neurogenic claudication. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Lumbar Decompression Without Fusion You have undergone the following operation: Lumbar Decompression Without Fusion Immediately after the operation: Activity:You should not lift anything greater than 10 lbs for 2 weeks.You will be more comfortable if you do not sit or stand more than~45 minutes without moving around. Rehabilitation/ Physical [MASKED] times a day you should go for a walk for [MASKED] minutes as part of your recovery.You can walk as much as you can tolerate.Limit any kind of lifting. Diet:Eat a normal healthy diet.You may have some constipation after surgery.You have been given medication to help with this issue. Brace:You may have been given a brace.If you have been given a brace, this brace is to be worn when you are walking.You may take it off when sitting in a chair or lying in bed. Wound Care: Please keep the Prevena wound vac system in place until your follow up appointment. If, for any reason, the wound vac system stops working or the canister fills, please call the [MASKED] and we can have another once placed. You should resume taking your normal home medications. You have also been given Additional Medications to control your pain.Please allow 72 hours for refill of narcotic prescriptions,so please plan ahead.You can either have them mailed to your home or pick them up at the clinic located on [MASKED] 2.We are not allowed to call in or fax narcotic prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In addition,we are only allowed to write for pain medications for 90 days from the date of surgery. Follow up: Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. At the 2-week visit we will check your incision, take baseline X-rays and answer any questions.We may at that time start physical therapy. We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: 1)Weight bearing as tolerated.2)Gait,balance training.3)No lifting >10 lbs.4)No significant bending/twisting. Treatments Frequency: Wound Care: Please keep the Prevena wound vac system in place until your follow up appointment. If, for any reason, the wound vac system stops working or the canister fills, please call the [MASKED] and we can have another once placed. Followup Instructions: [MASKED]	[]	[ "I10", "I2510", "Z955", "Z87891", "E785" ]	[ "M4806: Spinal stenosis, lumbar region", "I10: Essential (primary) hypertension", "M4807: Spinal stenosis, lumbosacral region", "M5417: Radiculopathy, lumbosacral region", "M5416: Radiculopathy, lumbar region", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "Z87891: Personal history of nicotine dependence", "E785: Hyperlipidemia, unspecified" ]
10,091,724	21,834,046	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Vancomycin Attending: ___. Chief Complaint: Atrial Flutter Major Surgical or Invasive Procedure: None History of Present Illness: FROM ADMISSION NOTE "Mr ___ is a ___ w/hx of HTN, CKDIII, DM, CAD, DVT/PE and atrial flutter with variable block s/p successful TEE cardioversion on ___, discharged just three days ago from ___ who now presents from ___ with recurrence of atrial flutter after working with physical therapy. Of note on prior admission patient demonstrated poor response to AV nodal blocking agents (diltiazem and Lopressor) for Aflutter with alternating episodes of tachycardia and bradycardia. This was further complicated by prolonged episodes of bradycardia with up to 9.9 seconds of pause due to decremental conduction and iatrogenic atrioventricular blockade. At that time all nodal agents were discontinued and patient underwent successful TEE cardioversion. Following cardioversion, there were few episodes of sinus bradycardia noted but otherwise course was uncomplicated. Patient was discharged with plans to arrange ___ of Hearts monitor and discuss elective ablation at a later time. Since discharge patient reports feeling well. He denies any palpitations, chest pain, pressure, or shortness of breath. His only complaint is a productive cough for the past several days. Denies fevers or chills. Patient was transported to the ED via EMS. En route, he received 6mg IV adenosine without response. On arrival to the ___ ED vitals were T98.5, HR 154, BP 123/80, RR20, 97% RA. EKG showed atrial flutter with LBBB and HR 150. Labs were notable for K 5.8 and Cr 1.6. In the ED, patient received 150 mg IV bolus of amiodarone and was subsequently started on gtt at 1mg/min with conversion to NSR with HR ___. On arrival to the floor, vital signs 130 / 68 R Lying 75 20 97 2L" Past Medical History: FROM ADMISSION NOTE "-s/p prostate cancer ___ with cyberknife therapy and radiation -s/p colon cancer in ___ -abductor tendonitis on the right -Hx of DVT/PE in ___ during an e/o necrotizing pancreatitis s/p IVC filter and warfarin, later removed and stopped in ___ -coronary artery disease -osteoarthritis -DM, type 2 -vitamin D deficiency -CKD III with solitary left kidney -hypertension -hyperlipidemia -pAtach/paroxysmal atrial flutter s/p TEE/DCCV in ___ now on amiodarone and eliquis -central retinal vein occlusion -chronic pain -MDD -dementia" Social History: ___ Family History: Maternal history of emphysema Sororal history of diabetes Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VS: 130 / 68 R Lying 75 20 97 2L NC GENERAL: Well appearing, comfortable, NAD HEENT: NCAT. Sclera anicteric. PERRL. NECK: Supple. JVP nonelevated CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: non-labored breathing, diffuse inspiratory and expiratory wheezing bilaterally ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No peripheral edema. SKIN: No significant skin lesions or rashes. DISCHARGE PHYSICAL EXAM: ====================== GEN: NAD, comfortably lying supine HEENT: anicteric, oropharynx clear NECK: supple, JVP undetectable at 30 degrees CV: RRR, S1/S2, no m/r/g PULM: unlabored, scattered coarse bibasilar breath sounds ABD: soft, non-distended, non-tender EXT: warm, trace pitting edema to knees NEURO: oriented, non-focal Pertinent Results: ADMISSION LABS: ============= ___ 04:20PM BLOOD WBC-8.8 RBC-4.94 Hgb-14.2 Hct-43.2 MCV-87 MCH-28.7 MCHC-32.9 RDW-14.4 RDWSD-44.9 Plt ___ ___ 04:20PM BLOOD ___ PTT-33.5 ___ ___ 04:20PM BLOOD Glucose-303* UreaN-26* Creat-1.6* Na-138 K-5.8* Cl-101 HCO3-22 AnGap-15 DISCHARGE LABS: ============= ___ 05:58AM BLOOD WBC-5.1 RBC-4.03* Hgb-11.8* Hct-35.6* MCV-88 MCH-29.3 MCHC-33.1 RDW-14.2 RDWSD-45.1 Plt ___ ___ 05:58AM BLOOD Glucose-209* UreaN-23* Creat-1.1 Na-139 K-4.7 Cl-103 HCO3-25 AnGap-11 ___ 05:58AM BLOOD Calcium-8.7 Phos-2.3* Mg-1.___ male with a history of paroxysmal atrial tachyarrhythmia, non-obstructive CAD, DVT/PE, formerly on warfarin, insulin-dependent type II diabetes, CKD stage III, hypertension, dementia, recently hospitalized for (1) atrial flutter with variable atrioventricular block and consequent profound bradycardia without escape rhythm, necessitating emergent cardioversion, which successfully restored sinus rhythm, and (2) non-ischemic cardiomyopathy who returns with hemodynamically stable atrial flutter/fibrillation with rapid ventricular response. Promptly converted to NSR after amiodarone load. #) Atrial flutter/fibrillation: in the context of physical therapy and absence of maintenance antiarrhythmic or rate control. Converted to NSR after 1-gram intravenous amiodarone in the emergency department. Recommended load is as follows: amiodarone 400 mg BID for one week, 400 mg daily for one week, 200 mg daily thereafter. Will forego ablation for probable focus of concurrent fibrillation. Nodal blockade held last hospitalization for AV block and profound bradycardia. Apixaban 5 mg BID continued. Plan for Zio patch at discharge. #) Non-ischemic cardiomyopathy/acute systolic heart failure: unclear etiology last hospitalization, but presume tachy-myopathy. No features of cardiogenic shock on return. No indication for diuretic. Lisinopril 20 mg resumed for goal directed medical therapy. Beta blockade held for prior bradyarrhythmia. #) Acute kidney injury on chronic kidney disease: creatinine 1.5 on arrival. Presume pre-renal in the context of tachyarrhythmia. Resolved with gently hydration. CHRONIC/STABLE ISSUES: #) Dementia/adjustment disorder: mental status at or better than baseline per collateral. Underwent psychiatric evaluation at rehab for grief in response to wife's recent passing. Daughter requested his psychotropics be discontinued altogether. #) Type II diabetes, insulin-dependent: home ___ 20U BID continued. Humalog SS added in-house. TRANSITIONAL ISSUES: ==================== NEW MEDICATIONS: -Amiodarone 400 mg PO BID x 7 days ___ to ___, then 400 mg PO daily x 7 days ___ to ___, then 200 mg PO daily ___ on) CHANGED MEDICATIONS: none HELD/STOPPED MEDICATIONS: none [ ]At discharge, weight = 90.5 kg [ ]Ensure follow-up with cardiology. [ ]Discharged with Ziopatch, which should be returned in two weeks. [ ]Recommend amiodarone safety labs (thyroid function tests, LFTs), pulmonary function tests, CXR, and ophthalmologic evaluation #CODE: DNAR/DNAI #CONTACT: ___, daughter (___) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN allergies 3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 4. Lisinopril 20 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Senna 8.6 mg PO QHS 8. TraMADol 25 mg PO BID:PRN Pain - Moderate 9. TraZODone 25 mg PO QHS:PRN insomnia 10. Vitamin D 1000 UNIT PO DAILY 11. Apixaban 5 mg PO BID 12. Melatin (melatonin) 3 mg oral QHS 13. mirabegron 25 mg oral QHS 14. Atorvastatin 20 mg PO QPM 15. Humalog ___ 20 Units Breakfast Humalog ___ 20 Units Dinner Discharge Medications: 1. Amiodarone 400 mg PO BID ___ BID x7d (___), 400mg daily x7d ___, ___, 200mg daily (ongoing, ___ 2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 3. Apixaban 5 mg PO BID 4. Atorvastatin 20 mg PO QPM 5. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN allergies 6. Humalog ___ 20 Units Breakfast Humalog ___ 20 Units Dinner 7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 8. Lisinopril 20 mg PO DAILY 9. Melatin (melatonin) 3 mg oral QHS 10. mirabegron 25 mg oral QHS 11. Multivitamins 1 TAB PO DAILY 12. Omeprazole 20 mg PO DAILY 13. Senna 8.6 mg PO QHS 14. TraMADol 25 mg PO BID:PRN Pain - Moderate 15. TraZODone 25 mg PO QHS:PRN insomnia 16. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: -Atrial flutter SECONDARY: -Non-ischemic cardiomyopathy/chronic systolic heart failure -Acute kidney injury -Type II diabetes, insulin dependent 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: See Discharge Worksheet. Followup Instructions: ___	[ "I4891", "I130", "I5022", "N179", "Z7901", "I4892", "N183", "E1122", "Z794", "Z86718", "Z86711", "Z85038", "Z8546", "Z923", "F329", "M810", "I2510", "I428", "E785", "G4700", "F0390", "M25552", "M25551", "Z66" ]	Allergies: Vancomycin Chief Complaint: Atrial Flutter Major Surgical or Invasive Procedure: None History of Present Illness: FROM ADMISSION NOTE "Mr [MASKED] is a [MASKED] w/hx of HTN, CKDIII, DM, CAD, DVT/PE and atrial flutter with variable block s/p successful TEE cardioversion on [MASKED], discharged just three days ago from [MASKED] who now presents from [MASKED] with recurrence of atrial flutter after working with physical therapy. Of note on prior admission patient demonstrated poor response to AV nodal blocking agents (diltiazem and Lopressor) for Aflutter with alternating episodes of tachycardia and bradycardia. This was further complicated by prolonged episodes of bradycardia with up to 9.9 seconds of pause due to decremental conduction and iatrogenic atrioventricular blockade. At that time all nodal agents were discontinued and patient underwent successful TEE cardioversion. Following cardioversion, there were few episodes of sinus bradycardia noted but otherwise course was uncomplicated. Patient was discharged with plans to arrange [MASKED] of Hearts monitor and discuss elective ablation at a later time. Since discharge patient reports feeling well. He denies any palpitations, chest pain, pressure, or shortness of breath. His only complaint is a productive cough for the past several days. Denies fevers or chills. Patient was transported to the ED via EMS. En route, he received 6mg IV adenosine without response. On arrival to the [MASKED] ED vitals were T98.5, HR 154, BP 123/80, RR20, 97% RA. EKG showed atrial flutter with LBBB and HR 150. Labs were notable for K 5.8 and Cr 1.6. In the ED, patient received 150 mg IV bolus of amiodarone and was subsequently started on gtt at 1mg/min with conversion to NSR with HR [MASKED]. On arrival to the floor, vital signs 130 / 68 R Lying 75 20 97 2L" Past Medical History: FROM ADMISSION NOTE "-s/p prostate cancer [MASKED] with cyberknife therapy and radiation -s/p colon cancer in [MASKED] -abductor tendonitis on the right -Hx of DVT/PE in [MASKED] during an e/o necrotizing pancreatitis s/p IVC filter and warfarin, later removed and stopped in [MASKED] -coronary artery disease -osteoarthritis -DM, type 2 -vitamin D deficiency -CKD III with solitary left kidney -hypertension -hyperlipidemia -pAtach/paroxysmal atrial flutter s/p TEE/DCCV in [MASKED] now on amiodarone and eliquis -central retinal vein occlusion -chronic pain -MDD -dementia" Social History: [MASKED] Family History: Maternal history of emphysema Sororal history of diabetes Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VS: 130 / 68 R Lying 75 20 97 2L NC GENERAL: Well appearing, comfortable, NAD HEENT: NCAT. Sclera anicteric. PERRL. NECK: Supple. JVP nonelevated CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: non-labored breathing, diffuse inspiratory and expiratory wheezing bilaterally ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No peripheral edema. SKIN: No significant skin lesions or rashes. DISCHARGE PHYSICAL EXAM: ====================== GEN: NAD, comfortably lying supine HEENT: anicteric, oropharynx clear NECK: supple, JVP undetectable at 30 degrees CV: RRR, S1/S2, no m/r/g PULM: unlabored, scattered coarse bibasilar breath sounds ABD: soft, non-distended, non-tender EXT: warm, trace pitting edema to knees NEURO: oriented, non-focal Pertinent Results: ADMISSION LABS: ============= [MASKED] 04:20PM BLOOD WBC-8.8 RBC-4.94 Hgb-14.2 Hct-43.2 MCV-87 MCH-28.7 MCHC-32.9 RDW-14.4 RDWSD-44.9 Plt [MASKED] [MASKED] 04:20PM BLOOD [MASKED] PTT-33.5 [MASKED] [MASKED] 04:20PM BLOOD Glucose-303* UreaN-26* Creat-1.6* Na-138 K-5.8* Cl-101 HCO3-22 AnGap-15 DISCHARGE LABS: ============= [MASKED] 05:58AM BLOOD WBC-5.1 RBC-4.03* Hgb-11.8* Hct-35.6* MCV-88 MCH-29.3 MCHC-33.1 RDW-14.2 RDWSD-45.1 Plt [MASKED] [MASKED] 05:58AM BLOOD Glucose-209* UreaN-23* Creat-1.1 Na-139 K-4.7 Cl-103 HCO3-25 AnGap-11 [MASKED] 05:58AM BLOOD Calcium-8.7 Phos-2.3* Mg-1.[MASKED] male with a history of paroxysmal atrial tachyarrhythmia, non-obstructive CAD, DVT/PE, formerly on warfarin, insulin-dependent type II diabetes, CKD stage III, hypertension, dementia, recently hospitalized for (1) atrial flutter with variable atrioventricular block and consequent profound bradycardia without escape rhythm, necessitating emergent cardioversion, which successfully restored sinus rhythm, and (2) non-ischemic cardiomyopathy who returns with hemodynamically stable atrial flutter/fibrillation with rapid ventricular response. Promptly converted to NSR after amiodarone load. #) Atrial flutter/fibrillation: in the context of physical therapy and absence of maintenance antiarrhythmic or rate control. Converted to NSR after 1-gram intravenous amiodarone in the emergency department. Recommended load is as follows: amiodarone 400 mg BID for one week, 400 mg daily for one week, 200 mg daily thereafter. Will forego ablation for probable focus of concurrent fibrillation. Nodal blockade held last hospitalization for AV block and profound bradycardia. Apixaban 5 mg BID continued. Plan for Zio patch at discharge. #) Non-ischemic cardiomyopathy/acute systolic heart failure: unclear etiology last hospitalization, but presume tachy-myopathy. No features of cardiogenic shock on return. No indication for diuretic. Lisinopril 20 mg resumed for goal directed medical therapy. Beta blockade held for prior bradyarrhythmia. #) Acute kidney injury on chronic kidney disease: creatinine 1.5 on arrival. Presume pre-renal in the context of tachyarrhythmia. Resolved with gently hydration. CHRONIC/STABLE ISSUES: #) Dementia/adjustment disorder: mental status at or better than baseline per collateral. Underwent psychiatric evaluation at rehab for grief in response to wife's recent passing. Daughter requested his psychotropics be discontinued altogether. #) Type II diabetes, insulin-dependent: home [MASKED] 20U BID continued. Humalog SS added in-house. TRANSITIONAL ISSUES: ==================== NEW MEDICATIONS: -Amiodarone 400 mg PO BID x 7 days [MASKED] to [MASKED], then 400 mg PO daily x 7 days [MASKED] to [MASKED], then 200 mg PO daily [MASKED] on) CHANGED MEDICATIONS: none HELD/STOPPED MEDICATIONS: none [ ]At discharge, weight = 90.5 kg [ ]Ensure follow-up with cardiology. [ ]Discharged with Ziopatch, which should be returned in two weeks. [ ]Recommend amiodarone safety labs (thyroid function tests, LFTs), pulmonary function tests, CXR, and ophthalmologic evaluation #CODE: DNAR/DNAI #CONTACT: [MASKED], daughter ([MASKED]) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN allergies 3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 4. Lisinopril 20 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Senna 8.6 mg PO QHS 8. TraMADol 25 mg PO BID:PRN Pain - Moderate 9. TraZODone 25 mg PO QHS:PRN insomnia 10. Vitamin D 1000 UNIT PO DAILY 11. Apixaban 5 mg PO BID 12. Melatin (melatonin) 3 mg oral QHS 13. mirabegron 25 mg oral QHS 14. Atorvastatin 20 mg PO QPM 15. Humalog [MASKED] 20 Units Breakfast Humalog [MASKED] 20 Units Dinner Discharge Medications: 1. Amiodarone 400 mg PO BID [MASKED] BID x7d ([MASKED]), 400mg daily x7d [MASKED], [MASKED], 200mg daily (ongoing, [MASKED] 2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 3. Apixaban 5 mg PO BID 4. Atorvastatin 20 mg PO QPM 5. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN allergies 6. Humalog [MASKED] 20 Units Breakfast Humalog [MASKED] 20 Units Dinner 7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 8. Lisinopril 20 mg PO DAILY 9. Melatin (melatonin) 3 mg oral QHS 10. mirabegron 25 mg oral QHS 11. Multivitamins 1 TAB PO DAILY 12. Omeprazole 20 mg PO DAILY 13. Senna 8.6 mg PO QHS 14. TraMADol 25 mg PO BID:PRN Pain - Moderate 15. TraZODone 25 mg PO QHS:PRN insomnia 16. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY: -Atrial flutter SECONDARY: -Non-ischemic cardiomyopathy/chronic systolic heart failure -Acute kidney injury -Type II diabetes, insulin dependent 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: See Discharge Worksheet. Followup Instructions: [MASKED]	[]	[ "I4891", "I130", "N179", "Z7901", "E1122", "Z794", "Z86718", "F329", "I2510", "E785", "G4700", "Z66" ]	[ "I4891: Unspecified atrial fibrillation", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5022: Chronic systolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "Z7901: Long term (current) use of anticoagulants", "I4892: Unspecified atrial flutter", "N183: Chronic kidney disease, stage 3 (moderate)", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z794: Long term (current) use of insulin", "Z86718: Personal history of other venous thrombosis and embolism", "Z86711: Personal history of pulmonary embolism", "Z85038: Personal history of other malignant neoplasm of large intestine", "Z8546: Personal history of malignant neoplasm of prostate", "Z923: Personal history of irradiation", "F329: Major depressive disorder, single episode, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I428: Other cardiomyopathies", "E785: Hyperlipidemia, unspecified", "G4700: Insomnia, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "M25552: Pain in left hip", "M25551: Pain in right hip", "Z66: Do not resuscitate" ]
10,091,724	24,733,508	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Vancomycin Attending: ___. Chief Complaint: Tachycardia Major Surgical or Invasive Procedure: Transesophageal echocardiogram/direct current cardioversion (___) History of Present Illness: FROM ADMISSION NOTE "Mr ___ is a ___ w/hx of paroxysmal atrial tachycardia/arrhythmias, HTN, CKD III, DM, CAD, hx of DVT/PE formerly on Coumadin, p/w tachycardia/hypotension from SNF Pt admitted to ___ from ___ ED on ___ s/p falls x3 at home. Per rehab records, pt was at baseline mental status found to have HR 140 and BP 92/67, only complaint was feeling hot but otherwise ASx. Pt was given 25mg PO Metop without improvement in BPs/HRs and transferred to ___ ED. Pt denies any complaints. Denies cp/sob. FSG 217. Pt is poor historian. Denies any CP or palpitations. Pt feeling increasingly sad, wife recently died. In the ED, initial VS were: T97.6 125 113/80 20 96% RA Exam notable for: ECG: HR 125, occ PWs, LAD, new LBBB, new TWI aVL. Prior EKG w/Lt hemiblock. Labs showed: K 5.7 > 5.0, BUN/Cr 32/1.4, Lac 2.4, VBG 7.35/47/27, UA 100 glu/30 prot/neg leuk-nit Imaging showed: -CXR w/no acute cardiopulmonary abnormality. Unchanged right hemidiaphragm elevation. -NCCTH w/no acute intracranial abnormality Patient received: Dilt 5mg IV x3?, Dilt 30 PO, 1L NS IVF Transfer VS were: T97.7 74 114/65 16 98% RA On arrival to the floor, patient reports feeling well apart from chronic Rt hip pain. Endorses some chest pain previously but none currently. Has some LH/dizziness when standing up. Has fallen numerous times recently, no palp, sob, abd pain, n/v/d/c, dysuria, GIB. +chronic dry cough." Past Medical History: FROM ADMISSION NOTE "-s/p prostate cancer ___ with cyberknife therapy and radiation -s/p colon cancer in ___ -abductor tendonitis on the right -Hx of DVT/PE in ___ during an e/o necrotizing pancreatitis s/p IVC filter and warfarin, later removed and stopped in ___ -coronary artery disease -osteoarthritis -DM -vitamin D deficiency -CKD III with solitary left kidney -hypertension -hyperlipidemia -pAtach -central retinal vein occlusion -chronic pain -MDD -dementia" Social History: ___ Family History: Maternal history of emphysema Sororal history of diabetes Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: 97.9 PO 129 / 99 Lying 82 16 95 Ra GENERAL: NAD, pleasant, tearful when discussing recently deceased wife ___: AT/NC, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no no JVD HEART: feint heart sounds throughout LUNGS: CTABL, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: soft, NDNT, no rebound/guarding EXTREMITIES: no ___ edema ___, non-ttp Rt hip, mild pain w/Rt hip rotation PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3 (thought B&W instead of ___, moving all 4 extremities with purpose. +DOWB, knows president/___ sox. Unable DOMB. PSYCH: tearful, depressed, no SI SKIN: warm and well perfused, several scrapes on ___ DISCHARGE PHYSICAL EXAM ======================== VITALS: T 98.2, HR 82, BP 128/79, RR 20, O2 95% RA GEN: NAD, well appearing ___: anicteric, oropharynx clear NECK: supple, JVP undetectable upright CV: RRR, S1/S2, no m/r/g PULM: unlabored, CTAB ABD: soft, non-distended, non-tender EXT: warm, trace pretibial edema NEURO: non-focal PSYCH: constricted affect Pertinent Results: ADMISSION LABS ============== ___ 04:05PM BLOOD WBC-8.0 RBC-5.51 Hgb-16.0 Hct-47.7 MCV-87 MCH-29.0 MCHC-33.5 RDW-14.0 RDWSD-43.6 Plt ___ ___ 04:05PM BLOOD Neuts-67.5 Lymphs-17.9* Monos-12.2 Eos-1.1 Baso-0.4 Im ___ AbsNeut-5.42 AbsLymp-1.44 AbsMono-0.98* AbsEos-0.09 AbsBaso-0.03 ___ 11:33PM BLOOD ___ PTT-29.5 ___ ___ 04:05PM BLOOD Glucose-264* UreaN-32* Creat-1.4* Na-139 K-5.7* Cl-101 HCO3-22 AnGap-16 ___ 04:05PM BLOOD CK(CPK)-57 ___ 04:05PM BLOOD CK-MB-3 cTropnT-0.01 ___ 04:05PM BLOOD Calcium-9.7 Phos-3.2 Mg-2.1 ___ 04:05PM BLOOD TSH-1.9 ___ 04:16PM BLOOD ___ pO2-31* pCO2-47* pH-7.35 calTCO2-27 Base XS--1 ___ 04:16PM BLOOD Lactate-2.4* PERTINENT LABS: ============== ___ 11:33PM BLOOD CK-MB-6 cTropnT-0.03* ___ 06:19AM BLOOD CK-MB-6 cTropnT-0.04* ___ 03:10PM BLOOD CK-MB-4 cTropnT-0.03* ___ 02:40AM BLOOD CK-MB-3 cTropnT-0.03* ___ 06:45AM BLOOD CK-MB-4 cTropnT-0.05* ___ 06:25AM BLOOD CK-MB-2 cTropnT-0.05* ___ 06:37AM BLOOD proBNP-1160* DISCHARGE LABS: ============== ___ 05:26AM BLOOD WBC-4.5 RBC-4.12* Hgb-12.2* Hct-36.8* MCV-89 MCH-29.6 MCHC-33.2 RDW-14.6 RDWSD-47.2* Plt ___ ___ 03:40PM BLOOD Glucose-381* UreaN-27* Creat-1.1 Na-137 K-4.9 Cl-103 HCO3-23 AnGap-11 ___ 03:40PM BLOOD Calcium-8.7 Phos-2.9 Mg-1.8 STUDIES: ======= CXR (___) IMPRESSION: No acute cardiopulmonary abnormality. Unchanged right hemidiaphragm elevation. CT HEAD WITHOUT CONTRAST (___) IMPRESSION: No acute intracranial abnormality. Large left maxillary molar dental ___ along with a right greater than left maxillary molar periodontal disease. TTE (___) CONCLUSIONS: The left atrial volume index is mildly increased. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is moderate regional left ventricular systolic dysfunction with apical akinesis (see schematic) and moderate global hypokinesis of the remaining segments. Quantitative biplane left ventricular ejection fraction is 36 %. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with focal hypokinesis of the apical free wall. There is abnormal septal motion c/w conduction abnormality/paced rhythm. The aortic sinus is mildly dilated with mildly dilated ascending aorta. The aortic arch is mildly dilated. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (?#) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral leaflets appear structurally normal with no mitral valve prolapse. The transmitral E-wave deceleration time is short (consistent with restrictive filling) There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is borderline elevated. There is no pericardial effusion. IMPRESSION: Adequate image quality. Mild symmetric left ventricular hypertrophy with normal cavity size and moderate regional and global systolic dysfunction c/w a mixed ischemic and nonischemic cardiomyopathy. Restrictive left venttricular filling CARDIAC PERFUSION PHARMACEUTICAL (___): IMPRESSION: 1. Normal myocardial perfusion. 2. Normal left ventricular cavity size. Mild systolic dysfunction with global hypokinesis. TEE (___): CONCLUSION: There is no spontaneous echo contrast or thrombus in the body of the left atrium/left atrial appendage. The left atrial appendage ejection velocity is normal. No spontaneous echo contrast or thrombus is seen in the body of the right atrium/right atrial appendage. The right atrial appendage ejection velocity is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. Global left ventricular systolic function is depressed. The right ventricle has uninterpretable free wall motion assessment. There are simple atheroma in the aortic arch with complex (>4mm, non-mobile) atheroma in the descending aorta. The aortic valve leaflets (3) are mildly thickened. There is trace aortic regurgitation. The mitral leaflets are mildly thickened with no mitral valve prolapse. There is physiologic mitral regurgitation. The tricuspid valve is not well seen. There is physiologic tricuspid regurgitation. Brief Hospital Course: ___ male with a history of paroxysmal atrial tachyarrhythmia, non-obstructive CAD, DVT/PE, formerly on warfarin, insulin-dependent type II diabetes, CKD stage III, hypertension, and dementia initially admitted for atrial flutter with rapid ventricular response, then transferred to cardiology for newly reduced ejection fraction with apical akinesis determined to be non-ischemic in nature. Hospitalization later complicated by variable atrioventricular block and consequent profound bradycardia without escape rhythm, necessitating cardioversion, which successfully restored sinus rhythm. #) Non-ischemic cardiomyopathy: echocardiogram revealed new reduction if LVEF = 36% with apical akinesis and mixed ischemic/non-ischemic features. He remained hemodynamically stable and euvolemic, and thus compensated for duration of this hospitalization. While tachymyopathy is probable, investigation of his coronary status was warranted. He proceeded with non-invasive study in the context of his comorbidities, namely dementia and uncertain goals of care. Pharmacologic nuclear stress was indeed unrevealing. Home lisinopril 20 mg was resumed when his renal function returned to baseline. Beta blockade was discontinued for bradycardia, as outlined below. Active or maintenance diuresis was not indicated. He was anticoagulated with apixaban for both apical akinesis and flutter. Anticipate surveillance echocardiogram after one to three months of medical optimization and consideration of coronary angiography in the absence of recovery at that time. #) Atrial flutter with variable block: initially presented in flutter with rapid ventricular response requiring several diltiazem and Lopressor pushes and titration of maintenance Lopressor to 37.5 mg Q6H for adequate rate control. He then alternated between tachycardia (2:1) and bradycardia (>4:1) secondary to variable block. He later tended toward bradycardia entirely with 7.3 and 9.9 second AV pauses due to decremental conduction and iatrogenic atrioventricular blockade. All nodal blockade was discontinued, and he proceed with emergent TEE/cardioversion, which successfully restored sinus rhythm. No indication for pacemaker in that regard. Very infrequent sinus bradycardia noted thereafter suggesting primarily decremental conduction, though possible component of infranodal disease appreciated in the absence of escape rhythm. Planned for ___ of Hearts at discharge. Elective flutter ablation to be determined thereafter. He was anticoagulated with apixaban 5 mg BID for CHA2DS2-VASc = 6. #) NSTEMI, type II: troponin-T 0.01 -> 0.05. Suspect demand in the context of initial tachyarrhythmia and unrevealing non-invasive survey of his coronaries. #) Acute kidney injury on chronic kidney disease: arrived with pre-renal acute kidney injury, which promptly resolved with fluid resuscitation and rate control. CHRONIC/STABLE ISSUES: #) Dementia/adjustment disorder: mental status at or better than baseline per collateral. Underwent psychiatric evaluation at rehab for grief in response to wife's recent passing. Daughter requested his psychotropics be discontinued altogether. #) Type II diabetes, insulin-dependent: home ___ 20U BID continued. Humalog SS added in-house. #) Chronic bilateral hip pain: home tramadol 25 mg BID continued. TRANSITIONAL ISSUES: NEW MEDICATIONS -Apixaban 5 mg BID CHANGED MEDICATIONS *DISCONTINUED MEDICATIONS -Metoprolol succinate 50 mg daily -Aspirin 81 mg daily -Buproprion XL 150 mg QAM, 100 mg QPM -Duloxetine 30 mg BID [ ]Discharge weight = 89 kg. Weigh patient daily; recommend diuretic (Lasix naïve) if weight increases by three pounds in one day or five pounds in one week. [ ]Discharge creatinine = 1.1. Recommend Chem-10 ___ and weekly thereafter. [ ]Facilitate cardiology and electrophysiology follow-up. The cardiology department was contacted prior to discharge, but were not able to secure appointments. [ ]Likewise facilitate follow-up with primary care physician. [ ]Patient discharged with ___ of Hearts monitor, but yet to be activated due to limited staffing on holiday weekend. Call electrophysiology department (___ lab) on ___ at ___ to activate. [ ]Recommend repeat surface echocardiogram after ___ months of medical optimization to assess for left ventricular recovery. Consider coronary angiography if yet to recover and aligned with goals of care. [ ]Do not implement beta blockade without first discussing with cardiology/electrophysiology. [ ]Aspirin 81 mg discontinued in the setting of compelling coronary atherosclerosis and tandem anticoagulation with apixaban; consider resuming if coronary angiography reveals atherosclerosis. [ ]Psychotropics held at daughter's request. Continue to explore indications for these. [ ]Recommend dental follow-up for radiographic evidence of carious left maxillary molar/periodontitis. #CODE: DNAR/DNAI by MOLST (___), confirmed #CONTACT: ___, daughter (___) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN allergies 4. Metoprolol Succinate XL 50 mg PO QHS 5. Omeprazole 20 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Humalog ___ 20 Units Breakfast Humalog ___ 20 Units Dinner 9. BuPROPion XL (Once Daily) 150 mg PO QAM 10. mirabegron 25 mg oral QHS 11. Senna 8.6 mg PO QHS 12. DULoxetine 30 mg PO BID 13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 14. Vitamin D 1000 UNIT PO DAILY 15. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 16. TraMADol 25 mg PO BID 17. Melatin (melatonin) 3 mg oral QHS 18. TraZODone 25 mg PO QHS:PRN insomnia 19. BuPROPion XL (Once Daily) 100 mg PO QPM Discharge Medications: 1. Apixaban 5 mg PO BID 2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 3. Atorvastatin 20 mg PO QPM 4. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN allergies 5. Humalog ___ 20 Units Breakfast Humalog ___ 20 Units Dinner 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 7. Lisinopril 20 mg PO DAILY 8. Melatin (melatonin) 3 mg oral QHS 9. mirabegron 25 mg oral QHS 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Senna 8.6 mg PO QHS 13. TraMADol 25 mg PO BID 14. TraZODone 25 mg PO QHS:PRN insomnia 15. Vitamin D 1000 UNIT PO DAILY 16. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until instructed by your primary doctor or cardiologist. 17. HELD- BuPROPion XL (Once Daily) 150 mg PO QAM This medication was held. Do not restart BuPROPion XL (Once Daily) until instructed by your primary doctor. 18. HELD- BuPROPion XL (Once Daily) 100 mg PO QPM This medication was held. Do not restart BuPROPion XL (Once Daily) until instructed by your primary doctor. 19. HELD- DULoxetine 30 mg PO BID This medication was held. Do not restart DULoxetine until until instructed by your primary doctor. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: -Atrial flutter with variable block status-post cardioversion SECONDARY: -Acute systolic heart failure -Non-ST elevation myocardial infarction -Chronic kidney disease -Type II diabetes, insulin-dependent -Adjustment disorder Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? -Your heart was beating very fast and your blood pressure was low. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? -We determined that your fast heart rate was due to abnormal rhythm called atrial flutter. Your heart rate then became very slow for the same reason. Our electrophysiologists shocked your heart, and it began beating normally again. They might perform a procedure (ablation) to prevent this from happening again. -You received a blood thinner (apixaban) to prevent a stroke. You should continue this medication at home. -We took pictures of your heart (echocardiogram), which showed that your heart is not squeezing as well as it once did. This could be due to the fast heart rate. -We then performed a stress test of your heart, which was normal. We don't think you had a heart attack for this reason. WHAT SHOULD I DO WHEN I GO HOME? -You are at high risk for stroke when your heart beats abnormally. It is very important you take your new blood thinner (apixaban) every day to prevent a stroke. -Please follow-up with cardiology. We were not able to schedule an appointment before you left, but someone will call you to do so. -Call our electrophysiology department on ___ at ___ to set up your heart monitor. -Weigh yourself daily. Call your primary doctor or cardiologist if your weight increases by 3 pounds in one day or 5 pounds in one week. We wish you all the best. Sincerely, Your ___ care team Followup Instructions: ___	[ "I4892", "I5021", "I130", "H348192", "N179", "G4700", "N183", "E1122", "I2510", "Z86711", "Z86718", "R001", "I447", "Z8546", "Z85038", "F0390", "E559", "E785", "I428", "G8929", "Z66", "I479", "F4320" ]	Allergies: Vancomycin Chief Complaint: Tachycardia Major Surgical or Invasive Procedure: Transesophageal echocardiogram/direct current cardioversion ([MASKED]) History of Present Illness: FROM ADMISSION NOTE "Mr [MASKED] is a [MASKED] w/hx of paroxysmal atrial tachycardia/arrhythmias, HTN, CKD III, DM, CAD, hx of DVT/PE formerly on Coumadin, p/w tachycardia/hypotension from SNF Pt admitted to [MASKED] from [MASKED] ED on [MASKED] s/p falls x3 at home. Per rehab records, pt was at baseline mental status found to have HR 140 and BP 92/67, only complaint was feeling hot but otherwise ASx. Pt was given 25mg PO Metop without improvement in BPs/HRs and transferred to [MASKED] ED. Pt denies any complaints. Denies cp/sob. FSG 217. Pt is poor historian. Denies any CP or palpitations. Pt feeling increasingly sad, wife recently died. In the ED, initial VS were: T97.6 125 113/80 20 96% RA Exam notable for: ECG: HR 125, occ PWs, LAD, new LBBB, new TWI aVL. Prior EKG w/Lt hemiblock. Labs showed: K 5.7 > 5.0, BUN/Cr 32/1.4, Lac 2.4, VBG 7.35/47/27, UA 100 glu/30 prot/neg leuk-nit Imaging showed: -CXR w/no acute cardiopulmonary abnormality. Unchanged right hemidiaphragm elevation. -NCCTH w/no acute intracranial abnormality Patient received: Dilt 5mg IV x3?, Dilt 30 PO, 1L NS IVF Transfer VS were: T97.7 74 114/65 16 98% RA On arrival to the floor, patient reports feeling well apart from chronic Rt hip pain. Endorses some chest pain previously but none currently. Has some LH/dizziness when standing up. Has fallen numerous times recently, no palp, sob, abd pain, n/v/d/c, dysuria, GIB. +chronic dry cough." Past Medical History: FROM ADMISSION NOTE "-s/p prostate cancer [MASKED] with cyberknife therapy and radiation -s/p colon cancer in [MASKED] -abductor tendonitis on the right -Hx of DVT/PE in [MASKED] during an e/o necrotizing pancreatitis s/p IVC filter and warfarin, later removed and stopped in [MASKED] -coronary artery disease -osteoarthritis -DM -vitamin D deficiency -CKD III with solitary left kidney -hypertension -hyperlipidemia -pAtach -central retinal vein occlusion -chronic pain -MDD -dementia" Social History: [MASKED] Family History: Maternal history of emphysema Sororal history of diabetes Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: 97.9 PO 129 / 99 Lying 82 16 95 Ra GENERAL: NAD, pleasant, tearful when discussing recently deceased wife [MASKED]: AT/NC, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no no JVD HEART: feint heart sounds throughout LUNGS: CTABL, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: soft, NDNT, no rebound/guarding EXTREMITIES: no [MASKED] edema [MASKED], non-ttp Rt hip, mild pain w/Rt hip rotation PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3 (thought B&W instead of [MASKED], moving all 4 extremities with purpose. +DOWB, knows president/[MASKED] sox. Unable DOMB. PSYCH: tearful, depressed, no SI SKIN: warm and well perfused, several scrapes on [MASKED] DISCHARGE PHYSICAL EXAM ======================== VITALS: T 98.2, HR 82, BP 128/79, RR 20, O2 95% RA GEN: NAD, well appearing [MASKED]: anicteric, oropharynx clear NECK: supple, JVP undetectable upright CV: RRR, S1/S2, no m/r/g PULM: unlabored, CTAB ABD: soft, non-distended, non-tender EXT: warm, trace pretibial edema NEURO: non-focal PSYCH: constricted affect Pertinent Results: ADMISSION LABS ============== [MASKED] 04:05PM BLOOD WBC-8.0 RBC-5.51 Hgb-16.0 Hct-47.7 MCV-87 MCH-29.0 MCHC-33.5 RDW-14.0 RDWSD-43.6 Plt [MASKED] [MASKED] 04:05PM BLOOD Neuts-67.5 Lymphs-17.9* Monos-12.2 Eos-1.1 Baso-0.4 Im [MASKED] AbsNeut-5.42 AbsLymp-1.44 AbsMono-0.98* AbsEos-0.09 AbsBaso-0.03 [MASKED] 11:33PM BLOOD [MASKED] PTT-29.5 [MASKED] [MASKED] 04:05PM BLOOD Glucose-264* UreaN-32* Creat-1.4* Na-139 K-5.7* Cl-101 HCO3-22 AnGap-16 [MASKED] 04:05PM BLOOD CK(CPK)-57 [MASKED] 04:05PM BLOOD CK-MB-3 cTropnT-0.01 [MASKED] 04:05PM BLOOD Calcium-9.7 Phos-3.2 Mg-2.1 [MASKED] 04:05PM BLOOD TSH-1.9 [MASKED] 04:16PM BLOOD [MASKED] pO2-31* pCO2-47* pH-7.35 calTCO2-27 Base XS--1 [MASKED] 04:16PM BLOOD Lactate-2.4* PERTINENT LABS: ============== [MASKED] 11:33PM BLOOD CK-MB-6 cTropnT-0.03* [MASKED] 06:19AM BLOOD CK-MB-6 cTropnT-0.04* [MASKED] 03:10PM BLOOD CK-MB-4 cTropnT-0.03* [MASKED] 02:40AM BLOOD CK-MB-3 cTropnT-0.03* [MASKED] 06:45AM BLOOD CK-MB-4 cTropnT-0.05* [MASKED] 06:25AM BLOOD CK-MB-2 cTropnT-0.05* [MASKED] 06:37AM BLOOD proBNP-1160* DISCHARGE LABS: ============== [MASKED] 05:26AM BLOOD WBC-4.5 RBC-4.12* Hgb-12.2* Hct-36.8* MCV-89 MCH-29.6 MCHC-33.2 RDW-14.6 RDWSD-47.2* Plt [MASKED] [MASKED] 03:40PM BLOOD Glucose-381* UreaN-27* Creat-1.1 Na-137 K-4.9 Cl-103 HCO3-23 AnGap-11 [MASKED] 03:40PM BLOOD Calcium-8.7 Phos-2.9 Mg-1.8 STUDIES: ======= CXR ([MASKED]) IMPRESSION: No acute cardiopulmonary abnormality. Unchanged right hemidiaphragm elevation. CT HEAD WITHOUT CONTRAST ([MASKED]) IMPRESSION: No acute intracranial abnormality. Large left maxillary molar dental [MASKED] along with a right greater than left maxillary molar periodontal disease. TTE ([MASKED]) CONCLUSIONS: The left atrial volume index is mildly increased. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is [MASKED] mmHg. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is moderate regional left ventricular systolic dysfunction with apical akinesis (see schematic) and moderate global hypokinesis of the remaining segments. Quantitative biplane left ventricular ejection fraction is 36 %. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with focal hypokinesis of the apical free wall. There is abnormal septal motion c/w conduction abnormality/paced rhythm. The aortic sinus is mildly dilated with mildly dilated ascending aorta. The aortic arch is mildly dilated. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (?#) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral leaflets appear structurally normal with no mitral valve prolapse. The transmitral E-wave deceleration time is short (consistent with restrictive filling) There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is borderline elevated. There is no pericardial effusion. IMPRESSION: Adequate image quality. Mild symmetric left ventricular hypertrophy with normal cavity size and moderate regional and global systolic dysfunction c/w a mixed ischemic and nonischemic cardiomyopathy. Restrictive left venttricular filling CARDIAC PERFUSION PHARMACEUTICAL ([MASKED]): IMPRESSION: 1. Normal myocardial perfusion. 2. Normal left ventricular cavity size. Mild systolic dysfunction with global hypokinesis. TEE ([MASKED]): CONCLUSION: There is no spontaneous echo contrast or thrombus in the body of the left atrium/left atrial appendage. The left atrial appendage ejection velocity is normal. No spontaneous echo contrast or thrombus is seen in the body of the right atrium/right atrial appendage. The right atrial appendage ejection velocity is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. Global left ventricular systolic function is depressed. The right ventricle has uninterpretable free wall motion assessment. There are simple atheroma in the aortic arch with complex (>4mm, non-mobile) atheroma in the descending aorta. The aortic valve leaflets (3) are mildly thickened. There is trace aortic regurgitation. The mitral leaflets are mildly thickened with no mitral valve prolapse. There is physiologic mitral regurgitation. The tricuspid valve is not well seen. There is physiologic tricuspid regurgitation. Brief Hospital Course: [MASKED] male with a history of paroxysmal atrial tachyarrhythmia, non-obstructive CAD, DVT/PE, formerly on warfarin, insulin-dependent type II diabetes, CKD stage III, hypertension, and dementia initially admitted for atrial flutter with rapid ventricular response, then transferred to cardiology for newly reduced ejection fraction with apical akinesis determined to be non-ischemic in nature. Hospitalization later complicated by variable atrioventricular block and consequent profound bradycardia without escape rhythm, necessitating cardioversion, which successfully restored sinus rhythm. #) Non-ischemic cardiomyopathy: echocardiogram revealed new reduction if LVEF = 36% with apical akinesis and mixed ischemic/non-ischemic features. He remained hemodynamically stable and euvolemic, and thus compensated for duration of this hospitalization. While tachymyopathy is probable, investigation of his coronary status was warranted. He proceeded with non-invasive study in the context of his comorbidities, namely dementia and uncertain goals of care. Pharmacologic nuclear stress was indeed unrevealing. Home lisinopril 20 mg was resumed when his renal function returned to baseline. Beta blockade was discontinued for bradycardia, as outlined below. Active or maintenance diuresis was not indicated. He was anticoagulated with apixaban for both apical akinesis and flutter. Anticipate surveillance echocardiogram after one to three months of medical optimization and consideration of coronary angiography in the absence of recovery at that time. #) Atrial flutter with variable block: initially presented in flutter with rapid ventricular response requiring several diltiazem and Lopressor pushes and titration of maintenance Lopressor to 37.5 mg Q6H for adequate rate control. He then alternated between tachycardia (2:1) and bradycardia (>4:1) secondary to variable block. He later tended toward bradycardia entirely with 7.3 and 9.9 second AV pauses due to decremental conduction and iatrogenic atrioventricular blockade. All nodal blockade was discontinued, and he proceed with emergent TEE/cardioversion, which successfully restored sinus rhythm. No indication for pacemaker in that regard. Very infrequent sinus bradycardia noted thereafter suggesting primarily decremental conduction, though possible component of infranodal disease appreciated in the absence of escape rhythm. Planned for [MASKED] of Hearts at discharge. Elective flutter ablation to be determined thereafter. He was anticoagulated with apixaban 5 mg BID for CHA2DS2-VASc = 6. #) NSTEMI, type II: troponin-T 0.01 -> 0.05. Suspect demand in the context of initial tachyarrhythmia and unrevealing non-invasive survey of his coronaries. #) Acute kidney injury on chronic kidney disease: arrived with pre-renal acute kidney injury, which promptly resolved with fluid resuscitation and rate control. CHRONIC/STABLE ISSUES: #) Dementia/adjustment disorder: mental status at or better than baseline per collateral. Underwent psychiatric evaluation at rehab for grief in response to wife's recent passing. Daughter requested his psychotropics be discontinued altogether. #) Type II diabetes, insulin-dependent: home [MASKED] 20U BID continued. Humalog SS added in-house. #) Chronic bilateral hip pain: home tramadol 25 mg BID continued. TRANSITIONAL ISSUES: NEW MEDICATIONS -Apixaban 5 mg BID CHANGED MEDICATIONS *DISCONTINUED MEDICATIONS -Metoprolol succinate 50 mg daily -Aspirin 81 mg daily -Buproprion XL 150 mg QAM, 100 mg QPM -Duloxetine 30 mg BID [ ]Discharge weight = 89 kg. Weigh patient daily; recommend diuretic (Lasix naïve) if weight increases by three pounds in one day or five pounds in one week. [ ]Discharge creatinine = 1.1. Recommend Chem-10 [MASKED] and weekly thereafter. [ ]Facilitate cardiology and electrophysiology follow-up. The cardiology department was contacted prior to discharge, but were not able to secure appointments. [ ]Likewise facilitate follow-up with primary care physician. [ ]Patient discharged with [MASKED] of Hearts monitor, but yet to be activated due to limited staffing on holiday weekend. Call electrophysiology department ([MASKED] lab) on [MASKED] at [MASKED] to activate. [ ]Recommend repeat surface echocardiogram after [MASKED] months of medical optimization to assess for left ventricular recovery. Consider coronary angiography if yet to recover and aligned with goals of care. [ ]Do not implement beta blockade without first discussing with cardiology/electrophysiology. [ ]Aspirin 81 mg discontinued in the setting of compelling coronary atherosclerosis and tandem anticoagulation with apixaban; consider resuming if coronary angiography reveals atherosclerosis. [ ]Psychotropics held at daughter's request. Continue to explore indications for these. [ ]Recommend dental follow-up for radiographic evidence of carious left maxillary molar/periodontitis. #CODE: DNAR/DNAI by MOLST ([MASKED]), confirmed #CONTACT: [MASKED], daughter ([MASKED]) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN allergies 4. Metoprolol Succinate XL 50 mg PO QHS 5. Omeprazole 20 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Humalog [MASKED] 20 Units Breakfast Humalog [MASKED] 20 Units Dinner 9. BuPROPion XL (Once Daily) 150 mg PO QAM 10. mirabegron 25 mg oral QHS 11. Senna 8.6 mg PO QHS 12. DULoxetine 30 mg PO BID 13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 14. Vitamin D 1000 UNIT PO DAILY 15. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 16. TraMADol 25 mg PO BID 17. Melatin (melatonin) 3 mg oral QHS 18. TraZODone 25 mg PO QHS:PRN insomnia 19. BuPROPion XL (Once Daily) 100 mg PO QPM Discharge Medications: 1. Apixaban 5 mg PO BID 2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 3. Atorvastatin 20 mg PO QPM 4. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN allergies 5. Humalog [MASKED] 20 Units Breakfast Humalog [MASKED] 20 Units Dinner 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 7. Lisinopril 20 mg PO DAILY 8. Melatin (melatonin) 3 mg oral QHS 9. mirabegron 25 mg oral QHS 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Senna 8.6 mg PO QHS 13. TraMADol 25 mg PO BID 14. TraZODone 25 mg PO QHS:PRN insomnia 15. Vitamin D 1000 UNIT PO DAILY 16. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until instructed by your primary doctor or cardiologist. 17. HELD- BuPROPion XL (Once Daily) 150 mg PO QAM This medication was held. Do not restart BuPROPion XL (Once Daily) until instructed by your primary doctor. 18. HELD- BuPROPion XL (Once Daily) 100 mg PO QPM This medication was held. Do not restart BuPROPion XL (Once Daily) until instructed by your primary doctor. 19. HELD- DULoxetine 30 mg PO BID This medication was held. Do not restart DULoxetine until until instructed by your primary doctor. Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY: -Atrial flutter with variable block status-post cardioversion SECONDARY: -Acute systolic heart failure -Non-ST elevation myocardial infarction -Chronic kidney disease -Type II diabetes, insulin-dependent -Adjustment disorder Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? -Your heart was beating very fast and your blood pressure was low. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? -We determined that your fast heart rate was due to abnormal rhythm called atrial flutter. Your heart rate then became very slow for the same reason. Our electrophysiologists shocked your heart, and it began beating normally again. They might perform a procedure (ablation) to prevent this from happening again. -You received a blood thinner (apixaban) to prevent a stroke. You should continue this medication at home. -We took pictures of your heart (echocardiogram), which showed that your heart is not squeezing as well as it once did. This could be due to the fast heart rate. -We then performed a stress test of your heart, which was normal. We don't think you had a heart attack for this reason. WHAT SHOULD I DO WHEN I GO HOME? -You are at high risk for stroke when your heart beats abnormally. It is very important you take your new blood thinner (apixaban) every day to prevent a stroke. -Please follow-up with cardiology. We were not able to schedule an appointment before you left, but someone will call you to do so. -Call our electrophysiology department on [MASKED] at [MASKED] to set up your heart monitor. -Weigh yourself daily. Call your primary doctor or cardiologist if your weight increases by 3 pounds in one day or 5 pounds in one week. We wish you all the best. Sincerely, Your [MASKED] care team Followup Instructions: [MASKED]	[]	[ "I130", "N179", "G4700", "E1122", "I2510", "Z86718", "E785", "G8929", "Z66" ]	[ "I4892: Unspecified atrial flutter", "I5021: Acute 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", "H348192: Central retinal vein occlusion, unspecified eye, stable/Old central retinal vein occlusion", "N179: Acute kidney failure, unspecified", "G4700: Insomnia, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z86711: Personal history of pulmonary embolism", "Z86718: Personal history of other venous thrombosis and embolism", "R001: Bradycardia, unspecified", "I447: Left bundle-branch block, unspecified", "Z8546: Personal history of malignant neoplasm of prostate", "Z85038: Personal history of other malignant neoplasm of large intestine", "F0390: Unspecified dementia without behavioral disturbance", "E559: Vitamin D deficiency, unspecified", "E785: Hyperlipidemia, unspecified", "I428: Other cardiomyopathies", "G8929: Other chronic pain", "Z66: Do not resuscitate", "I479: Paroxysmal tachycardia, unspecified", "F4320: Adjustment disorder, unspecified" ]
10,091,873	20,111,136	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing / Iodinated Contrast Media - IV Dye Attending: ___. Chief Complaint: throat pain, nausea, and vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a pleasant ___ w/ invasive squamous cell ca of OP who was just started on Cisplatin/XRT ___ who p/w progressive odynophagia, unable to eat for several days. He was unable to attend XRT today due to vomiting, nearly ___ since ___. Emesis is NBNB and throat pain is progressively worse as well. He has had throat pain before however over the past two days, he has had significantly worse throat pain, worse with swallowing. In ED, received Zofran w/o effect. He received 1 mg Ativan w/ reglan 10 mg, as well as 1L NS, 0.5 mg IV dilaudid. He experienced significant relief w/ the dilaudid and was asleep on arrival to OMED. However on my evaluation, on awakening, he had significant difficulty speaking due to oral pain. He notes the pain is limited to his OP area, none in his chest. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): C1D1 CISplatin ___ PAST MEDICAL HISTORY (per OMR): 1. Graves disease 2. Kidney stones 3. Sleep apnea 4. Anxiety with OCD features Social History: ___ Family History: Mother has ___ disease, father has emphysema, uncle recently diagnosed with head and neck cancer. Physical Exam: ADMISSION PHYSICAL EXAM: ===================== VITAL SIGNS: ___ ___ 16 98% RA General: NAD, Resting in bed comfortably, has significant difficulty speaking due to pain and dry throat HEENT: MM dry, + thrush, + hard palate and soft palate mucositis CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no palpable masses or HSM LIMBS: WWP, no ___, no tremors SKIN: No rashes on the extremities NEURO: Grossly normal DISCHARGE PHYSICAL EXAM: ====================== VITAL SIGNS: 98.2 122/84 84 18 97% RA General: NAD, lying comfortably in bed, hoarse voice HEENT: White plaque in posterior oropharynx, with white lesions on palate. Has desquamation of the hard palate and soft palate CV: RRR. Normal S1/S2. No murmurs, rubs, or gallops. PULM: No increase work of breathing. CTA b/l. No crackles, murmurs, rhonchi ABD: BS+, soft, nontender, nondistended. LIMBS: WWP, no ___ edema. SKIN: No rashes on the extremities NEURO: AOx3. Pertinent Results: ADMISSION LABS: ============== ___ 10:10PM BLOOD WBC-6.7# RBC-4.54* Hgb-13.6* Hct-38.8* MCV-86 MCH-30.0 MCHC-35.1 RDW-12.5 RDWSD-38.7 Plt ___ ___ 10:10PM BLOOD Neuts-85.6* Lymphs-4.8* Monos-8.6 Eos-0.4* Baso-0.0 Im ___ AbsNeut-5.76# AbsLymp-0.32* AbsMono-0.58 AbsEos-0.03* AbsBaso-0.00* ___ 10:10PM BLOOD Glucose-123* UreaN-27* Creat-1.0 Na-135 K-3.5 Cl-96 HCO3-27 AnGap-16 ___ 10:10PM BLOOD ALT-33 AST-16 AlkPhos-97 TotBili-0.5 ___ 10:10PM BLOOD Lipase-55 ___ 10:10PM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.4 Mg-1.7 DISCHARGE LABS: ============== ___ 07:23AM BLOOD WBC-6.0 RBC-3.55* Hgb-10.8* Hct-31.2* MCV-88 MCH-30.4 MCHC-34.6 RDW-12.8 RDWSD-40.9 Plt ___ ___ 07:23AM BLOOD Glucose-94 UreaN-7 Creat-0.9 Na-138 K-3.4 Cl-102 HCO3-29 AnGap-10 ___ 07:23AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.7 IMAGING: ======= None Brief Hospital Course: ___ w/ HPV positive oropharyngeal cancer (Stage ___, T2N2M0) currently on Cisplatin/XRT started on ___, presenting with severe odynophagia and persistent N/V. #Odynophagia Patient presented with severe throat pain with evidence of mucositis likely due to radiation therapy. Patient also with evidence of thrush on initial exam with likely oropharyngeal candidiasis. Patient was started on fluconazole and nystatin for a 10 day course to treat the candidiasis. We continued his viscous lidocaine to treat the pain. He was also started on Maalox/diphenhydramine/lidocaine and liquid morphine. #Nausea and vomiting: Patient with nausea and vomiting, likely due to chemotherapy despite long interval between treatment initiation and symptom appearance. His severe pain could also play a factor. Patient did not have any abdominal pain or diarrhea to indicate gastroenteritis. Patient was passing gas. His zofran was changed from PRN to a standing dose. He was also started on PRN Ativan, olanzapine, and prochlorperazine for symptom control. #Oropharyngeal squamous cell carcinoma: Patient is stage ___, T2N2M0 currently on cisplatin/xrt (D1= ___. He was continued on radiation therapy as an inpatient. His next dose of cisplatin on ___. #Hypothyroidism: Patient with hypothyroidism. He was continued on his home methimazole. #Anxiety: Patient was continued on his home clonazepam #Depression: Patient was continued on his home citalopram MEDICATION CHANGES: ================== - started on fluconazole 200 mg PO/NG q24h - started on morphine oral solution 2mg/mL 10 mg PO q4H PRN pain - started on multivitamin 5mL PO daily - started on olanzapine ODT 5mg PO daily PRN for nausea - started on lorazepam 0.5-1 mg SL q4H PRN for nausea - changed ondansetron ODT 8mg SL q8h from PRN to standing for nausea - changed citalopram from 40mg qHS to 20mg qHS until he completes his course of fluconazole TRANSITIONAL ISSUES: =================== - Patient started on standing Zofran for nausea control. Please reassess need for continued use for symptom control. - Patient with likely oropharyngeal candidiasis, started on fluconazole for 10 day course ___ - ___. - Patient's citalopram was lowered from 40mg qHS to 20mg qHS due to drug interaction with fluconazole. Please resume citalopram at pre-admission dose once fluconazole treatment finished. FULL CODE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 40 mg PO QHS 2. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 3. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 4. Methimazole 10 mg PO QHS 5. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN Pain - Moderate 6. Ondansetron ODT 8 mg PO Q8H:PRN nausea Discharge Medications: 1. Aquaphor Ointment 1 Appl TP TID:PRN radiation burn neck RX white petrolatum [Vaseline White Petroleum] apply to neck rash TID PRN Disp #30 Packet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 50 mg/5 mL 10 ml by mouth twice a day Refills:0 3. Fluconazole 200 mg PO Q24H Duration: 10 Days RX fluconazole 200 mg 1 tablet(s) by mouth daily Disp #8 Tablet Refills:0 4. LORazepam 0.5-1 mg SL Q4H:PRN nausea RX lorazepam 0.5 mg ___ tablet(s) by mouth q4 PRN Disp #60 Tablet Refills:0 5. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID 6. Multivitamins 5 mL PO DAILY RX multivitamin 5 ml by mouth daily Disp ___ Milliliter Refills:0 7. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY:PRN nausea RX olanzapine 5 mg 1 tablet(s) by mouth daily PRN Disp #30 Tablet Refills:0 8. Scopolamine Patch 1 PTCH TD ONCE Duration: 72 Hours RX scopolamine base [Transderm-Scop] 1.5 mg (delivers 1 mg over 3 days) place on neck q72h Disp #10 Each Refills:0 9. Senna 8.6 mg PO BID RX sennosides [senna] 8.8 mg/5 mL 5 ml by mouth twice a day Refills:0 10. Citalopram 20 mg PO QHS dose lowered due to drug interaction with antifungal medication RX citalopram 20 mg 1 tablet(s) by mouth at bedtime Disp #9 Tablet Refills:0 11. Ondansetron ODT 8 mg PO Q8H RX ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours Disp #30 Tablet Refills:*0 12. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 13. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 14. Methimazole 10 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Odynophagia Dysphagia Nausea Vomiting Oropharyngeal Candidiasis SECONDARY DIAGNOSIS: =================== Oropharyngeal squamous cell carcinoma Hypothyroidism Anxiety Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ with throat pain, nausea, and vomiting. We believe that your nausea and vomiting was the result of your chemotherapy treatment. We gave you fluids through the blood to help prevent dehydration. We also started you on medications to control your nausea and vomiting. Please continue to take these medications to control any nausea or vomiting symptoms. Your throat pain was likely due to your radiation treatment. We gave you pain medications to control your pain. However, we also suspected that you had a fungal infection in your mouth and throat and gave you medications to treat the infection. Please continue to take the antifungal medications until ___. During your admission, you also continued to receive your radiation therapy. Please continue seeing your outpatient oncologist for continuation of your cancer treatment. We wish you the best with your health, Your ___ Care Team Followup Instructions: ___	[ "K1233", "B370", "C770", "C109", "A630", "E039", "F419", "F329", "R112", "T451X5A", "Y842", "Y929" ]	Allergies: Iodine-Iodine Containing / Iodinated Contrast Media - IV Dye Chief Complaint: throat pain, nausea, and vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a pleasant [MASKED] w/ invasive squamous cell ca of OP who was just started on Cisplatin/XRT [MASKED] who p/w progressive odynophagia, unable to eat for several days. He was unable to attend XRT today due to vomiting, nearly [MASKED] since [MASKED]. Emesis is NBNB and throat pain is progressively worse as well. He has had throat pain before however over the past two days, he has had significantly worse throat pain, worse with swallowing. In ED, received Zofran w/o effect. He received 1 mg Ativan w/ reglan 10 mg, as well as 1L NS, 0.5 mg IV dilaudid. He experienced significant relief w/ the dilaudid and was asleep on arrival to OMED. However on my evaluation, on awakening, he had significant difficulty speaking due to oral pain. He notes the pain is limited to his OP area, none in his chest. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): C1D1 CISplatin [MASKED] PAST MEDICAL HISTORY (per OMR): 1. Graves disease 2. Kidney stones 3. Sleep apnea 4. Anxiety with OCD features Social History: [MASKED] Family History: Mother has [MASKED] disease, father has emphysema, uncle recently diagnosed with head and neck cancer. Physical Exam: ADMISSION PHYSICAL EXAM: ===================== VITAL SIGNS: [MASKED] [MASKED] 16 98% RA General: NAD, Resting in bed comfortably, has significant difficulty speaking due to pain and dry throat HEENT: MM dry, + thrush, + hard palate and soft palate mucositis CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no palpable masses or HSM LIMBS: WWP, no [MASKED], no tremors SKIN: No rashes on the extremities NEURO: Grossly normal DISCHARGE PHYSICAL EXAM: ====================== VITAL SIGNS: 98.2 122/84 84 18 97% RA General: NAD, lying comfortably in bed, hoarse voice HEENT: White plaque in posterior oropharynx, with white lesions on palate. Has desquamation of the hard palate and soft palate CV: RRR. Normal S1/S2. No murmurs, rubs, or gallops. PULM: No increase work of breathing. CTA b/l. No crackles, murmurs, rhonchi ABD: BS+, soft, nontender, nondistended. LIMBS: WWP, no [MASKED] edema. SKIN: No rashes on the extremities NEURO: AOx3. Pertinent Results: ADMISSION LABS: ============== [MASKED] 10:10PM BLOOD WBC-6.7# RBC-4.54* Hgb-13.6* Hct-38.8* MCV-86 MCH-30.0 MCHC-35.1 RDW-12.5 RDWSD-38.7 Plt [MASKED] [MASKED] 10:10PM BLOOD Neuts-85.6* Lymphs-4.8* Monos-8.6 Eos-0.4* Baso-0.0 Im [MASKED] AbsNeut-5.76# AbsLymp-0.32* AbsMono-0.58 AbsEos-0.03* AbsBaso-0.00* [MASKED] 10:10PM BLOOD Glucose-123* UreaN-27* Creat-1.0 Na-135 K-3.5 Cl-96 HCO3-27 AnGap-16 [MASKED] 10:10PM BLOOD ALT-33 AST-16 AlkPhos-97 TotBili-0.5 [MASKED] 10:10PM BLOOD Lipase-55 [MASKED] 10:10PM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.4 Mg-1.7 DISCHARGE LABS: ============== [MASKED] 07:23AM BLOOD WBC-6.0 RBC-3.55* Hgb-10.8* Hct-31.2* MCV-88 MCH-30.4 MCHC-34.6 RDW-12.8 RDWSD-40.9 Plt [MASKED] [MASKED] 07:23AM BLOOD Glucose-94 UreaN-7 Creat-0.9 Na-138 K-3.4 Cl-102 HCO3-29 AnGap-10 [MASKED] 07:23AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.7 IMAGING: ======= None Brief Hospital Course: [MASKED] w/ HPV positive oropharyngeal cancer (Stage [MASKED], T2N2M0) currently on Cisplatin/XRT started on [MASKED], presenting with severe odynophagia and persistent N/V. #Odynophagia Patient presented with severe throat pain with evidence of mucositis likely due to radiation therapy. Patient also with evidence of thrush on initial exam with likely oropharyngeal candidiasis. Patient was started on fluconazole and nystatin for a 10 day course to treat the candidiasis. We continued his viscous lidocaine to treat the pain. He was also started on Maalox/diphenhydramine/lidocaine and liquid morphine. #Nausea and vomiting: Patient with nausea and vomiting, likely due to chemotherapy despite long interval between treatment initiation and symptom appearance. His severe pain could also play a factor. Patient did not have any abdominal pain or diarrhea to indicate gastroenteritis. Patient was passing gas. His zofran was changed from PRN to a standing dose. He was also started on PRN Ativan, olanzapine, and prochlorperazine for symptom control. #Oropharyngeal squamous cell carcinoma: Patient is stage [MASKED], T2N2M0 currently on cisplatin/xrt (D1= [MASKED]. He was continued on radiation therapy as an inpatient. His next dose of cisplatin on [MASKED]. #Hypothyroidism: Patient with hypothyroidism. He was continued on his home methimazole. #Anxiety: Patient was continued on his home clonazepam #Depression: Patient was continued on his home citalopram MEDICATION CHANGES: ================== - started on fluconazole 200 mg PO/NG q24h - started on morphine oral solution 2mg/mL 10 mg PO q4H PRN pain - started on multivitamin 5mL PO daily - started on olanzapine ODT 5mg PO daily PRN for nausea - started on lorazepam 0.5-1 mg SL q4H PRN for nausea - changed ondansetron ODT 8mg SL q8h from PRN to standing for nausea - changed citalopram from 40mg qHS to 20mg qHS until he completes his course of fluconazole TRANSITIONAL ISSUES: =================== - Patient started on standing Zofran for nausea control. Please reassess need for continued use for symptom control. - Patient with likely oropharyngeal candidiasis, started on fluconazole for 10 day course [MASKED] - [MASKED]. - Patient's citalopram was lowered from 40mg qHS to 20mg qHS due to drug interaction with fluconazole. Please resume citalopram at pre-admission dose once fluconazole treatment finished. FULL CODE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 40 mg PO QHS 2. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 3. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 4. Methimazole 10 mg PO QHS 5. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN Pain - Moderate 6. Ondansetron ODT 8 mg PO Q8H:PRN nausea Discharge Medications: 1. Aquaphor Ointment 1 Appl TP TID:PRN radiation burn neck RX white petrolatum [Vaseline White Petroleum] apply to neck rash TID PRN Disp #30 Packet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 50 mg/5 mL 10 ml by mouth twice a day Refills:0 3. Fluconazole 200 mg PO Q24H Duration: 10 Days RX fluconazole 200 mg 1 tablet(s) by mouth daily Disp #8 Tablet Refills:0 4. LORazepam 0.5-1 mg SL Q4H:PRN nausea RX lorazepam 0.5 mg [MASKED] tablet(s) by mouth q4 PRN Disp #60 Tablet Refills:0 5. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID 6. Multivitamins 5 mL PO DAILY RX multivitamin 5 ml by mouth daily Disp [MASKED] Milliliter Refills:0 7. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY:PRN nausea RX olanzapine 5 mg 1 tablet(s) by mouth daily PRN Disp #30 Tablet Refills:0 8. Scopolamine Patch 1 PTCH TD ONCE Duration: 72 Hours RX scopolamine base [Transderm-Scop] 1.5 mg (delivers 1 mg over 3 days) place on neck q72h Disp #10 Each Refills:0 9. Senna 8.6 mg PO BID RX sennosides [senna] 8.8 mg/5 mL 5 ml by mouth twice a day Refills:0 10. Citalopram 20 mg PO QHS dose lowered due to drug interaction with antifungal medication RX citalopram 20 mg 1 tablet(s) by mouth at bedtime Disp #9 Tablet Refills:0 11. Ondansetron ODT 8 mg PO Q8H RX ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours Disp #30 Tablet Refills:*0 12. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 13. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 14. Methimazole 10 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Odynophagia Dysphagia Nausea Vomiting Oropharyngeal Candidiasis SECONDARY DIAGNOSIS: =================== Oropharyngeal squamous cell carcinoma Hypothyroidism Anxiety Depression 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] with throat pain, nausea, and vomiting. We believe that your nausea and vomiting was the result of your chemotherapy treatment. We gave you fluids through the blood to help prevent dehydration. We also started you on medications to control your nausea and vomiting. Please continue to take these medications to control any nausea or vomiting symptoms. Your throat pain was likely due to your radiation treatment. We gave you pain medications to control your pain. However, we also suspected that you had a fungal infection in your mouth and throat and gave you medications to treat the infection. Please continue to take the antifungal medications until [MASKED]. During your admission, you also continued to receive your radiation therapy. Please continue seeing your outpatient oncologist for continuation of your cancer treatment. We wish you the best with your health, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "E039", "F419", "F329", "Y929" ]	[ "K1233: Oral mucositis (ulcerative) due to radiation", "B370: Candidal stomatitis", "C770: Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck", "C109: Malignant neoplasm of oropharynx, unspecified", "A630: Anogenital (venereal) warts", "E039: Hypothyroidism, unspecified", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "R112: Nausea with vomiting, unspecified", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y842: Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable" ]
10,091,873	20,326,539	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing / Iodinated Contrast Media - IV Dye Attending: ___. Chief Complaint: Nausea and vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Note Date: ___ Signed by ___, MD on ___ at 11:08 pm Affiliation: ___ ============================================================= ONCOLOGY ___ ADMISSION NOTE ___ Time: 1800 ============================================================= PRIMARY ONCOLOGIST: ___ PRIMARY DIAGNOSIS: HPV+ Oropharyngeal Squamous Cell Cancer TREATMENT REGIMEN: CC: ___ and vomiting HISTORY OF PRESENTING ILLNESS: Mr. ___ is a ___ year old male, with past history of Stage IV HPV oropharyngeal cancer recently admitted with recurrent right jaw pain and weight loss with G-tube placement who is admitted from the ED with nausea, vomiting, and diarrhea. Patient admitted ___ to ___. At the time he had recurrent jaw pain and poor po intake with weight loss. He was treated empirically for ___ esophagitis and aspiration pneumonia. Also had G-tube placed ___ and initiated TF's. During hospitalization there was concern for localized tumor recurrence. Repeat PET-CT showed increased FDG avidity, although unclear if recurrence of if post-radiation effects. CT scan of neck shows evidence of mass, could include recurrence of disease or scar tissue or post-treatment changes. CT shows overall decrease in size of previously seen mass but with an area of necrosis. Previous PET scan done that did show some residual activity. No visible ulceration on fiberoptic exam performed by ENT but did see cavitary lesion with fibrinous debris. No evidence of significant infection seen grossly but patient did spike a fever and he was started on unasyn and switched to Augmentin for total treatment course of 5 days. Given concern for recurrence of disease, MRI was obtained which showed "Peripherally enhancing and centrally non-enhancing right oropharyngeal lesion may represent posttreatment changes. However, residual tumor is not excluded". Biopsy was not obtained. He was given his MRI images to bring to evaluation at Mass Eye and Ear ___. His pain was controlled with fentanyl patch 25 mg, po oxycodone ___ mg q4hours, gabapentin 300 TID. He was evaluated by ___ and ENT and inpatient workup was further deferred with plan for referral to Mass Eye and Ear. On discharge, patient was tolerating small amount of po along with 1 can TF's daily. He was discharged on aggressive bowel reg due to constipation. ___ night went home had nonbloody diarrhea (first BM in a while). Yesterday nurse came and he threw up the tube feeds. 6 AM woke up with vomiting, tried po Zofran, at 8 AM again with diarrhea. Cans went in yesterday no problem no abd pain but 15 min later vomited it up. Today slightly dizzy with standing but not currently. Most of his pain is in his right jaw area and neck at site of mass, pain remains at ___ which is about where it was during his last admission. This is largely stable, but continues to be severely bothersome and impairing his ability to eat or swallow pills well but his primary reason for returning to hospital is nausea/vomiting/diarrhea. Since discharge, patient has felt "generally awful", including nausea and vomiting and diarrhea. Reports ___ episodes of non-bloody diarrhea daily along with inability to tolerate any po (difficulty swallowing due to pain, but also as above he vomited up the tube feed cans within 15 minutes of administration). He was prescribed Zofran last night without effect. Due to symptoms he presented to the ED today. In the ED, initial VS were pain 3, T 97.3, HR 118, BP 97/78, RR 18, O2 100%RA. Labs notable for ALT 39, K 4.6 HCO3 24, Cr 0.7, ALT 39, AST 3, ALP 88, TBIli 0.3, Alb 4.1, WBC 4.6 HCT 38.9, WBC 468. Plain film of abdomen showed G-tube in place with tip pointing to fundus. ___ was consulted who felt tube was in appropriate position. Patient was given 2L NS and IV Zofran. VS prior to transfer were pain 0, T 98.6, HR 89, BP 113/82, RR 18, O2 99%RA. On arrival to the floor, patient states he feels largely well as hi slast episode of nausea vomiting and diarrhea were all around 6 AM today and he has had none since. All other 10 point ROS neg including fevers, dysuria, flank pain, headache, visual changes. No sick contacts. No recent travel. No fevers or abodminal pain. Otherwise, no CP, no SOB. Patient was supposed to go to Mass Eye and Ear today to work up recurrence of cancer. Past Medical History: PAST ONCOLOGIC HISTORY: - ___ he was started on Cisplatin and RT. - ___ - ___ - Admission for nausea, vomiting and bleeding from oral cavity - ___ C2 Cisplatin - ___ - ___ - Admission for throat pain, inability to take PO and vomiting - Cisplatin discontinued - patient decided not to receive the third cycle. - ___ - Completion of RT. PAST MEDICAL HISTORY: 1. Graves disease 2. Kidney stones 3. Sleep apnea 4. Anxiety with OCD features 5. Oropharyngeal cancer Past Surgical History: 1. Carpal tunnel syndrome Social History: ___ Family History: Mother has ___ disease, father has emphysema, uncle diagnosed with head and neck cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 98.3 HR 89 BP 102/78 RR 18 SAT 100 % O2 on RA GENERAL: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI; HEENT: Oropharynx difficult to examine as cannot open mouth wide due to pain, but thrush on tongue visible. Pt in excruciating pain to the point of tears at even light palpation of the right side of the neck though no external erythema or skin breakdown at that area CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses, 2+ DP pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly. No erythema/drainage around G tube insertion site MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE PHYSICAL EXAM 98.3PO 98 / 58 R Lying 90 16 99 RA Heart RRR S1 and S2 normal No MRG Lungs- CTAB, No crackles or wheezes Abdomen- Soft NT ND Extremities No edema Mouth- unable to open mouth completely, out of visualized portion no thrush noted. Pertinent Results: ___ 07:00AM BLOOD WBC-2.8* RBC-3.57* Hgb-11.0* Hct-32.6* MCV-91 MCH-30.8 MCHC-33.7 RDW-11.4 RDWSD-38.0 Plt ___ ___ 07:00AM BLOOD Glucose-93 UreaN-10 Creat-0.6 Na-140 K-4.6 Cl-102 HCO3-28 AnGap-15 ___ 2:15 am STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). Brief Hospital Course: Mr. ___ is a ___ year old male, with past history of Stage IV HPV oropharyngeal cancer recently admitted with recurrent right jaw pain and weight loss with G-tube placement who is admitted from the ED with 3 days of nausea, vomiting, and diarrhea, also with persistent severe right sided neck pain. His symptoms improved by itself and infectious workup for noro and c diff was negative. He was evaluated by ___ while inpatient as he was unable to attend outpt ENT Appointment and he will be seen at their ___ facility for a biopsy and possible surgery. # Nausea/vomiting/diarrhea - Resolved. Likely viral etiology seen by ___ and G tube seems to be in correct place. TF were resumed yesterday 480cc bolus TID of OSmolite 1.5 patient tolerated tube feeds well. C.Diff and Noro virus PCR negative # Right neck pain/Cancer associated pain # Trismus: # Right Neck Swelling/Lymphadenopathy: # Right Jaw Pain: Regular US of neck was essentially normal. Pain well controlled with his current regimen. - Con't home fentanyl 25mcg - Oxycodone PRN - Gabapentin - crushed and through PEG tube. - trial lido patch over right neck # HPV+ Stage IV Oropharyngeal Carcinoma, s/p chemotherapy, XRT: Recent PET scan suggesting potential recurrence given uptake. See above for question of recurrence under neck pain. # Thrush: Treated with fluconazole for total course of 7 days (ended on ___ # Severe Malnutrition # Weight Loss: ___ to difficulty with eating because of pain, as well as likely underlying malignancy. Patient has lost 50 pounds since diagnosis with loss of 20 pounds in last three weeks. A PEG tube was placed on ___ and he was started on tube feeds. TUBE FEED PLAN on dishcarge: bolus 480 mL (2 cans) Osmolite 1.5 TID daily (2160 calories, 90 grams protein, 1097 mL free water). His tube feeds were resumed on D2 of hospitalization and he tolerated it well without any nausea or adverse events # Graves Disease: Methimazole able to be crushed, cont methimiazole 10 mg qhs. # Anxiety/Insomnia: Cont clonazepam # Depression with features of OCD: refused citalopram since he has not been taking it at home for sometime. Will stop citalopram. Summary, ___ y M with HPV + R oropharyngeal carcinoma presents with nausea , vomiting and diarrhea and inability to tolerate tube feeds well. Sx resolved on admission. Infectious workup for C diff and Noro negative. Seen by OMFS and he will follow with them as outpt for further management of the R oropharyngeal mass. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe 2. Fentanyl Patch 25 mcg/h TD Q72H 3. ClonazePAM 0.5 mg PO QHS:PRN insomnia 4. Methimazole 10 mg PO QHS 5. Bisacodyl 10 mg PO DAILY constipation 6. Docusate Sodium 100 mg PO BID 7. Gabapentin 600 mg PO TID 8. Senna 8.6 mg PO BID constipation 9. Citalopram 20 mg PO DAILY Discharge Medications: 1. Lidocaine 5% Patch 1 PTCH TD QPM 2. Ondansetron 8 mg PO Q8H:PRN nausea 3. Bisacodyl 10 mg PO DAILY constipation 4. ClonazePAM 0.5 mg PO QHS:PRN insomnia 5. Docusate Sodium 100 mg PO BID 6. Fentanyl Patch 25 mcg/h TD Q72H 7. Gabapentin 600 mg PO TID 8. Methimazole 10 mg PO QHS 9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe 10. Senna 8.6 mg PO BID constipation Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Nausea, vomiting and diarrhea R facial pain from oropharyngeal mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were admitted for increasing pain in your R face and nausea and diarrhea after takig tube feeds. Your symptoms resolved while you were inpatient and you tolerated the tube feeds well. You were evaluated by oromaxillofacial surgeons who will see you as an outpatient to perform a biopsy to help guide your treatment. It was a pleasure taking care of you. Sincerely ___ MD ___ Followup Instructions: ___	[ "R112", "R197", "R6884", "R252", "R591", "B379", "E43", "Z6821", "Z931", "Z85818", "E0500", "F418", "G4700", "F329", "G4730" ]	Allergies: Iodine-Iodine Containing / Iodinated Contrast Media - IV Dye Chief Complaint: Nausea and vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Note Date: [MASKED] Signed by [MASKED], MD on [MASKED] at 11:08 pm Affiliation: [MASKED] ============================================================= ONCOLOGY [MASKED] ADMISSION NOTE [MASKED] Time: 1800 ============================================================= PRIMARY ONCOLOGIST: [MASKED] PRIMARY DIAGNOSIS: HPV+ Oropharyngeal Squamous Cell Cancer TREATMENT REGIMEN: CC: [MASKED] and vomiting HISTORY OF PRESENTING ILLNESS: Mr. [MASKED] is a [MASKED] year old male, with past history of Stage IV HPV oropharyngeal cancer recently admitted with recurrent right jaw pain and weight loss with G-tube placement who is admitted from the ED with nausea, vomiting, and diarrhea. Patient admitted [MASKED] to [MASKED]. At the time he had recurrent jaw pain and poor po intake with weight loss. He was treated empirically for [MASKED] esophagitis and aspiration pneumonia. Also had G-tube placed [MASKED] and initiated TF's. During hospitalization there was concern for localized tumor recurrence. Repeat PET-CT showed increased FDG avidity, although unclear if recurrence of if post-radiation effects. CT scan of neck shows evidence of mass, could include recurrence of disease or scar tissue or post-treatment changes. CT shows overall decrease in size of previously seen mass but with an area of necrosis. Previous PET scan done that did show some residual activity. No visible ulceration on fiberoptic exam performed by ENT but did see cavitary lesion with fibrinous debris. No evidence of significant infection seen grossly but patient did spike a fever and he was started on unasyn and switched to Augmentin for total treatment course of 5 days. Given concern for recurrence of disease, MRI was obtained which showed "Peripherally enhancing and centrally non-enhancing right oropharyngeal lesion may represent posttreatment changes. However, residual tumor is not excluded". Biopsy was not obtained. He was given his MRI images to bring to evaluation at Mass Eye and Ear [MASKED]. His pain was controlled with fentanyl patch 25 mg, po oxycodone [MASKED] mg q4hours, gabapentin 300 TID. He was evaluated by [MASKED] and ENT and inpatient workup was further deferred with plan for referral to Mass Eye and Ear. On discharge, patient was tolerating small amount of po along with 1 can TF's daily. He was discharged on aggressive bowel reg due to constipation. [MASKED] night went home had nonbloody diarrhea (first BM in a while). Yesterday nurse came and he threw up the tube feeds. 6 AM woke up with vomiting, tried po Zofran, at 8 AM again with diarrhea. Cans went in yesterday no problem no abd pain but 15 min later vomited it up. Today slightly dizzy with standing but not currently. Most of his pain is in his right jaw area and neck at site of mass, pain remains at [MASKED] which is about where it was during his last admission. This is largely stable, but continues to be severely bothersome and impairing his ability to eat or swallow pills well but his primary reason for returning to hospital is nausea/vomiting/diarrhea. Since discharge, patient has felt "generally awful", including nausea and vomiting and diarrhea. Reports [MASKED] episodes of non-bloody diarrhea daily along with inability to tolerate any po (difficulty swallowing due to pain, but also as above he vomited up the tube feed cans within 15 minutes of administration). He was prescribed Zofran last night without effect. Due to symptoms he presented to the ED today. In the ED, initial VS were pain 3, T 97.3, HR 118, BP 97/78, RR 18, O2 100%RA. Labs notable for ALT 39, K 4.6 HCO3 24, Cr 0.7, ALT 39, AST 3, ALP 88, TBIli 0.3, Alb 4.1, WBC 4.6 HCT 38.9, WBC 468. Plain film of abdomen showed G-tube in place with tip pointing to fundus. [MASKED] was consulted who felt tube was in appropriate position. Patient was given 2L NS and IV Zofran. VS prior to transfer were pain 0, T 98.6, HR 89, BP 113/82, RR 18, O2 99%RA. On arrival to the floor, patient states he feels largely well as hi slast episode of nausea vomiting and diarrhea were all around 6 AM today and he has had none since. All other 10 point ROS neg including fevers, dysuria, flank pain, headache, visual changes. No sick contacts. No recent travel. No fevers or abodminal pain. Otherwise, no CP, no SOB. Patient was supposed to go to Mass Eye and Ear today to work up recurrence of cancer. Past Medical History: PAST ONCOLOGIC HISTORY: - [MASKED] he was started on Cisplatin and RT. - [MASKED] - [MASKED] - Admission for nausea, vomiting and bleeding from oral cavity - [MASKED] C2 Cisplatin - [MASKED] - [MASKED] - Admission for throat pain, inability to take PO and vomiting - Cisplatin discontinued - patient decided not to receive the third cycle. - [MASKED] - Completion of RT. PAST MEDICAL HISTORY: 1. Graves disease 2. Kidney stones 3. Sleep apnea 4. Anxiety with OCD features 5. Oropharyngeal cancer Past Surgical History: 1. Carpal tunnel syndrome Social History: [MASKED] Family History: Mother has [MASKED] disease, father has emphysema, uncle diagnosed with head and neck cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 98.3 HR 89 BP 102/78 RR 18 SAT 100 % O2 on RA GENERAL: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI; HEENT: Oropharynx difficult to examine as cannot open mouth wide due to pain, but thrush on tongue visible. Pt in excruciating pain to the point of tears at even light palpation of the right side of the neck though no external erythema or skin breakdown at that area CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses, 2+ DP pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly. No erythema/drainage around G tube insertion site MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE PHYSICAL EXAM 98.3PO 98 / 58 R Lying 90 16 99 RA Heart RRR S1 and S2 normal No MRG Lungs- CTAB, No crackles or wheezes Abdomen- Soft NT ND Extremities No edema Mouth- unable to open mouth completely, out of visualized portion no thrush noted. Pertinent Results: [MASKED] 07:00AM BLOOD WBC-2.8* RBC-3.57* Hgb-11.0* Hct-32.6* MCV-91 MCH-30.8 MCHC-33.7 RDW-11.4 RDWSD-38.0 Plt [MASKED] [MASKED] 07:00AM BLOOD Glucose-93 UreaN-10 Creat-0.6 Na-140 K-4.6 Cl-102 HCO3-28 AnGap-15 [MASKED] 2:15 am STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old male, with past history of Stage IV HPV oropharyngeal cancer recently admitted with recurrent right jaw pain and weight loss with G-tube placement who is admitted from the ED with 3 days of nausea, vomiting, and diarrhea, also with persistent severe right sided neck pain. His symptoms improved by itself and infectious workup for noro and c diff was negative. He was evaluated by [MASKED] while inpatient as he was unable to attend outpt ENT Appointment and he will be seen at their [MASKED] facility for a biopsy and possible surgery. # Nausea/vomiting/diarrhea - Resolved. Likely viral etiology seen by [MASKED] and G tube seems to be in correct place. TF were resumed yesterday 480cc bolus TID of OSmolite 1.5 patient tolerated tube feeds well. C.Diff and Noro virus PCR negative # Right neck pain/Cancer associated pain # Trismus: # Right Neck Swelling/Lymphadenopathy: # Right Jaw Pain: Regular US of neck was essentially normal. Pain well controlled with his current regimen. - Con't home fentanyl 25mcg - Oxycodone PRN - Gabapentin - crushed and through PEG tube. - trial lido patch over right neck # HPV+ Stage IV Oropharyngeal Carcinoma, s/p chemotherapy, XRT: Recent PET scan suggesting potential recurrence given uptake. See above for question of recurrence under neck pain. # Thrush: Treated with fluconazole for total course of 7 days (ended on [MASKED] # Severe Malnutrition # Weight Loss: [MASKED] to difficulty with eating because of pain, as well as likely underlying malignancy. Patient has lost 50 pounds since diagnosis with loss of 20 pounds in last three weeks. A PEG tube was placed on [MASKED] and he was started on tube feeds. TUBE FEED PLAN on dishcarge: bolus 480 mL (2 cans) Osmolite 1.5 TID daily (2160 calories, 90 grams protein, 1097 mL free water). His tube feeds were resumed on D2 of hospitalization and he tolerated it well without any nausea or adverse events # Graves Disease: Methimazole able to be crushed, cont methimiazole 10 mg qhs. # Anxiety/Insomnia: Cont clonazepam # Depression with features of OCD: refused citalopram since he has not been taking it at home for sometime. Will stop citalopram. Summary, [MASKED] y M with HPV + R oropharyngeal carcinoma presents with nausea , vomiting and diarrhea and inability to tolerate tube feeds well. Sx resolved on admission. Infectious workup for C diff and Noro negative. Seen by OMFS and he will follow with them as outpt for further management of the R oropharyngeal mass. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Severe 2. Fentanyl Patch 25 mcg/h TD Q72H 3. ClonazePAM 0.5 mg PO QHS:PRN insomnia 4. Methimazole 10 mg PO QHS 5. Bisacodyl 10 mg PO DAILY constipation 6. Docusate Sodium 100 mg PO BID 7. Gabapentin 600 mg PO TID 8. Senna 8.6 mg PO BID constipation 9. Citalopram 20 mg PO DAILY Discharge Medications: 1. Lidocaine 5% Patch 1 PTCH TD QPM 2. Ondansetron 8 mg PO Q8H:PRN nausea 3. Bisacodyl 10 mg PO DAILY constipation 4. ClonazePAM 0.5 mg PO QHS:PRN insomnia 5. Docusate Sodium 100 mg PO BID 6. Fentanyl Patch 25 mcg/h TD Q72H 7. Gabapentin 600 mg PO TID 8. Methimazole 10 mg PO QHS 9. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Severe 10. Senna 8.6 mg PO BID constipation Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Nausea, vomiting and diarrhea R facial pain from oropharyngeal mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], You were admitted for increasing pain in your R face and nausea and diarrhea after takig tube feeds. Your symptoms resolved while you were inpatient and you tolerated the tube feeds well. You were evaluated by oromaxillofacial surgeons who will see you as an outpatient to perform a biopsy to help guide your treatment. It was a pleasure taking care of you. Sincerely [MASKED] MD [MASKED] Followup Instructions: [MASKED]	[]	[ "G4700", "F329" ]	[ "R112: Nausea with vomiting, unspecified", "R197: Diarrhea, unspecified", "R6884: Jaw pain", "R252: Cramp and spasm", "R591: Generalized enlarged lymph nodes", "B379: Candidiasis, unspecified", "E43: Unspecified severe protein-calorie malnutrition", "Z6821: Body mass index [BMI] 21.0-21.9, adult", "Z931: Gastrostomy status", "Z85818: Personal history of malignant neoplasm of other sites of lip, oral cavity, and pharynx", "E0500: Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm", "F418: Other specified anxiety disorders", "G4700: Insomnia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "G4730: Sleep apnea, unspecified" ]
10,091,873	25,427,289	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing / Iodinated Contrast Media - IV Dye Attending: ___ Chief Complaint: Nausea, vomiting, neck pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ M PMHx notable for metastatic invasive oropharyngeal squamous cell carcinoma s/p chemotherapy/radiation (___), Grave's disease, kidney stones, and anxiety who presents with vomiting, neck pain, and neck swelling. Patient states that he was in his usual state of health, as recently as two days ago. Yesterday he began having anterior neck tenderness and swelling; it is described as "tender" and does not radiate. Pain is exacerbated by palpation of the exterior anterior neck, and mildly by swallowing; it is not relieved by anything. Pt tried to feed himself as usual through his G-tube, whereupon he began having vomiting. After several episodes of vomiting clear liquid, he noticed a scant amount of blood on his lips (though never saw any bright red in his emesis). Pt has been unable to keep anything down since that time, vomiting with even small sips of liquid at home. His nausea was not significantly improved with home ondansetron. Pt notes an episode of chills on the night prior to arrival (though he slept with the heat off). He denies overt fevers, cough, chest pain, shortness of breath, palpitations, diarrhea, urinary Sx, lightheadedness/dizziness, and numbness/tingling/focal weakness. In the ED, initial vitals: 97.4 111 119/73 16 100% RA - Labs were notable for: 13.2>12.6/37.1<239 Na 136 K 3.9 Cl 94 HCO3 23 BUN 27 Cr 0.9 Gluc 180 Lactate:2.3 - Imaging: CXR (___): IMPRESSION: No acute cardiopulmonary process. MRA Neck w/ and w/o contrast (___): Pending - Patient was given: Vanc/zosyn Morphine 1L NS - Consults: ___ and ENT were consulted. - Decision was made to admit to ___ for management of sepsis - Vitals prior to transfer were 99.1 93 201/66 18 98% RA Of note, patient had two recent admissions: 1) Patient was admitted ___ to ___. At the time he had recurrent jaw pain and poor po intake with weight loss. Imaging was concerning for possible recurrence, with CT showing neck mass. He was treated empirically for ___ esophagitis and aspiration pneumonia. Due to poor po intake, he had a G-tube placed ___ and initiated TF's. 2) Patient admitted ___ to ___ for nausea, vomiting, and pain. He received uptitrated pain medications with improvement. He was seen by his Oncologist, Dr. ___ follow up on ___. He also follows with Dr. ___ from ___, who performed a neck biopsy for R neck swelling on ___. He underwent outpatient direct laryngoscopy and biopsy by ___ on ___ procedure was uncomplicated. Biopsy showed "Necro-inflammatory debris with focal bacterial overgrowth. Granulation tissue with focal atypical cells". On arrival to the floor, Pt endorses the above history. He states he feels "very dehydrated" and is asking for more IV fluids. Does not have an appetite, though is willing to try some ice cubes to moisten his mouth. Past Medical History: PAST ONCOLOGIC HISTORY: - ___ he was started on Cisplatin and RT. - ___ - ___ - Admission for nausea, vomiting and bleeding from oral cavity - ___ C2 Cisplatin - ___ - ___ - Admission for throat pain, inability to take PO and vomiting - Cisplatin discontinued - patient decided not to receive the third cycle. - ___ - Completion of RT. PAST MEDICAL HISTORY: -Graves disease -Kidney stones -Sleep apnea -Anxiety with OCD features PAST SURGICAL HISTORY: -Carpal tunnel syndrome Social History: ___ Family History: Mother has ___ disease, father has emphysema, uncle diagnosed with head and neck cancer. Physical Exam: ADMISSION: Vitals: T 99.3 BP 110/73 HR 101 RR 20 O2 96% on RA GENERAL: Thin Caucasian gentleman, lying in bed and uncomfortable appearing. HEENT: Sclerae anicteric. Trismus bilaterally, with Pt able to open his mouth approximately 3-4cm. Mucous membranes moist, with some white patches on tongue that clear with swallow. Palpable area of tensor tympani spasm bilaterally, which Pt endorses is tender. EOMI, PERRLA. NECK: 1cm x 1cm firm fixed lymph node in the R anterior cervical chain, nontender. Soft 3cm x 4cm mass visible above the sternal notch, which is tender to palpation but not firm or fixed or truly discernable on palpation. No subcutaneous emphysema in the neck space. Thyroid nonpalpable. LUNGS: Clear to auscultation bilaterally. No stridor, wheezes, rales, rhonchi. CV: Regular rate and rhythm, normal S1/S2, no murmurs/gallops/rubs. ABD: Normoactive bowel sounds. G tube present in the mid-abdomen at the level of the umbilicus, covered with a clean dry dressing. Abdomen is soft and nontender to palpation throughout. No hepatosplenomegaly. EXT: Warm and well perfused. No cyanosis or edema of the lower extremities. +2 dorsalis pedis pulses bilaterally. SKIN: Mild darkening of skin of anterior neck from the top of the cricoid cartilage to sternal notch. NEURO: CN II-XII intact. ___ strength in the upper and lower extremities bilaterally. A&O x3, appropriate thought content. ACCESS: PIV DISCHARGE: Vitals: 98.7 ___ 18 97% RA I/O: 1280/2450 / NR GENERAL: Thin Caucasian gentleman, lying in bed and somewhat uncomfortable. Able to drink sips of water demonstrably without difficulty. HEENT: Sclerae anicteric. Trismus bilaterally, with Pt able to open his mouth approximately 3-4cm. Mucous membranes moist. NECK: 1cm x 1cm firm fixed lymph node in the R anterior cervical chain, nontender and stable from prior exam. Soft 3cm x 4cm mass visible above the sternal notch, no longer tender to palpation; very soft to the touch. No subcutaneous emphysema in the neck space. LUNGS: Clear to auscultation bilaterally. No stridor, wheezes, rales, rhonchi. CV: Regular rate and rhythm, normal S1/S2, no murmurs/gallops/rubs. ABD: Normoactive bowel sounds. G tube present in the mid-abdomen at the level of the umbilicus, covered with a clean dry dressing. Abdomen is soft and nontender to palpation throughout. EXT: Warm and well perfused. No cyanosis or edema of the lower extremities. +2 dorsalis pedis pulses bilaterally. SKIN: Mild darkening of skin of anterior neck from the top of the cricoid cartilage to sternal notch, extending to line of medial clavicles. No warmth or tenderness to palpation of this skin change. NEURO: A&O x3. Moves all four extremities spontaneously. Endorses "tingling" R jaw pain, stable from prior. ACCESS: PIV Pertinent Results: ADMISSION LABS: ___ 08:36AM BLOOD WBC-13.2# RBC-4.07 Hgb-12.6* Hct-37.1* MCV-91 MCH-31.0 MCHC-34.0 RDW-13.4 RDWSD-44.4 Plt ___ ___ 08:36AM BLOOD Neuts-93.6* Lymphs-2.4* Monos-3.3* Eos-0.0* Baso-0.2 Im ___ AbsNeut-12.31# AbsLymp-0.31 AbsMono-0.44 AbsEos-0.00* AbsBaso-0.02 ___ 08:36AM BLOOD Glucose-180* UreaN-27* Creat-0.9 Na-136 K-3.9 Cl-94* HCO3-23 AnGap-23* ___ 07:05PM BLOOD ALT-16 AST-14 LD(LDH)-102 AlkPhos-53 TotBili-0.6 ___ 07:05PM BLOOD Calcium-8.8 Phos-2.2* Mg-1.8 PERTINENT LABS: Iron-15* ___ 07:05PM BLOOD calTIBC-229* Hapto-238* Ferritn-579* TRF-176* ___ 08:00AM BLOOD TSH-1.1 ___ 08:00AM BLOOD T4-7.7 IMAGING: -CXR (___): IMPRESSION: No acute cardiopulmonary process. -MRI NECK SOFT TISSUE ___, final report): 1. Slight interval decrease in size of a 19 x 19 mm ill-defined heterogeneously enhancing right tonsillar mass, which may represent posttreatment change, though residual tumor is not excluded. *ALTHOUGH IT IS GETTING SMALLER, IT WOULD BE SURPRISING IF THERE WERE NO RESIDUAL TUMOR. MORE LIEKLY THE DECREASE REFLECTS RESPONSE TO THERAPY BUT THE LESION WE SEE IS TUMOR.* 1. Diffuse edema throughout the anterior superficial soft tissues of the neck, leading to the upper chest and may represent post radiation effect, though cellulitis remains a possibility. This does not appear to contiguously extend into the deep spaces of the neck. 2. Minimal edema in the retropharyngeal space appears unchanged to the ___ examination, and may be a result of posttreatment effect. 3. No organizing/drainable fluid collection. -ECG (___): Sinus rhythm. Non-specific anterior repolarization abnormalities. Compared to the previous tracing of ___ no diagnostic interim change. MICRO: ___ 8:13 pm URINE Source: ___. FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 2:55 pm URINE FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 11:25 am BLOOD CULTURE *FINAL REPORT ___ Blood Culture, Routine (Final ___: CANCELLED. Culture negative as of: 17:20 ___ ON ___. Test canceled/culture discontinued per: ___. PATIENT CREDITED. __________________________________________________________ ___ 11:25 am BLOOD CULTURE #2. Blood Culture, Routine (Pending): Brief Hospital Course: ___ with metastatic invasive R oropharyngeal squamous cell carcinoma (s/p chemotherapy and radiation for 2 cycles), Grave's disease, and malnutrition requiring G-tube placement (___) who presented with sudden-onset nausea, vomiting, and neck pain one day prior to arrival. He had inability to tolerate anything by mouth or G-tube due to vomiting, so he came to the ED for further evaluation. He was found to have leukocytosis to 13, soft pressures, and a mild lactate elevation to 2.3. He was given IV fluids, IV ondansetron, and metoclopramide - to eventual relief of his nausea. For his neck pain, he was given IV morphine while unable to tolerate PO. An MRI neck was performed to evaluate for deep neck space infections; it did not show any abscesses or fluid collections, but did comment on some possible residual tumor in the R tonsillar area. After close monitoring, the pt's diet was gradually advanced to his home tube feeding regimen, and he was able to take oxycodone by mouth to control his pain. He was discharged with close follow-up with his PCP, as well as plan for follow-up with his primary oncologist. ============= ACTIVE ISSUES ============= # NECK PAIN, SWELLING: With somewhat prominent anterior neck soft tissue mass, soft to palpation and without subcutaneous emphysema; also a small 1cm x 1cm firm fixed nodule in the R submandibular area where Pt states his previous tumor was. MRI neck performed due to concern for abscess/deep neck space infection; no infection noted, though possible residual tumor present in the R tonsillar area. DDx for his pain includes residual tumor (as noted on MRI neck), post radiation-treatment change/pain. Pain improved with IV morphine in-house, and was well controlled with his home PO oxycodone (and an uptitrated dose of his home gabapentin) prior to discharge. - Continued home fentanyl 25mcg patch and home oxycodone. - Uptitrated home gabapentin 600mg TID -> 800mg TID. # VOMITING: With sudden onset and rapid resolution. Pt reported small amount of blood streaking in his emesis after several bouts of retching, consistent with small ___ tear. Possibly due to some viral gastroenteritis vs. constipation. Started metoclopramide, to improvement of constipation and possibly nausea. Briefly entertained possibility of kidney stones (with hematuria, see below), though unlikely given no flank pain. -Discharged on metoclopramide 5mg QIDACHS -Discharged with zofran # HEMATURIA: Urine grossly appeared yellow. Pt without flank pain, though has h/o kidney stones and this could represent chronic renal calculi. On further review, Pt has had hematuria to this degree for several years without workup. He should be referred to Urology for further evaluation. ===================== CHRONIC/STABLE ISSUES ===================== # HPV+ Stage IV Oropharyngeal Carcinoma, s/p chemotherapy, XRT: Recent PET scan suggesting potential recurrence given uptake, and MRI neck during this admission with possible residual tumor. Pt states he would be willing to undergo another cycle of chemo/radiation if needed. He will need a referral for a PET scan. He will follow up with Dr. ___ ongoing discussion. # Severe Malnutrition: # Weight Loss: Chronic and baseline. Tolerated bolus tube feeds at home rate prior to discharge. # Graves Disease: His TFTs were within normal limits with TSH 1.1, T4 7. He was continued on methimazole # Anxiety/Insomnia: He was continued on his home clonazepam # Depression with features of OCD: No longer on treatment. He should have ongoing PHQ-9 monitoring and discussion re: referral for therapy. =================== TRANSITIONAL ISSUES =================== # HCP/Contact: ___ (wife) ___, ___ # Code: Full [ ] MEDICATION CHANGES: - Added metoclopramide 5mg QIDACHS - Uptitrated gabapentin from 600mg TID -> 800mg TID [ ] HEMATURIA: - Consider referral to urology for outpatient workup. [ ] OROPHARYNGEAL SQUAMOUS CELL CARCINOMA: - Pt with possible residual tumor based on his MRI during this hospital stay. - Will need assistance with scheduling PET scan Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 600 mg PO TID 2. Methimazole 10 mg PO QHS 3. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 4. Docusate Sodium 100 mg PO DAILY:PRN when taking home oxycodone 5. Fentanyl Patch 25 mcg/h TD Q72H 6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Discharge Medications: 1. Gabapentin 800 mg PO TID RX gabapentin 800 mg 1 tablet(s) by mouth three times a day Disp #9 Tablet Refills:0 2. Metoclopramide 5 mg PO QIDACHS RX metoclopramide HCl 5 mg 5 mg by mouth QIDACHS Disp #60 Tablet Refills:3 3. Ondansetron 4 mg PO Q8H:PRN nausea RX ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #60 Tablet Refills:1 4. Gabapentin 800 mg PO TID RX gabapentin 300 mg/6 mL (6 mL) 15 mL by mouth three times a day Disp #1350 Milliliter Refills:1 5. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 6. Docusate Sodium 100 mg PO DAILY:PRN when taking home oxycodone 7. Fentanyl Patch 25 mcg/h TD Q72H 8. Methimazole 10 mg PO QHS 9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg ___ tablet(s) by mouth q4 Disp #40 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY ======= Nausea and vomiting Neck pain SECONDARY ========= History of metastatic tonsillar squamous cell carcinoma, with possible recurrence Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure to care for you at the ___ ___. =============================== WHY WAS I SEEN IN THE HOSPITAL? =============================== - You were seen because you were having nausea and vomiting after eating. - You also had new pain and swelling in the front of your neck, which made us worried about a neck infection. ========================================== WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - We gave you medicine through the IV ("Zofran") for your nausea. - We also started a new medicine by mouth called "metoclopramide" (or "Reglan"), which can help with nausea and constipation. - We gave you pain medicine through the IV to help with your neck pain. - We gradually increased your diet, until you were back on your home tube feeding regimen. - We took a special picture of your neck ("MRI") to look for abscesses or deep infections in the neck. It did not show any signs concerning for infection. However, our radiologists are not sure if there is any remaining tumor in your neck after your recent round of chemo and radiation. ==================================== WHAT SHOULD I DO WHEN I RETURN HOME? ==================================== - Continue to eat and drink as you usually do. - Continue to take the metoclopramide for your nausea and constipation before you eat or give yourself tube feeds. You can also take zofran as needed for nausea - Your pharmacy will be able to order the liquid gabapentin for you. Please take the pills at a dose of 800mg three times daily until the liquid formulation is available. - Please follow up with your primary care physician (Dr. ___ next week. Dr. ___ will help set up an appointment for the following week to discuss the next steps in following up your symptoms. We wish you the best, Your ___ Oncology Care Team Followup Instructions: ___	[ "R112", "E43", "C140", "M542", "Z9221", "Z923", "E0500", "F419", "G4700", "Z6823", "R3129" ]	Allergies: Iodine-Iodine Containing / Iodinated Contrast Media - IV Dye Chief Complaint: Nausea, vomiting, neck pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] M PMHx notable for metastatic invasive oropharyngeal squamous cell carcinoma s/p chemotherapy/radiation ([MASKED]), Grave's disease, kidney stones, and anxiety who presents with vomiting, neck pain, and neck swelling. Patient states that he was in his usual state of health, as recently as two days ago. Yesterday he began having anterior neck tenderness and swelling; it is described as "tender" and does not radiate. Pain is exacerbated by palpation of the exterior anterior neck, and mildly by swallowing; it is not relieved by anything. Pt tried to feed himself as usual through his G-tube, whereupon he began having vomiting. After several episodes of vomiting clear liquid, he noticed a scant amount of blood on his lips (though never saw any bright red in his emesis). Pt has been unable to keep anything down since that time, vomiting with even small sips of liquid at home. His nausea was not significantly improved with home ondansetron. Pt notes an episode of chills on the night prior to arrival (though he slept with the heat off). He denies overt fevers, cough, chest pain, shortness of breath, palpitations, diarrhea, urinary Sx, lightheadedness/dizziness, and numbness/tingling/focal weakness. In the ED, initial vitals: 97.4 111 119/73 16 100% RA - Labs were notable for: 13.2>12.6/37.1<239 Na 136 K 3.9 Cl 94 HCO3 23 BUN 27 Cr 0.9 Gluc 180 Lactate:2.3 - Imaging: CXR ([MASKED]): IMPRESSION: No acute cardiopulmonary process. MRA Neck w/ and w/o contrast ([MASKED]): Pending - Patient was given: Vanc/zosyn Morphine 1L NS - Consults: [MASKED] and ENT were consulted. - Decision was made to admit to [MASKED] for management of sepsis - Vitals prior to transfer were 99.1 93 201/66 18 98% RA Of note, patient had two recent admissions: 1) Patient was admitted [MASKED] to [MASKED]. At the time he had recurrent jaw pain and poor po intake with weight loss. Imaging was concerning for possible recurrence, with CT showing neck mass. He was treated empirically for [MASKED] esophagitis and aspiration pneumonia. Due to poor po intake, he had a G-tube placed [MASKED] and initiated TF's. 2) Patient admitted [MASKED] to [MASKED] for nausea, vomiting, and pain. He received uptitrated pain medications with improvement. He was seen by his Oncologist, Dr. [MASKED] follow up on [MASKED]. He also follows with Dr. [MASKED] from [MASKED], who performed a neck biopsy for R neck swelling on [MASKED]. He underwent outpatient direct laryngoscopy and biopsy by [MASKED] on [MASKED] procedure was uncomplicated. Biopsy showed "Necro-inflammatory debris with focal bacterial overgrowth. Granulation tissue with focal atypical cells". On arrival to the floor, Pt endorses the above history. He states he feels "very dehydrated" and is asking for more IV fluids. Does not have an appetite, though is willing to try some ice cubes to moisten his mouth. Past Medical History: PAST ONCOLOGIC HISTORY: - [MASKED] he was started on Cisplatin and RT. - [MASKED] - [MASKED] - Admission for nausea, vomiting and bleeding from oral cavity - [MASKED] C2 Cisplatin - [MASKED] - [MASKED] - Admission for throat pain, inability to take PO and vomiting - Cisplatin discontinued - patient decided not to receive the third cycle. - [MASKED] - Completion of RT. PAST MEDICAL HISTORY: -Graves disease -Kidney stones -Sleep apnea -Anxiety with OCD features PAST SURGICAL HISTORY: -Carpal tunnel syndrome Social History: [MASKED] Family History: Mother has [MASKED] disease, father has emphysema, uncle diagnosed with head and neck cancer. Physical Exam: ADMISSION: Vitals: T 99.3 BP 110/73 HR 101 RR 20 O2 96% on RA GENERAL: Thin Caucasian gentleman, lying in bed and uncomfortable appearing. HEENT: Sclerae anicteric. Trismus bilaterally, with Pt able to open his mouth approximately 3-4cm. Mucous membranes moist, with some white patches on tongue that clear with swallow. Palpable area of tensor tympani spasm bilaterally, which Pt endorses is tender. EOMI, PERRLA. NECK: 1cm x 1cm firm fixed lymph node in the R anterior cervical chain, nontender. Soft 3cm x 4cm mass visible above the sternal notch, which is tender to palpation but not firm or fixed or truly discernable on palpation. No subcutaneous emphysema in the neck space. Thyroid nonpalpable. LUNGS: Clear to auscultation bilaterally. No stridor, wheezes, rales, rhonchi. CV: Regular rate and rhythm, normal S1/S2, no murmurs/gallops/rubs. ABD: Normoactive bowel sounds. G tube present in the mid-abdomen at the level of the umbilicus, covered with a clean dry dressing. Abdomen is soft and nontender to palpation throughout. No hepatosplenomegaly. EXT: Warm and well perfused. No cyanosis or edema of the lower extremities. +2 dorsalis pedis pulses bilaterally. SKIN: Mild darkening of skin of anterior neck from the top of the cricoid cartilage to sternal notch. NEURO: CN II-XII intact. [MASKED] strength in the upper and lower extremities bilaterally. A&O x3, appropriate thought content. ACCESS: PIV DISCHARGE: Vitals: 98.7 [MASKED] 18 97% RA I/O: 1280/2450 / NR GENERAL: Thin Caucasian gentleman, lying in bed and somewhat uncomfortable. Able to drink sips of water demonstrably without difficulty. HEENT: Sclerae anicteric. Trismus bilaterally, with Pt able to open his mouth approximately 3-4cm. Mucous membranes moist. NECK: 1cm x 1cm firm fixed lymph node in the R anterior cervical chain, nontender and stable from prior exam. Soft 3cm x 4cm mass visible above the sternal notch, no longer tender to palpation; very soft to the touch. No subcutaneous emphysema in the neck space. LUNGS: Clear to auscultation bilaterally. No stridor, wheezes, rales, rhonchi. CV: Regular rate and rhythm, normal S1/S2, no murmurs/gallops/rubs. ABD: Normoactive bowel sounds. G tube present in the mid-abdomen at the level of the umbilicus, covered with a clean dry dressing. Abdomen is soft and nontender to palpation throughout. EXT: Warm and well perfused. No cyanosis or edema of the lower extremities. +2 dorsalis pedis pulses bilaterally. SKIN: Mild darkening of skin of anterior neck from the top of the cricoid cartilage to sternal notch, extending to line of medial clavicles. No warmth or tenderness to palpation of this skin change. NEURO: A&O x3. Moves all four extremities spontaneously. Endorses "tingling" R jaw pain, stable from prior. ACCESS: PIV Pertinent Results: ADMISSION LABS: [MASKED] 08:36AM BLOOD WBC-13.2# RBC-4.07 Hgb-12.6* Hct-37.1* MCV-91 MCH-31.0 MCHC-34.0 RDW-13.4 RDWSD-44.4 Plt [MASKED] [MASKED] 08:36AM BLOOD Neuts-93.6* Lymphs-2.4* Monos-3.3* Eos-0.0* Baso-0.2 Im [MASKED] AbsNeut-12.31# AbsLymp-0.31 AbsMono-0.44 AbsEos-0.00* AbsBaso-0.02 [MASKED] 08:36AM BLOOD Glucose-180* UreaN-27* Creat-0.9 Na-136 K-3.9 Cl-94* HCO3-23 AnGap-23* [MASKED] 07:05PM BLOOD ALT-16 AST-14 LD(LDH)-102 AlkPhos-53 TotBili-0.6 [MASKED] 07:05PM BLOOD Calcium-8.8 Phos-2.2* Mg-1.8 PERTINENT LABS: Iron-15* [MASKED] 07:05PM BLOOD calTIBC-229* Hapto-238* Ferritn-579* TRF-176* [MASKED] 08:00AM BLOOD TSH-1.1 [MASKED] 08:00AM BLOOD T4-7.7 IMAGING: -CXR ([MASKED]): IMPRESSION: No acute cardiopulmonary process. -MRI NECK SOFT TISSUE [MASKED], final report): 1. Slight interval decrease in size of a 19 x 19 mm ill-defined heterogeneously enhancing right tonsillar mass, which may represent posttreatment change, though residual tumor is not excluded. *ALTHOUGH IT IS GETTING SMALLER, IT WOULD BE SURPRISING IF THERE WERE NO RESIDUAL TUMOR. MORE LIEKLY THE DECREASE REFLECTS RESPONSE TO THERAPY BUT THE LESION WE SEE IS TUMOR.* 1. Diffuse edema throughout the anterior superficial soft tissues of the neck, leading to the upper chest and may represent post radiation effect, though cellulitis remains a possibility. This does not appear to contiguously extend into the deep spaces of the neck. 2. Minimal edema in the retropharyngeal space appears unchanged to the [MASKED] examination, and may be a result of posttreatment effect. 3. No organizing/drainable fluid collection. -ECG ([MASKED]): Sinus rhythm. Non-specific anterior repolarization abnormalities. Compared to the previous tracing of [MASKED] no diagnostic interim change. MICRO: [MASKED] 8:13 pm URINE Source: [MASKED]. FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 2:55 pm URINE FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 11:25 am BLOOD CULTURE *FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: CANCELLED. Culture negative as of: 17:20 [MASKED] ON [MASKED]. Test canceled/culture discontinued per: [MASKED]. PATIENT CREDITED. [MASKED] [MASKED] 11:25 am BLOOD CULTURE #2. Blood Culture, Routine (Pending): Brief Hospital Course: [MASKED] with metastatic invasive R oropharyngeal squamous cell carcinoma (s/p chemotherapy and radiation for 2 cycles), Grave's disease, and malnutrition requiring G-tube placement ([MASKED]) who presented with sudden-onset nausea, vomiting, and neck pain one day prior to arrival. He had inability to tolerate anything by mouth or G-tube due to vomiting, so he came to the ED for further evaluation. He was found to have leukocytosis to 13, soft pressures, and a mild lactate elevation to 2.3. He was given IV fluids, IV ondansetron, and metoclopramide - to eventual relief of his nausea. For his neck pain, he was given IV morphine while unable to tolerate PO. An MRI neck was performed to evaluate for deep neck space infections; it did not show any abscesses or fluid collections, but did comment on some possible residual tumor in the R tonsillar area. After close monitoring, the pt's diet was gradually advanced to his home tube feeding regimen, and he was able to take oxycodone by mouth to control his pain. He was discharged with close follow-up with his PCP, as well as plan for follow-up with his primary oncologist. ============= ACTIVE ISSUES ============= # NECK PAIN, SWELLING: With somewhat prominent anterior neck soft tissue mass, soft to palpation and without subcutaneous emphysema; also a small 1cm x 1cm firm fixed nodule in the R submandibular area where Pt states his previous tumor was. MRI neck performed due to concern for abscess/deep neck space infection; no infection noted, though possible residual tumor present in the R tonsillar area. DDx for his pain includes residual tumor (as noted on MRI neck), post radiation-treatment change/pain. Pain improved with IV morphine in-house, and was well controlled with his home PO oxycodone (and an uptitrated dose of his home gabapentin) prior to discharge. - Continued home fentanyl 25mcg patch and home oxycodone. - Uptitrated home gabapentin 600mg TID -> 800mg TID. # VOMITING: With sudden onset and rapid resolution. Pt reported small amount of blood streaking in his emesis after several bouts of retching, consistent with small [MASKED] tear. Possibly due to some viral gastroenteritis vs. constipation. Started metoclopramide, to improvement of constipation and possibly nausea. Briefly entertained possibility of kidney stones (with hematuria, see below), though unlikely given no flank pain. -Discharged on metoclopramide 5mg QIDACHS -Discharged with zofran # HEMATURIA: Urine grossly appeared yellow. Pt without flank pain, though has h/o kidney stones and this could represent chronic renal calculi. On further review, Pt has had hematuria to this degree for several years without workup. He should be referred to Urology for further evaluation. ===================== CHRONIC/STABLE ISSUES ===================== # HPV+ Stage IV Oropharyngeal Carcinoma, s/p chemotherapy, XRT: Recent PET scan suggesting potential recurrence given uptake, and MRI neck during this admission with possible residual tumor. Pt states he would be willing to undergo another cycle of chemo/radiation if needed. He will need a referral for a PET scan. He will follow up with Dr. [MASKED] ongoing discussion. # Severe Malnutrition: # Weight Loss: Chronic and baseline. Tolerated bolus tube feeds at home rate prior to discharge. # Graves Disease: His TFTs were within normal limits with TSH 1.1, T4 7. He was continued on methimazole # Anxiety/Insomnia: He was continued on his home clonazepam # Depression with features of OCD: No longer on treatment. He should have ongoing PHQ-9 monitoring and discussion re: referral for therapy. =================== TRANSITIONAL ISSUES =================== # HCP/Contact: [MASKED] (wife) [MASKED], [MASKED] # Code: Full [ ] MEDICATION CHANGES: - Added metoclopramide 5mg QIDACHS - Uptitrated gabapentin from 600mg TID -> 800mg TID [ ] HEMATURIA: - Consider referral to urology for outpatient workup. [ ] OROPHARYNGEAL SQUAMOUS CELL CARCINOMA: - Pt with possible residual tumor based on his MRI during this hospital stay. - Will need assistance with scheduling PET scan Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 600 mg PO TID 2. Methimazole 10 mg PO QHS 3. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 4. Docusate Sodium 100 mg PO DAILY:PRN when taking home oxycodone 5. Fentanyl Patch 25 mcg/h TD Q72H 6. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate Discharge Medications: 1. Gabapentin 800 mg PO TID RX gabapentin 800 mg 1 tablet(s) by mouth three times a day Disp #9 Tablet Refills:0 2. Metoclopramide 5 mg PO QIDACHS RX metoclopramide HCl 5 mg 5 mg by mouth QIDACHS Disp #60 Tablet Refills:3 3. Ondansetron 4 mg PO Q8H:PRN nausea RX ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #60 Tablet Refills:1 4. Gabapentin 800 mg PO TID RX gabapentin 300 mg/6 mL (6 mL) 15 mL by mouth three times a day Disp #1350 Milliliter Refills:1 5. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 6. Docusate Sodium 100 mg PO DAILY:PRN when taking home oxycodone 7. Fentanyl Patch 25 mcg/h TD Q72H 8. Methimazole 10 mg PO QHS 9. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg [MASKED] tablet(s) by mouth q4 Disp #40 Tablet Refills:0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY ======= Nausea and vomiting Neck pain SECONDARY ========= History of metastatic tonsillar squamous cell carcinoma, with possible recurrence 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 to care for you at the [MASKED] [MASKED]. =============================== WHY WAS I SEEN IN THE HOSPITAL? =============================== - You were seen because you were having nausea and vomiting after eating. - You also had new pain and swelling in the front of your neck, which made us worried about a neck infection. ========================================== WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - We gave you medicine through the IV ("Zofran") for your nausea. - We also started a new medicine by mouth called "metoclopramide" (or "Reglan"), which can help with nausea and constipation. - We gave you pain medicine through the IV to help with your neck pain. - We gradually increased your diet, until you were back on your home tube feeding regimen. - We took a special picture of your neck ("MRI") to look for abscesses or deep infections in the neck. It did not show any signs concerning for infection. However, our radiologists are not sure if there is any remaining tumor in your neck after your recent round of chemo and radiation. ==================================== WHAT SHOULD I DO WHEN I RETURN HOME? ==================================== - Continue to eat and drink as you usually do. - Continue to take the metoclopramide for your nausea and constipation before you eat or give yourself tube feeds. You can also take zofran as needed for nausea - Your pharmacy will be able to order the liquid gabapentin for you. Please take the pills at a dose of 800mg three times daily until the liquid formulation is available. - Please follow up with your primary care physician (Dr. [MASKED] next week. Dr. [MASKED] will help set up an appointment for the following week to discuss the next steps in following up your symptoms. We wish you the best, Your [MASKED] Oncology Care Team Followup Instructions: [MASKED]	[]	[ "F419", "G4700" ]	[ "R112: Nausea with vomiting, unspecified", "E43: Unspecified severe protein-calorie malnutrition", "C140: Malignant neoplasm of pharynx, unspecified", "M542: Cervicalgia", "Z9221: Personal history of antineoplastic chemotherapy", "Z923: Personal history of irradiation", "E0500: Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "Z6823: Body mass index [BMI] 23.0-23.9, adult", "R3129: Other microscopic hematuria" ]
10,091,873	25,541,989	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing / Iodinated Contrast Media - IV Dye Attending: ___. Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: None this hospitalization. History of Present Illness: Mr. ___ is a ___ year old man with locoregionally advanced HPV positive oropharyngeal cancer stage is T2N2M0, Stage ___ on XRT with concurrent cisplatin who is admitted with N/V. Patient with multiple recent admissions attributed to chemotherapy. His most recent episode began ___ when he developed intractable N/V with an po intake. He has associated sore throat. Due to his symptoms he presented to the ED. In the ED, initial VS were pain 9, T 99, HR 120, BP 98/76, RR 16, O2 98%RA. Labs were notable for WBC 2.2 (ANC 1550), HCT 36.3, PLT 356. Na 136, K 4.7, HCO3 19, Cr 1.0. ALT 10 AST 11 ALP 99, TBIli 0.4, Lipase 23, lactate 1.0. Patient was given 1L NS, IV Zofran, and IV Ativan prior to transfer for further management. On arrival to the floor, patient notes intractable nausea and vomiting as above. Denies Fevers or chills. No abdominal pain, No diarrhea. Last BM on ___ was normal. Chronic sore throat due to radiation. Past Medical History: Mr. ___ is a very pleasant ___ gentleman with history of Grave's disease, kidney stones and anxiety, who first noticed some sore throat in mid ___. At that time he saw his PCP but no lesions were found on physical exam and he was oriented to monitor symptoms and seek further evaluation in case of no resolution. Over time the sore throat did not improve and he went to see Dr. ___ in ___ for further evaluation. He was found to have a right oropharyngeal mass and upon biopsy was diagnosed with invasive squamous cell carcinoma, moderately differentiated, invading into skeletal muscle, positive for p16, suggestive of HPV associated (___). He underwent staging testing with CT neck on ___ which showed a 3.5 x 2.5 mass in the right tonsillar region and bilateral enlarged level 2 a lymph nodes with intrinsic hyperdensities indicative of metastasis. On ___ he underwent a PET scan which showed that the right oropharyngeal mass had an SUV max of 24.56 and the bilateral cervical LNs also had increased SUV ranging from 6.91 to 15.00. No distant metastatic disease was identified. The patient was referred to our clinic to discuss treatment options for his locally advanced HPV positive oropharyngeal cancer, for which we recommended definitive radiation therapy combined with cisplatin q3weeks. - ___ he was started on Cisplatin and RT. - ___ - ___ - Admission for nausea, vomiting and bleeding from oral cavity - ___ C2 Cisplatin - ___ - ___ - Admission for throat pain, inability to take PO and vomiting PAST MEDICAL HISTORY: 1. Graves disease 2. Kidney stones 3. Sleep apnea 4. Anxiety with OCD features Past Surgical History: 1. Carpal tunnel syndrome Social History: ___ Family History: Mother has ___ disease, father has emphysema, uncle recently diagnosed with head and neck cancer. Physical Exam: ======================== Admission Physical Exam: ======================== VS: T 98.8 HR 119 BP 101/69 RR 18 SAT 98% O2 on RA. GENERAL: Well developed, but appears older than stated age. Uncomfortable appearing on his side retching during exam. HEENT: Anicteric, PERLL, OP with fullness around the right tonsil with surrounding erythema. CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Normal bowel sounds, soft, nontender, nondistended, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema. PULSES: 2+ radial pulses, 2+ DP pulses. NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact. SKIN: No significant rashes. ======================== Discharge Physical Exam: ======================== VS: Temp 97.9, BP 119/80, HR 76, RR 18, O2 sat 96% RA. GENERAL: Appears comfortable, in no acute distress. HEENT: Anicteric, PERLL, OP with fullness around the right tonsil with surrounding erythema. CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Normal bowel sounds, soft, non-tender, nondistended, no hepatomegaly, no splenomegaly. BACK: No flank tenderness to palpation. EXT: Warm, well perfused, no lower extremity edema. PULSES: 2+ radial pulses, 2+ DP pulses. NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact. SKIN: No significant rashes. Pertinent Results: =============== Admission Labs: =============== ___ 01:44AM BLOOD WBC-2.2* RBC-4.03* Hgb-12.3* Hct-36.3* MCV-90 MCH-30.5 MCHC-33.9 RDW-13.8 RDWSD-44.0 Plt ___ ___ 01:44AM BLOOD Neuts-71.4* Lymphs-6.9* Monos-19.8* Eos-0.5* Baso-0.5 Im ___ AbsNeut-1.55* AbsLymp-0.15* AbsMono-0.43 AbsEos-0.01* AbsBaso-0.01 ___ 01:44AM BLOOD Glucose-121* UreaN-25* Creat-1.0 Na-136 K-4.7 Cl-94* HCO3-19* AnGap-28* ___ 01:44AM BLOOD ALT-10 AST-11 AlkPhos-99 TotBili-0.4 ___ 01:44AM BLOOD Lipase-23 ___ 01:44AM BLOOD Albumin-4.2 Calcium-10.0 Phos-2.9 Mg-1.9 ___ 07:38AM BLOOD TSH-0.37 ___ 08:33AM BLOOD ___ pO2-193* pCO2-31* pH-7.42 calTCO2-21 Base XS--2 ___ 08:33AM BLOOD Lactate-1.0 =============== Discharge Labs: =============== ___ 07:45AM BLOOD WBC-3.3# RBC-3.39 Hgb-10.3* Hct-30.2* MCV-89 MCH-30.4 MCHC-34.1 RDW-14.2 RDWSD-45.3 Plt ___ ___ 07:45AM BLOOD Glucose-106* UreaN-23* Creat-0.8 Na-140 K-4.1 Cl-102 HCO3-28 AnGap-14 ============= Microbiology: ============= None. ======== Imaging: ======== Head CT w/o Contrast ___ 1. No acute intracranial abnormality, with no definite evidence of intracranial mass. 2. Please note MRI of the brain is more sensitive for the detection of acute infarct or intracranial masses. 3. Paranasal sinus disease as described. CT Abdomen/Pelvis w/ Contrast ___ 1. Since ___, a mid left ureteral stone has enlarged in the CC dimension and there is mildly worsened left hydronephrosis, now moderate to severe. 2. Curvilinear calcifications in the dependent portion of the urinary bladder may represent small stones. Brief Hospital Course: Mr. ___ is a ___ year old man with locoregionally advanced HPV positive oropharyngeal cancer stage ___ on XRT with concurrent cisplatin who is admitted with N/V. # Nausea/Vomiting secondary to Nephrolithiasis: Previous episodes thought due to chemotherapy, although he notably has not had chemo since ___. He was recently admitted for similar symptoms and was treated with anti-emetics and oropharyngeal candidiasis with fluconazole and nystatin. LFTs and lipase normal. Head CT without abnormality. His nausea was initially treated with Zofran, Compazine, Zyprexa, Ativan, and Scopalamine. However, patient passed large kidney stone with subsequent improvement in his symptoms. His nausea and vomiting was likely secondary to nephrolithiasis. He required no further anti-emetics, feeling significantly improved without nausea, and was tolerating a regular diet at time of discharge. His outpatient Urologist Dr. ___ was contacted and the patient will have close follow-up after discharge given finding of enlarging renal stone and slight worsening of hydronephrosis after discharge. He was urinating well with normal renal function. # Radiation-Induced Pharyngitis: Continued home magic mouthwash and viscous lidocaine. # Oropharyngeal Cancer: Missed his C3 appt for Cisplatin. Per Dr. ___, may not be able to tolerate any additional chemo. He will follow-up with Dr. ___ discharge. # Hyperthyroidism: Repeat TSH normal. Continued home methimazole. # Anxiety/Depression: Continued home citalopram and clonazepam. ==================== Transitional Issues: ==================== - Please note enlarging mid-left ureteral stone with mildly worsened left hydronephrosis. Patient will follow-up with Dr. ___ scheduled lithotripsy and stent placement. - Please follow-up pending renal stone analysis form ___. Code Status: Full Code Contact: ___ (wife/HCP) ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 2. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 3. Methimazole 10 mg PO QHS 4. Senna 8.6 mg PO BID 5. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY:PRN nausea 6. Multivitamins 5 mL PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Citalopram 20 mg PO QHS 9. Ondansetron ODT 8 mg PO Q8H 10. Aquaphor Ointment 1 Appl TP TID:PRN radiation burn neck 11. LORazepam 0.5-1 mg SL Q4H:PRN nausea 12. Scopolamine Patch 1 PTCH TD ONCE 13. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID Discharge Medications: 1. Aquaphor Ointment 1 Appl TP TID:PRN radiation burn neck 2. Citalopram 20 mg PO QHS 3. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 4. Docusate Sodium 100 mg PO BID 5. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 6. LORazepam 0.5-1 mg SL Q4H:PRN nausea 7. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID 8. Methimazole 10 mg PO QHS 9. Multivitamins 5 mL PO DAILY 10. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY:PRN nausea 11. Ondansetron ODT 8 mg PO Q8H 12. Scopolamine Patch 1 PTCH TD ONCE 13. Senna 8.6 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Nephrolithiasis - Nausea/Vomiting Secondary Diagnosis: - Oropharyngeal Cancer - Hyperthyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___. You were admitted to the hospital with nausea and vomiting. You were treated with anti-nausea medications. You had imaging of your head which was normal. You then passed a kidney stone and your symptoms improved. It is likely that your nausea was due to the kidney stone. You had a scan of your abdomen which showed an enlarging left kidney stone with worsening swelling of your left kidney. After discussion with your Urologist Dr. ___ would like you to return for a procedure on ___. All the best, Your ___ Team Followup Instructions: ___	[ "N132", "R64", "T66XXXA", "C770", "C109", "E0500", "F419", "F329", "Y842", "J029", "Y929", "Z6826" ]	Allergies: Iodine-Iodine Containing / Iodinated Contrast Media - IV Dye Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: None this hospitalization. History of Present Illness: Mr. [MASKED] is a [MASKED] year old man with locoregionally advanced HPV positive oropharyngeal cancer stage is T2N2M0, Stage [MASKED] on XRT with concurrent cisplatin who is admitted with N/V. Patient with multiple recent admissions attributed to chemotherapy. His most recent episode began [MASKED] when he developed intractable N/V with an po intake. He has associated sore throat. Due to his symptoms he presented to the ED. In the ED, initial VS were pain 9, T 99, HR 120, BP 98/76, RR 16, O2 98%RA. Labs were notable for WBC 2.2 (ANC 1550), HCT 36.3, PLT 356. Na 136, K 4.7, HCO3 19, Cr 1.0. ALT 10 AST 11 ALP 99, TBIli 0.4, Lipase 23, lactate 1.0. Patient was given 1L NS, IV Zofran, and IV Ativan prior to transfer for further management. On arrival to the floor, patient notes intractable nausea and vomiting as above. Denies Fevers or chills. No abdominal pain, No diarrhea. Last BM on [MASKED] was normal. Chronic sore throat due to radiation. Past Medical History: Mr. [MASKED] is a very pleasant [MASKED] gentleman with history of Grave's disease, kidney stones and anxiety, who first noticed some sore throat in mid [MASKED]. At that time he saw his PCP but no lesions were found on physical exam and he was oriented to monitor symptoms and seek further evaluation in case of no resolution. Over time the sore throat did not improve and he went to see Dr. [MASKED] in [MASKED] for further evaluation. He was found to have a right oropharyngeal mass and upon biopsy was diagnosed with invasive squamous cell carcinoma, moderately differentiated, invading into skeletal muscle, positive for p16, suggestive of HPV associated ([MASKED]). He underwent staging testing with CT neck on [MASKED] which showed a 3.5 x 2.5 mass in the right tonsillar region and bilateral enlarged level 2 a lymph nodes with intrinsic hyperdensities indicative of metastasis. On [MASKED] he underwent a PET scan which showed that the right oropharyngeal mass had an SUV max of 24.56 and the bilateral cervical LNs also had increased SUV ranging from 6.91 to 15.00. No distant metastatic disease was identified. The patient was referred to our clinic to discuss treatment options for his locally advanced HPV positive oropharyngeal cancer, for which we recommended definitive radiation therapy combined with cisplatin q3weeks. - [MASKED] he was started on Cisplatin and RT. - [MASKED] - [MASKED] - Admission for nausea, vomiting and bleeding from oral cavity - [MASKED] C2 Cisplatin - [MASKED] - [MASKED] - Admission for throat pain, inability to take PO and vomiting PAST MEDICAL HISTORY: 1. Graves disease 2. Kidney stones 3. Sleep apnea 4. Anxiety with OCD features Past Surgical History: 1. Carpal tunnel syndrome Social History: [MASKED] Family History: Mother has [MASKED] disease, father has emphysema, uncle recently diagnosed with head and neck cancer. Physical Exam: ======================== Admission Physical Exam: ======================== VS: T 98.8 HR 119 BP 101/69 RR 18 SAT 98% O2 on RA. GENERAL: Well developed, but appears older than stated age. Uncomfortable appearing on his side retching during exam. HEENT: Anicteric, PERLL, OP with fullness around the right tonsil with surrounding erythema. CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Normal bowel sounds, soft, nontender, nondistended, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema. PULSES: 2+ radial pulses, 2+ DP pulses. NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact. SKIN: No significant rashes. ======================== Discharge Physical Exam: ======================== VS: Temp 97.9, BP 119/80, HR 76, RR 18, O2 sat 96% RA. GENERAL: Appears comfortable, in no acute distress. HEENT: Anicteric, PERLL, OP with fullness around the right tonsil with surrounding erythema. CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Normal bowel sounds, soft, non-tender, nondistended, no hepatomegaly, no splenomegaly. BACK: No flank tenderness to palpation. EXT: Warm, well perfused, no lower extremity edema. PULSES: 2+ radial pulses, 2+ DP pulses. NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact. SKIN: No significant rashes. Pertinent Results: =============== Admission Labs: =============== [MASKED] 01:44AM BLOOD WBC-2.2* RBC-4.03* Hgb-12.3* Hct-36.3* MCV-90 MCH-30.5 MCHC-33.9 RDW-13.8 RDWSD-44.0 Plt [MASKED] [MASKED] 01:44AM BLOOD Neuts-71.4* Lymphs-6.9* Monos-19.8* Eos-0.5* Baso-0.5 Im [MASKED] AbsNeut-1.55* AbsLymp-0.15* AbsMono-0.43 AbsEos-0.01* AbsBaso-0.01 [MASKED] 01:44AM BLOOD Glucose-121* UreaN-25* Creat-1.0 Na-136 K-4.7 Cl-94* HCO3-19* AnGap-28* [MASKED] 01:44AM BLOOD ALT-10 AST-11 AlkPhos-99 TotBili-0.4 [MASKED] 01:44AM BLOOD Lipase-23 [MASKED] 01:44AM BLOOD Albumin-4.2 Calcium-10.0 Phos-2.9 Mg-1.9 [MASKED] 07:38AM BLOOD TSH-0.37 [MASKED] 08:33AM BLOOD [MASKED] pO2-193* pCO2-31* pH-7.42 calTCO2-21 Base XS--2 [MASKED] 08:33AM BLOOD Lactate-1.0 =============== Discharge Labs: =============== [MASKED] 07:45AM BLOOD WBC-3.3# RBC-3.39 Hgb-10.3* Hct-30.2* MCV-89 MCH-30.4 MCHC-34.1 RDW-14.2 RDWSD-45.3 Plt [MASKED] [MASKED] 07:45AM BLOOD Glucose-106* UreaN-23* Creat-0.8 Na-140 K-4.1 Cl-102 HCO3-28 AnGap-14 ============= Microbiology: ============= None. ======== Imaging: ======== Head CT w/o Contrast [MASKED] 1. No acute intracranial abnormality, with no definite evidence of intracranial mass. 2. Please note MRI of the brain is more sensitive for the detection of acute infarct or intracranial masses. 3. Paranasal sinus disease as described. CT Abdomen/Pelvis w/ Contrast [MASKED] 1. Since [MASKED], a mid left ureteral stone has enlarged in the CC dimension and there is mildly worsened left hydronephrosis, now moderate to severe. 2. Curvilinear calcifications in the dependent portion of the urinary bladder may represent small stones. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old man with locoregionally advanced HPV positive oropharyngeal cancer stage [MASKED] on XRT with concurrent cisplatin who is admitted with N/V. # Nausea/Vomiting secondary to Nephrolithiasis: Previous episodes thought due to chemotherapy, although he notably has not had chemo since [MASKED]. He was recently admitted for similar symptoms and was treated with anti-emetics and oropharyngeal candidiasis with fluconazole and nystatin. LFTs and lipase normal. Head CT without abnormality. His nausea was initially treated with Zofran, Compazine, Zyprexa, Ativan, and Scopalamine. However, patient passed large kidney stone with subsequent improvement in his symptoms. His nausea and vomiting was likely secondary to nephrolithiasis. He required no further anti-emetics, feeling significantly improved without nausea, and was tolerating a regular diet at time of discharge. His outpatient Urologist Dr. [MASKED] was contacted and the patient will have close follow-up after discharge given finding of enlarging renal stone and slight worsening of hydronephrosis after discharge. He was urinating well with normal renal function. # Radiation-Induced Pharyngitis: Continued home magic mouthwash and viscous lidocaine. # Oropharyngeal Cancer: Missed his C3 appt for Cisplatin. Per Dr. [MASKED], may not be able to tolerate any additional chemo. He will follow-up with Dr. [MASKED] discharge. # Hyperthyroidism: Repeat TSH normal. Continued home methimazole. # Anxiety/Depression: Continued home citalopram and clonazepam. ==================== Transitional Issues: ==================== - Please note enlarging mid-left ureteral stone with mildly worsened left hydronephrosis. Patient will follow-up with Dr. [MASKED] scheduled lithotripsy and stent placement. - Please follow-up pending renal stone analysis form [MASKED]. Code Status: Full Code Contact: [MASKED] (wife/HCP) [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 2. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 3. Methimazole 10 mg PO QHS 4. Senna 8.6 mg PO BID 5. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY:PRN nausea 6. Multivitamins 5 mL PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Citalopram 20 mg PO QHS 9. Ondansetron ODT 8 mg PO Q8H 10. Aquaphor Ointment 1 Appl TP TID:PRN radiation burn neck 11. LORazepam 0.5-1 mg SL Q4H:PRN nausea 12. Scopolamine Patch 1 PTCH TD ONCE 13. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID Discharge Medications: 1. Aquaphor Ointment 1 Appl TP TID:PRN radiation burn neck 2. Citalopram 20 mg PO QHS 3. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 4. Docusate Sodium 100 mg PO BID 5. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 6. LORazepam 0.5-1 mg SL Q4H:PRN nausea 7. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID 8. Methimazole 10 mg PO QHS 9. Multivitamins 5 mL PO DAILY 10. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY:PRN nausea 11. Ondansetron ODT 8 mg PO Q8H 12. Scopolamine Patch 1 PTCH TD ONCE 13. Senna 8.6 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Nephrolithiasis - Nausea/Vomiting Secondary Diagnosis: - Oropharyngeal Cancer - Hyperthyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]. You were admitted to the hospital with nausea and vomiting. You were treated with anti-nausea medications. You had imaging of your head which was normal. You then passed a kidney stone and your symptoms improved. It is likely that your nausea was due to the kidney stone. You had a scan of your abdomen which showed an enlarging left kidney stone with worsening swelling of your left kidney. After discussion with your Urologist Dr. [MASKED] would like you to return for a procedure on [MASKED]. All the best, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "F419", "F329", "Y929" ]	[ "N132: Hydronephrosis with renal and ureteral calculous obstruction", "R64: Cachexia", "T66XXXA: Radiation sickness, unspecified, initial encounter", "C770: Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck", "C109: Malignant neoplasm of oropharynx, unspecified", "E0500: Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Y842: Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "J029: Acute pharyngitis, unspecified", "Y929: Unspecified place or not applicable", "Z6826: Body mass index [BMI] 26.0-26.9, adult" ]
10,091,873	26,085,230	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing / Iodinated Contrast Media - IV Dye Attending: ___ Chief Complaint: Weight Loss, Right Mouth Pain. Major Surgical or Invasive Procedure: ENT Endoscopic Examination ___ PEG Tube Placement ___ History of Present Illness: Mr. ___ is a ___ year old male, with past history of HPV+ Oropharyngeal T2, N2a, Stage ___ squamous cell carcinoma of the tonsil, treated with cisplatin and IMRT (30 fractions with delivery to gross and nodal disease), now presenting with increased weight loss, and worsening right tooth pain. Patient reports that his current symptoms are very similar to his prior symptoms of when he was diagnosed. During his chemotherapy, and half way through his radiation therapy, he had interval improvement in his right jaw pain to the point where it had gone away. Patient had a 30 lb reported weight loss during the time of his therapy, and then reports that over the past 3 weeks he has been having increased difficulty with eating and therefore reports about a 20 lb weight loss. He states this is very reminiscent of his prior diagnosis where he had pain that then resolved. He also reports that he has been unable to really open his mouth, and has had 4 episodes of nausea/vomiting, with cottage cheese emesis. It has become much harder for him to eat, and he has been eating more liquids. Patient reports that he has been having about ___ pain, worse with swallowing, and touching the right side of his jaw, and this radiates across the anterior aspect of his ___, temporal area to the back of his head. Notably, patient was last seen on ___ by radiation oncology for an earache. At that time, it was noted that he had completed 3 month interval from chemotherapy and radiation, and an ongoing earache for which he was given oxycodone without any significant effect. He was also complaining of odynophagia, and was trying to drink supplements ___ cans / day. Patient was also found to have thrush, for which he was given a 2 week script for fluconazole. In the ED, initial vitals: 9 98.6 129 114/87 18 100% RA - Exam notable for right sided facial swelling. - Labs were notable for: WBC 8.1, Hgb 14, hct 40.5, Platelet 280. Lactate 2.0. Sodium 133, Chloride 90, BUN 25, Creatinine 0.8. Bicarb 17. Calcium9.7, Magnesium 2, Phosph 3. ALT 14, AST 32, T-bili 0.6, Albumin 4. TSH 0.51. - Imaging: None obtained. - Patient was given: ___ 11:19 IV Ondansetron 4 mg ___ 11:19 IVF NS ( 1000 mL ordered) ___ 13:03 IV Ondansetron 4 mg ___ 13:19 IV Morphine Sulfate 4 mg - Decision was made to admit to ___ for increased pain, dehydration, and PO intolerance. - Vitals prior to transfer were 98.9 100 119/79 100% RA On arrival to the floor, patient reports that he is having right jaw pain. 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: - ___ he was started on Cisplatin and RT. - ___ - ___ - Admission for nausea, vomiting and bleeding from oral cavity - ___ C2 Cisplatin - ___ - ___ - Admission for throat pain, inability to take PO and vomiting - Cisplatin discontinued - patient decided not to receive the third cycle. - ___ - Completion of RT. PAST MEDICAL HISTORY: 1. Graves disease 2. Kidney stones 3. Sleep apnea 4. Anxiety with OCD features 5. Oropharyngeal cancer Past Surgical History: 1. Carpal tunnel syndrome Social History: ___ Family History: Mother has ___ disease, father has emphysema, uncle diagnosed with head and neck cancer. Physical Exam: ADMISSION EXAM ============== GENERAL: Patient is fatigued appearing. He is quite dry in the mouth, no cyanosis, no tachypnea, able to converse, voice is good. HEENT: There is significant right sided swelling, submandibular, and right throat. He pain radiates across temporal area, but no tenderness to significant palpation distinctly in the right temporal area. NECK: As above. Left side is quite small, no major cervical lymphadenopathy appreciated. LUNGS: low lung volumes, no rhonchi heard. CV: Tachycardic, S1, S2. No extra sounds. ABD: Flat, abdomen, + BS. EXT: No ___ edema bilaterally, sensation intact. SKIN: Dry. NEURO: CN II-XII grossly intact. ACCESS: Peripheral. DISCHARGE EXAM ============== Physical Exam: Vitals: T max 98.2-98.6 BP ___ ___ 18 97RA GENERAL: NAD, no cyanosis, no tachypnea, able to converse, voice is at baseline according to patient and sounds normal. Very thin. HEENT: Dry mucous membranes. There is significant right sided swelling, submandibular, and right throat. no tenderness to significant palpation distinctly in the right temporal area. NECK: As above. Left side is quite small, no major cervical lymphadenopathy appreciated. LUNGS: low lung volumes, no rhonchi heard. no wheezing. CV: RRR, S1, S2. No extra sounds. ABD: Flat, abdomen, + BS. EXT: No ___ edema bilaterally, sensation intact. SKIN: Dry. NEURO: CN II-XII grossly intact. ACCESS: Peripheral. Pertinent Results: ADMISSION LABS ============== ___ 11:15AM BLOOD WBC-8.1# RBC-4.47* Hgb-14.0 Hct-40.5 MCV-91 MCH-31.3 MCHC-34.6 RDW-11.3 RDWSD-37.3 Plt ___ ___ 11:15AM BLOOD Neuts-83.2* Lymphs-6.3* Monos-9.5 Eos-0.2* Baso-0.4 Im ___ AbsNeut-6.75# AbsLymp-0.51 AbsMono-0.77 AbsEos-0.02* AbsBaso-0.03 ___ 11:15AM BLOOD Plt ___ ___ 11:15AM BLOOD Glucose-110* UreaN-25* Creat-0.8 Na-133 K-5.5* Cl-90* HCO3-17* AnGap-32* ___ 11:15AM BLOOD ALT-14 AST-32 AlkPhos-82 TotBili-0.6 ___ 11:15AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.0 Mg-2.0 ___ 11:15AM BLOOD TSH-0.51 ___ 11:16AM BLOOD Lactate-2.0 K-4.2 IMAGING ======= CT NECK ___: =========== IMPRESSION: 1. Overall decrease in size of previously seen mass, now demonstrating an area of necrosis, and extending to the medial mandible, with no evidence of bony erosion. 2. A saccular early enhancing an atrophic submandibular glands, consistent with post therapy changes. 3. Decrease in size of previously enlarged lymph nodes, with no evidence of new abnormally enlarged lymph nodes. CXR ___ ======= IMPRESSION: Left basilar opacities likely reflect atelectasis. MRI ___ IMPRESSION: 1. Motion limited exam. 2. Peripherally enhancing and centrally nonenhancing right oropharyngeal lesion may represent posttreatment changes. However, residual tumor is not excluded, given incomplete resolution of FDG avidity on the ___ PET-CT. This would be best re-evaluated with a follow-up PET-CT. 3. Resolution of cervical lymphadenopathy. DISCHARGE LABS ============== ___ 07:30AM BLOOD WBC-3.9* RBC-3.81* Hgb-11.7* Hct-35.4* MCV-93 MCH-30.7 MCHC-33.1 RDW-11.3 RDWSD-38.5 Plt ___ ___ 07:30AM BLOOD Plt ___ ___ 07:30AM BLOOD Glucose-95 UreaN-7 Creat-0.6 Na-140 K-5.0 Cl-100 HCO3-32 AnGap-13 ___ 07:30AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.5 Brief Hospital Course: Mr. ___ is a ___ year old male, with past history of Stage IV HPV oropharyngeal cancer, now presenting with increasing right jaw pain and poor po intake and weight loss. # Trismus: # Right Neck Swelling/Lymphadenopathy: # Right Jaw Pain: CT scan of neck shows evidence of mass, could include recurrence of disease or scar tissue or post-treatment changes. CT shows overall decrease in size of previously seen mass but with an area of necrosis. Previous PET scan done that did show some residual activity. No visible ulceration on fiberoptic exam performed by ENT but did see cavitary lesion with fibrinous debris. No evidence of significant infection seen grossly but patient did spike a fever and he was started on unasyn and switched to Augmentin for total treatment course of 5 days. Given concern for recurrence of disease, MRI was obtained which showed "Peripherally enhancing and centrally non-enhancing right oropharyngeal lesion may represent posttreatment changes. However, residual tumor is not excluded". Biopsy was not obtained. He was given his MRI images to bring to evaluation at Mass ___ and ___ on ___ after discharge. His pain was controlled with fentaynl patch 25 mg, po oxycodone ___ mg q4hours, gabapentin 300 TID. His pain is worsened by trismus and he will see speech and swallow as an outpatient to obtain swallowing therapy. # HPV+ Stage IV Oropharyngeal Carcinoma, s/p chemotherapy, XRT: Recent PET scan suggesting potential recurrence given uptake. See above for management. # Thrush: Difficult to visualize because of trismus. However with history of thrush as well vomitus that he described as "cottage cheese", he was treated with fluconazole for total course of 7 days (end on ___. # Severe Malnutrition # Weight Loss: ___ to difficulty with eating because of pain, as well as likely underlying malignancy. Patient has lost 50 pounds since diagnosis with loss of 20 pounds in last three weeks. A PEG tube was placed on ___ and he was started on tube feeds. TUBE FEED PLANS: bolus 480 mL (2 cans) Osmolite 1.5 TID daily (2160 calories, 90 grams protein, 1097 mL free water). He should continue on a regular diet as tolerated. # Graves Disease: Methimazole able to be crushed and continued on methimiazole 10 mg qhs. # Anxiety/Insomnia: Continued on clonazepam # Depression: Continued on citalopram TRANSITIONAL ISSUES =================== [] TUBE FEED PLAN: patient to continue to increase as an outpatient to 2 cans TID with feeding (tolerating 1 can at discharge). [] Pain management: please continue to address as outpatient. He was given prescriptions for oxycodone 10 mg PRN, Gabapentin 600 mg TID, and fentanyl patch at 25 mcg. [] FOLLOW UP WITH ENT: Patient to f/u with primary oncologist, and second opinion Dr. ___. Information was faxed to Dr. ___ ___ prior to discharge, and CDs regarding imaging were sent with patient. # HCP/Contact: ___ (Wife) ___ # Code: Full, Confirmed. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Methimazole 10 mg PO QHS 2. ClonazePAM 0.5 mg PO QHS:PRN insomnia 3. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 4. Citalopram 20 mg PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PO DAILY constipation RX bisacodyl 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #30 Capsule Refills:0 3. Fentanyl Patch 25 mcg/h TD Q72H RX fentanyl 25 mcg/hour Please place every 72 hours Q72 hours Disp #5 Patch Refills:0 4. Gabapentin 600 mg PO TID RX gabapentin 300 mg 2 capsule(s) by mouth three times daily Disp #90 Capsule Refills:0 5. Senna 8.6 mg PO BID constipation RX sennosides [senna] 8.6 mg 1 tab by mouth daily Disp #30 Tablet Refills:0 6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe RX oxycodone 10 mg ___ tablet(s) by mouth every ___ hours Disp #60 Tablet Refills:0 7. Citalopram 20 mg PO DAILY 8. ClonazePAM 0.5 mg PO QHS:PRN insomnia 9. Methimazole 10 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================= HPV+ Stage IV Oropharyngeal Carcinoma Severe Malnutrition Trismus Thrush Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure meeting you at ___. You were admitted to ___ because you were having right mouth pain and weight loss. While you were here, the ___, nose, and throat doctors saw ___ and used a scope to look and they found a mass in your neck. We tried to control your pain by changing your pain medications. Because you were losing a lot of weight and having pain with eating, we placed a gastric tube so that you could get tube feeds. When you leave the hospital, you should see your cancer doctor and see Dr. ___ at ___ on ___. Please see below for your medication changes. We wish you the best, Your care team at ___ Followup Instructions: ___	[ "C099", "E43", "B370", "E860", "Z931", "A630", "Z6821", "R509", "K5900", "R252", "E0500", "F329", "F419", "G4733", "G4700", "Z9221", "Z923" ]	Allergies: Iodine-Iodine Containing / Iodinated Contrast Media - IV Dye Chief Complaint: Weight Loss, Right Mouth Pain. Major Surgical or Invasive Procedure: ENT Endoscopic Examination [MASKED] PEG Tube Placement [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] year old male, with past history of HPV+ Oropharyngeal T2, N2a, Stage [MASKED] squamous cell carcinoma of the tonsil, treated with cisplatin and IMRT (30 fractions with delivery to gross and nodal disease), now presenting with increased weight loss, and worsening right tooth pain. Patient reports that his current symptoms are very similar to his prior symptoms of when he was diagnosed. During his chemotherapy, and half way through his radiation therapy, he had interval improvement in his right jaw pain to the point where it had gone away. Patient had a 30 lb reported weight loss during the time of his therapy, and then reports that over the past 3 weeks he has been having increased difficulty with eating and therefore reports about a 20 lb weight loss. He states this is very reminiscent of his prior diagnosis where he had pain that then resolved. He also reports that he has been unable to really open his mouth, and has had 4 episodes of nausea/vomiting, with cottage cheese emesis. It has become much harder for him to eat, and he has been eating more liquids. Patient reports that he has been having about [MASKED] pain, worse with swallowing, and touching the right side of his jaw, and this radiates across the anterior aspect of his [MASKED], temporal area to the back of his head. Notably, patient was last seen on [MASKED] by radiation oncology for an earache. At that time, it was noted that he had completed 3 month interval from chemotherapy and radiation, and an ongoing earache for which he was given oxycodone without any significant effect. He was also complaining of odynophagia, and was trying to drink supplements [MASKED] cans / day. Patient was also found to have thrush, for which he was given a 2 week script for fluconazole. In the ED, initial vitals: 9 98.6 129 114/87 18 100% RA - Exam notable for right sided facial swelling. - Labs were notable for: WBC 8.1, Hgb 14, hct 40.5, Platelet 280. Lactate 2.0. Sodium 133, Chloride 90, BUN 25, Creatinine 0.8. Bicarb 17. Calcium9.7, Magnesium 2, Phosph 3. ALT 14, AST 32, T-bili 0.6, Albumin 4. TSH 0.51. - Imaging: None obtained. - Patient was given: [MASKED] 11:19 IV Ondansetron 4 mg [MASKED] 11:19 IVF NS ( 1000 mL ordered) [MASKED] 13:03 IV Ondansetron 4 mg [MASKED] 13:19 IV Morphine Sulfate 4 mg - Decision was made to admit to [MASKED] for increased pain, dehydration, and PO intolerance. - Vitals prior to transfer were 98.9 100 119/79 100% RA On arrival to the floor, patient reports that he is having right jaw pain. 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] he was started on Cisplatin and RT. - [MASKED] - [MASKED] - Admission for nausea, vomiting and bleeding from oral cavity - [MASKED] C2 Cisplatin - [MASKED] - [MASKED] - Admission for throat pain, inability to take PO and vomiting - Cisplatin discontinued - patient decided not to receive the third cycle. - [MASKED] - Completion of RT. PAST MEDICAL HISTORY: 1. Graves disease 2. Kidney stones 3. Sleep apnea 4. Anxiety with OCD features 5. Oropharyngeal cancer Past Surgical History: 1. Carpal tunnel syndrome Social History: [MASKED] Family History: Mother has [MASKED] disease, father has emphysema, uncle diagnosed with head and neck cancer. Physical Exam: ADMISSION EXAM ============== GENERAL: Patient is fatigued appearing. He is quite dry in the mouth, no cyanosis, no tachypnea, able to converse, voice is good. HEENT: There is significant right sided swelling, submandibular, and right throat. He pain radiates across temporal area, but no tenderness to significant palpation distinctly in the right temporal area. NECK: As above. Left side is quite small, no major cervical lymphadenopathy appreciated. LUNGS: low lung volumes, no rhonchi heard. CV: Tachycardic, S1, S2. No extra sounds. ABD: Flat, abdomen, + BS. EXT: No [MASKED] edema bilaterally, sensation intact. SKIN: Dry. NEURO: CN II-XII grossly intact. ACCESS: Peripheral. DISCHARGE EXAM ============== Physical Exam: Vitals: T max 98.2-98.6 BP [MASKED] [MASKED] 18 97RA GENERAL: NAD, no cyanosis, no tachypnea, able to converse, voice is at baseline according to patient and sounds normal. Very thin. HEENT: Dry mucous membranes. There is significant right sided swelling, submandibular, and right throat. no tenderness to significant palpation distinctly in the right temporal area. NECK: As above. Left side is quite small, no major cervical lymphadenopathy appreciated. LUNGS: low lung volumes, no rhonchi heard. no wheezing. CV: RRR, S1, S2. No extra sounds. ABD: Flat, abdomen, + BS. EXT: No [MASKED] edema bilaterally, sensation intact. SKIN: Dry. NEURO: CN II-XII grossly intact. ACCESS: Peripheral. Pertinent Results: ADMISSION LABS ============== [MASKED] 11:15AM BLOOD WBC-8.1# RBC-4.47* Hgb-14.0 Hct-40.5 MCV-91 MCH-31.3 MCHC-34.6 RDW-11.3 RDWSD-37.3 Plt [MASKED] [MASKED] 11:15AM BLOOD Neuts-83.2* Lymphs-6.3* Monos-9.5 Eos-0.2* Baso-0.4 Im [MASKED] AbsNeut-6.75# AbsLymp-0.51 AbsMono-0.77 AbsEos-0.02* AbsBaso-0.03 [MASKED] 11:15AM BLOOD Plt [MASKED] [MASKED] 11:15AM BLOOD Glucose-110* UreaN-25* Creat-0.8 Na-133 K-5.5* Cl-90* HCO3-17* AnGap-32* [MASKED] 11:15AM BLOOD ALT-14 AST-32 AlkPhos-82 TotBili-0.6 [MASKED] 11:15AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.0 Mg-2.0 [MASKED] 11:15AM BLOOD TSH-0.51 [MASKED] 11:16AM BLOOD Lactate-2.0 K-4.2 IMAGING ======= CT NECK [MASKED]: =========== IMPRESSION: 1. Overall decrease in size of previously seen mass, now demonstrating an area of necrosis, and extending to the medial mandible, with no evidence of bony erosion. 2. A saccular early enhancing an atrophic submandibular glands, consistent with post therapy changes. 3. Decrease in size of previously enlarged lymph nodes, with no evidence of new abnormally enlarged lymph nodes. CXR [MASKED] ======= IMPRESSION: Left basilar opacities likely reflect atelectasis. MRI [MASKED] IMPRESSION: 1. Motion limited exam. 2. Peripherally enhancing and centrally nonenhancing right oropharyngeal lesion may represent posttreatment changes. However, residual tumor is not excluded, given incomplete resolution of FDG avidity on the [MASKED] PET-CT. This would be best re-evaluated with a follow-up PET-CT. 3. Resolution of cervical lymphadenopathy. DISCHARGE LABS ============== [MASKED] 07:30AM BLOOD WBC-3.9* RBC-3.81* Hgb-11.7* Hct-35.4* MCV-93 MCH-30.7 MCHC-33.1 RDW-11.3 RDWSD-38.5 Plt [MASKED] [MASKED] 07:30AM BLOOD Plt [MASKED] [MASKED] 07:30AM BLOOD Glucose-95 UreaN-7 Creat-0.6 Na-140 K-5.0 Cl-100 HCO3-32 AnGap-13 [MASKED] 07:30AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.5 Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old male, with past history of Stage IV HPV oropharyngeal cancer, now presenting with increasing right jaw pain and poor po intake and weight loss. # Trismus: # Right Neck Swelling/Lymphadenopathy: # Right Jaw Pain: CT scan of neck shows evidence of mass, could include recurrence of disease or scar tissue or post-treatment changes. CT shows overall decrease in size of previously seen mass but with an area of necrosis. Previous PET scan done that did show some residual activity. No visible ulceration on fiberoptic exam performed by ENT but did see cavitary lesion with fibrinous debris. No evidence of significant infection seen grossly but patient did spike a fever and he was started on unasyn and switched to Augmentin for total treatment course of 5 days. Given concern for recurrence of disease, MRI was obtained which showed "Peripherally enhancing and centrally non-enhancing right oropharyngeal lesion may represent posttreatment changes. However, residual tumor is not excluded". Biopsy was not obtained. He was given his MRI images to bring to evaluation at Mass [MASKED] and [MASKED] on [MASKED] after discharge. His pain was controlled with fentaynl patch 25 mg, po oxycodone [MASKED] mg q4hours, gabapentin 300 TID. His pain is worsened by trismus and he will see speech and swallow as an outpatient to obtain swallowing therapy. # HPV+ Stage IV Oropharyngeal Carcinoma, s/p chemotherapy, XRT: Recent PET scan suggesting potential recurrence given uptake. See above for management. # Thrush: Difficult to visualize because of trismus. However with history of thrush as well vomitus that he described as "cottage cheese", he was treated with fluconazole for total course of 7 days (end on [MASKED]. # Severe Malnutrition # Weight Loss: [MASKED] to difficulty with eating because of pain, as well as likely underlying malignancy. Patient has lost 50 pounds since diagnosis with loss of 20 pounds in last three weeks. A PEG tube was placed on [MASKED] and he was started on tube feeds. TUBE FEED PLANS: bolus 480 mL (2 cans) Osmolite 1.5 TID daily (2160 calories, 90 grams protein, 1097 mL free water). He should continue on a regular diet as tolerated. # Graves Disease: Methimazole able to be crushed and continued on methimiazole 10 mg qhs. # Anxiety/Insomnia: Continued on clonazepam # Depression: Continued on citalopram TRANSITIONAL ISSUES =================== [] TUBE FEED PLAN: patient to continue to increase as an outpatient to 2 cans TID with feeding (tolerating 1 can at discharge). [] Pain management: please continue to address as outpatient. He was given prescriptions for oxycodone 10 mg PRN, Gabapentin 600 mg TID, and fentanyl patch at 25 mcg. [] FOLLOW UP WITH ENT: Patient to f/u with primary oncologist, and second opinion Dr. [MASKED]. Information was faxed to Dr. [MASKED] [MASKED] prior to discharge, and CDs regarding imaging were sent with patient. # HCP/Contact: [MASKED] (Wife) [MASKED] # Code: Full, Confirmed. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Methimazole 10 mg PO QHS 2. ClonazePAM 0.5 mg PO QHS:PRN insomnia 3. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 4. Citalopram 20 mg PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PO DAILY constipation RX bisacodyl 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #30 Capsule Refills:0 3. Fentanyl Patch 25 mcg/h TD Q72H RX fentanyl 25 mcg/hour Please place every 72 hours Q72 hours Disp #5 Patch Refills:0 4. Gabapentin 600 mg PO TID RX gabapentin 300 mg 2 capsule(s) by mouth three times daily Disp #90 Capsule Refills:0 5. Senna 8.6 mg PO BID constipation RX sennosides [senna] 8.6 mg 1 tab by mouth daily Disp #30 Tablet Refills:0 6. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Severe RX oxycodone 10 mg [MASKED] tablet(s) by mouth every [MASKED] hours Disp #60 Tablet Refills:0 7. Citalopram 20 mg PO DAILY 8. ClonazePAM 0.5 mg PO QHS:PRN insomnia 9. Methimazole 10 mg PO QHS Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS ================= HPV+ Stage IV Oropharyngeal Carcinoma Severe Malnutrition Trismus Thrush 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 meeting you at [MASKED]. You were admitted to [MASKED] because you were having right mouth pain and weight loss. While you were here, the [MASKED], nose, and throat doctors saw [MASKED] and used a scope to look and they found a mass in your neck. We tried to control your pain by changing your pain medications. Because you were losing a lot of weight and having pain with eating, we placed a gastric tube so that you could get tube feeds. When you leave the hospital, you should see your cancer doctor and see Dr. [MASKED] at [MASKED] on [MASKED]. Please see below for your medication changes. We wish you the best, Your care team at [MASKED] Followup Instructions: [MASKED]	[]	[ "K5900", "F329", "F419", "G4733", "G4700" ]	[ "C099: Malignant neoplasm of tonsil, unspecified", "E43: Unspecified severe protein-calorie malnutrition", "B370: Candidal stomatitis", "E860: Dehydration", "Z931: Gastrostomy status", "A630: Anogenital (venereal) warts", "Z6821: Body mass index [BMI] 21.0-21.9, adult", "R509: Fever, unspecified", "K5900: Constipation, unspecified", "R252: Cramp and spasm", "E0500: Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "G4700: Insomnia, unspecified", "Z9221: Personal history of antineoplastic chemotherapy", "Z923: Personal history of irradiation" ]
10,091,873	28,218,996	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing / Iodinated Contrast Media - IV Dye Attending: ___. Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a pleasant ___ w/ invasive squamous cell ca of OP who was just started on Cisplatin ___. He tolerated chemo well on D1 and by next day was supposed to take dexamethasone BID but did not pick up the medication from the pharmacy. He developed persistent nausea and vomiting and unable to tolerate anything PO. He went to the ED and improved w/ Zofran. He also recently had tooth extraction from he has had scant bleeding. His vomiting has been blood tinged. He is taking Augmentin for the dental extraction. REVIEW OF SYSTEMS: 10 point ROS reviewed in detail and negative except for what is mentioned above in HPI Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): C1D1 CISplatin ___ PAST MEDICAL HISTORY (per OMR): 1. Graves disease 2. Kidney stones 3. Sleep apnea 4. Anxiety with OCD features Social History: ___ Family History: Mother has ___ disease, father has emphysema, uncle recently diagnosed with head and neck cancer. Physical Exam: ADMISSION EXAM: VITAL SIGNS: 129/89 98% RA 86 General: NAD, Resting in bed appears fatigued, uncomfortable, nauseated, basin at bedside w/ clear emesis HEENT: MMD, no OP lesions CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no palpable masses or HSM LIMBS: WWP, no ___, no tremors SKIN: No rashes on the extremities NEURO: Grossly normal DISCHARGE EXAM: VITAL SIGNS: 97.8 BP 140/84 HR 76 RR 18 O2 96%RA General: NAD, sitting up in bed. Comfortable appearing HEENT: MMD, no OP lesions CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no palpable masses or HSM LIMBS: WWP, no ___, no tremors SKIN: No rashes on the extremities NEURO: Grossly normal Pertinent Results: ADMISSION LABS: ___ 11:20PM BLOOD WBC-12.9* RBC-4.73 Hgb-14.5 Hct-42.1 MCV-89 MCH-30.7 MCHC-34.4 RDW-12.7 RDWSD-41.2 Plt ___ ___ 11:20PM BLOOD ___ PTT-27.3 ___ ___ 11:20PM BLOOD Glucose-124* UreaN-26* Creat-1.0 Na-137 K-4.1 Cl-100 HCO3-21* AnGap-20 ___ 06:47AM BLOOD ALT-23 AST-17 LD(LDH)-167 AlkPhos-84 TotBili-0.8 ___ 07:15AM BLOOD Calcium-9.3 Phos-2.3* Mg-2.2 ___ 06:47AM BLOOD TSH-0.43 ___ 06:47AM BLOOD T3-106 Free T4-1.3 DISCHARGE LABS: ___ 07:10AM BLOOD WBC-5.3 RBC-4.54* Hgb-13.7 Hct-39.9* MCV-88 MCH-30.2 MCHC-34.3 RDW-12.3 RDWSD-39.3 Plt ___ ___ 07:10AM BLOOD Glucose-146* UreaN-22* Creat-0.9 Na-135 K-4.3 Cl-100 HCO3-27 AnGap-12 ___ 07:10AM BLOOD Calcium-9.7 Phos-3.0 Mg-2.0 Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION: ___ w/ invasive squamous cell ca of OP who was just started on Cisplatin ___ who p/w persistent nausea and vomiting on D2 of Cisplatin. # Nausea/Vomiting # Concern for Hemetemesis # Oropharyngeal squamous cell cancer On admission, his symptoms were thought most likely due to chemotherapy. No diarrhea, fevers, leukocytosis, or abdominal pain to suggest enteritis. Labs unremarkable. Did have blood in emesis, but suspect the blood may have been from bleeding tooth extraction site. However, given question of coffee ground emesis, he was started on IV PPI and patient was evaluated by GI and ENT who deferred further evaluation. Patient improved greatly by day of discharge after treatment with IVF, IV dexamethasone, IV Zofran, IV ativan, and Compazine. His hematocrit stayed stable and he was discharged in good condition. He continued his scheduled XRT admissions and will follow up with radiation and medical oncology as previously planned. # Prior dental extraction: Continued prophylactic augmentin, and completed 5 day course. # Hypothyroid: cont methimazole. Rechecked thyroid labs, which were normal. # Anxiety: Continued home clonazepam DVT PROPHYLAXIS: teds ACCESS: PIV CODE STATUS: Full code, presumed HCP: Health Care Proxy: ___ PCP: ___, MD DISPO: Home Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron ODT 8 mg PO Q8H:PRN nausea 2. Dexamethasone 8 mg PO Q12H 3 days following each chemo 3. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 4. Methimazole 10 mg PO QHS 5. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN Pain - Moderate 6. Citalopram 40 mg PO QHS 7. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 8. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Discharge Medications: 1. Prochlorperazine 10 mg PO Q6H:PRN nausea RX prochlorperazine maleate 10 mg 1 tablet(s) by mouth q6 hours Disp #30 Tablet Refills:0 2. Citalopram 40 mg PO QHS 3. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 4. Dexamethasone 8 mg PO Q12H 3 days following each chemo 5. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 6. Methimazole 10 mg PO QHS 7. Ondansetron ODT 8 mg PO Q8H:PRN nausea RX ondansetron 8 mg 1 tablet(s) by mouth q8 hours Disp #30 Tablet Refills:0 8. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN Pain - Moderate Discharge Disposition: Home Discharge Diagnosis: Head and neck cancer Nausea and vomiting due to chemotherapy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It has been a pleasure taking care of you at ___. You were admitted because of severe nausea, vomiting, and bleeding. The nausea and vomiting was likely related to your chemotherapy, and you were bleeding from your extracted tooth. The bleeding stopped, and we had our GI and ENT doctors ___, who thought there was no other concerning site of bleeding. Your symptoms resolved with IVF fluids and anti-nausea medications. Please follow up with your regular doctors as previously ___. We wish you all the best, Your ___ Care Team Followup Instructions: ___	[ "R112", "K91840", "C109", "T451X5A", "Y929", "G4730", "F419", "E039", "Y838" ]	Allergies: Iodine-Iodine Containing / Iodinated Contrast Media - IV Dye Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a pleasant [MASKED] w/ invasive squamous cell ca of OP who was just started on Cisplatin [MASKED]. He tolerated chemo well on D1 and by next day was supposed to take dexamethasone BID but did not pick up the medication from the pharmacy. He developed persistent nausea and vomiting and unable to tolerate anything PO. He went to the ED and improved w/ Zofran. He also recently had tooth extraction from he has had scant bleeding. His vomiting has been blood tinged. He is taking Augmentin for the dental extraction. REVIEW OF SYSTEMS: 10 point ROS reviewed in detail and negative except for what is mentioned above in HPI Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): C1D1 CISplatin [MASKED] PAST MEDICAL HISTORY (per OMR): 1. Graves disease 2. Kidney stones 3. Sleep apnea 4. Anxiety with OCD features Social History: [MASKED] Family History: Mother has [MASKED] disease, father has emphysema, uncle recently diagnosed with head and neck cancer. Physical Exam: ADMISSION EXAM: VITAL SIGNS: 129/89 98% RA 86 General: NAD, Resting in bed appears fatigued, uncomfortable, nauseated, basin at bedside w/ clear emesis HEENT: MMD, no OP lesions CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no palpable masses or HSM LIMBS: WWP, no [MASKED], no tremors SKIN: No rashes on the extremities NEURO: Grossly normal DISCHARGE EXAM: VITAL SIGNS: 97.8 BP 140/84 HR 76 RR 18 O2 96%RA General: NAD, sitting up in bed. Comfortable appearing HEENT: MMD, no OP lesions CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no palpable masses or HSM LIMBS: WWP, no [MASKED], no tremors SKIN: No rashes on the extremities NEURO: Grossly normal Pertinent Results: ADMISSION LABS: [MASKED] 11:20PM BLOOD WBC-12.9* RBC-4.73 Hgb-14.5 Hct-42.1 MCV-89 MCH-30.7 MCHC-34.4 RDW-12.7 RDWSD-41.2 Plt [MASKED] [MASKED] 11:20PM BLOOD [MASKED] PTT-27.3 [MASKED] [MASKED] 11:20PM BLOOD Glucose-124* UreaN-26* Creat-1.0 Na-137 K-4.1 Cl-100 HCO3-21* AnGap-20 [MASKED] 06:47AM BLOOD ALT-23 AST-17 LD(LDH)-167 AlkPhos-84 TotBili-0.8 [MASKED] 07:15AM BLOOD Calcium-9.3 Phos-2.3* Mg-2.2 [MASKED] 06:47AM BLOOD TSH-0.43 [MASKED] 06:47AM BLOOD T3-106 Free T4-1.3 DISCHARGE LABS: [MASKED] 07:10AM BLOOD WBC-5.3 RBC-4.54* Hgb-13.7 Hct-39.9* MCV-88 MCH-30.2 MCHC-34.3 RDW-12.3 RDWSD-39.3 Plt [MASKED] [MASKED] 07:10AM BLOOD Glucose-146* UreaN-22* Creat-0.9 Na-135 K-4.3 Cl-100 HCO3-27 AnGap-12 [MASKED] 07:10AM BLOOD Calcium-9.7 Phos-3.0 Mg-2.0 Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION: [MASKED] w/ invasive squamous cell ca of OP who was just started on Cisplatin [MASKED] who p/w persistent nausea and vomiting on D2 of Cisplatin. # Nausea/Vomiting # Concern for Hemetemesis # Oropharyngeal squamous cell cancer On admission, his symptoms were thought most likely due to chemotherapy. No diarrhea, fevers, leukocytosis, or abdominal pain to suggest enteritis. Labs unremarkable. Did have blood in emesis, but suspect the blood may have been from bleeding tooth extraction site. However, given question of coffee ground emesis, he was started on IV PPI and patient was evaluated by GI and ENT who deferred further evaluation. Patient improved greatly by day of discharge after treatment with IVF, IV dexamethasone, IV Zofran, IV ativan, and Compazine. His hematocrit stayed stable and he was discharged in good condition. He continued his scheduled XRT admissions and will follow up with radiation and medical oncology as previously planned. # Prior dental extraction: Continued prophylactic augmentin, and completed 5 day course. # Hypothyroid: cont methimazole. Rechecked thyroid labs, which were normal. # Anxiety: Continued home clonazepam DVT PROPHYLAXIS: teds ACCESS: PIV CODE STATUS: Full code, presumed HCP: Health Care Proxy: [MASKED] PCP: [MASKED], MD DISPO: Home Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron ODT 8 mg PO Q8H:PRN nausea 2. Dexamethasone 8 mg PO Q12H 3 days following each chemo 3. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 4. Methimazole 10 mg PO QHS 5. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN Pain - Moderate 6. Citalopram 40 mg PO QHS 7. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 8. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H Discharge Medications: 1. Prochlorperazine 10 mg PO Q6H:PRN nausea RX prochlorperazine maleate 10 mg 1 tablet(s) by mouth q6 hours Disp #30 Tablet Refills:0 2. Citalopram 40 mg PO QHS 3. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 4. Dexamethasone 8 mg PO Q12H 3 days following each chemo 5. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 6. Methimazole 10 mg PO QHS 7. Ondansetron ODT 8 mg PO Q8H:PRN nausea RX ondansetron 8 mg 1 tablet(s) by mouth q8 hours Disp #30 Tablet Refills:0 8. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN Pain - Moderate Discharge Disposition: Home Discharge Diagnosis: Head and neck cancer Nausea and vomiting due to chemotherapy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It has been a pleasure taking care of you at [MASKED]. You were admitted because of severe nausea, vomiting, and bleeding. The nausea and vomiting was likely related to your chemotherapy, and you were bleeding from your extracted tooth. The bleeding stopped, and we had our GI and ENT doctors [MASKED], who thought there was no other concerning site of bleeding. Your symptoms resolved with IVF fluids and anti-nausea medications. Please follow up with your regular doctors as previously [MASKED]. We wish you all the best, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "Y929", "F419", "E039" ]	[ "R112: Nausea with vomiting, unspecified", "K91840: Postprocedural hemorrhage of a digestive system organ or structure following a digestive system procedure", "C109: Malignant neoplasm of oropharynx, unspecified", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y929: Unspecified place or not applicable", "G4730: Sleep apnea, unspecified", "F419: Anxiety disorder, unspecified", "E039: Hypothyroidism, 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" ]
10,091,873	29,623,870	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing / Iodinated Contrast Media - IV Dye Attending: ___. Chief Complaint: Nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ with locally advanced HPV positive oropharyngeal squamous cell carcinoma s/p definitive chemoradiotherapy with sensitizing cisplatin (curative intent) who presents with nausea and vomiting x 5 days. Was doing alright after his recent discharge on ___ for a similar episode where his symptoms were attributed to passage of a kidney stone, but he disagres with this assessment. Feels that his symptoms are related to the severe mucositis he is suffering from that leads to mouth irritation, dry mouth, chocking and gagging and then retching. Denies fevers, chills, or sweats, but endorses chills. He tried Zofran, lidocaine, magic mouthwash, Ativan at home without relief. He denies any lightheadness or near syncope. In the ED, initial vital signs were 97.6 123 ___ 99% RA. He received NS x 3 L with improved in his tachycardia as well as ondansetron 4 mg IV x 2. A UA was notable for WBC>182. Past Medical History: Mr. ___ is a very pleasant ___ gentleman with history of Grave's disease, kidney stones and anxiety, who first noticed some sore throat in mid ___. At that time he saw his PCP but no lesions were found on physical exam and he was oriented to monitor symptoms and seek further evaluation in case of no resolution. Over time the sore throat did not improve and he went to see Dr. ___ in ___ for further evaluation. He was found to have a right oropharyngeal mass and upon biopsy was diagnosed with invasive squamous cell carcinoma, moderately differentiated, invading into skeletal muscle, positive for p16, suggestive of HPV associated (___). He underwent staging testing with CT neck on ___ which showed a 3.5 x 2.5 mass in the right tonsillar region and bilateral enlarged level 2 a lymph nodes with intrinsic hyperdensities indicative of metastasis. On ___ he underwent a PET scan which showed that the right oropharyngeal mass had an SUV max of 24.56 and the bilateral cervical LNs also had increased SUV ranging from 6.91 to 15.00. No distant metastatic disease was identified. The patient was referred to our clinic to discuss treatment options for his locally advanced HPV positive oropharyngeal cancer, for which we recommended definitive radiation therapy combined with cisplatin q3weeks. - ___ he was started on Cisplatin and RT. - ___ - ___ - Admission for nausea, vomiting and bleeding from oral cavity - ___ C2 Cisplatin - ___ - ___ - Admission for throat pain, inability to take PO and vomiting PAST MEDICAL HISTORY: 1. Graves disease 2. Kidney stones 3. Sleep apnea 4. Anxiety with OCD features Past Surgical History: 1. Carpal tunnel syndrome Social History: ___ Family History: Mother has ___ disease, father has emphysema, uncle recently diagnosed with head and neck cancer. Physical Exam: ADMISSION PHYSICAL EXAM ==================================== 98, 86, 130/90, 18, 99RA General: NAD HEENT: severe mucositis and errythem in the posterior oropharynx and buccal mucosa, halitosis CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB ABD: BS+, soft, NTND, no masses or hepatosplenomegaly, no CVA tenderness LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed, no nystagmus; strength is ___ of the proximal and distal upper and lower extremities; reflexes are 2+ of the biceps, triceps, patellar DISCHARGE PHYSICAL EXAM ==================================== VS: 97.9PO ___ 18 98 RA GEN: Sitting comfortably in bed, pleasant, no acute distress HEENT: Oropharynx without erythema or erosions. No cervical, supraclavicular, or axillary LAD Cards: RR S1/S2 normal. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: BS+, soft, NT, no rebound/guarding, no HSM, no ___ sign Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes or bruising Neuro: AOx3, CNs II-XII intact. ___ strength in U/L extremities. DTRs 2+ ___. sensation intact to LT, cerebellar fxn intact (FTN, HTS). gait WNL. Pertinent Results: ADMISSION LABS ======================================== ___ 09:23AM BLOOD WBC-5.6# RBC-4.24# Hgb-13.0# Hct-38.0# MCV-90 MCH-30.7 MCHC-34.2 RDW-15.2 RDWSD-49.4 Plt ___ ___ 09:23AM BLOOD Neuts-83.6* Lymphs-4.9* Monos-10.1 Eos-0.2* Baso-0.7 Im ___ AbsNeut-4.64# AbsLymp-0.27* AbsMono-0.56 AbsEos-0.01* AbsBaso-0.04 ___ 09:23AM BLOOD Glucose-99 UreaN-21* Creat-1.0 Na-137 K-4.8 Cl-94* HCO3-18* AnGap-30* ___ 09:23AM BLOOD Calcium-9.8 Phos-3.0 Mg-1.9 DISCHARGE LABS ========================================= ___ 06:55AM BLOOD WBC-5.6# RBC-3.41* Hgb-10.4* Hct-30.7* MCV-90 MCH-30.5 MCHC-33.9 RDW-15.6* RDWSD-50.4* Plt ___ ___ 06:55AM BLOOD Glucose-105* UreaN-17 Creat-0.6 Na-138 K-4.3 Cl-102 HCO3-25 AnGap-15 ___ 06:55AM BLOOD Calcium-9.5 Phos-3.1 Mg-2.0 MICROBIOLOGY ========================================= ___ 12:00 pm URINE *FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. IMAGING ========================================== CXR ___ IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: This is a ___ with locally advanced HPV+ oropharyngeal SCC s/p definiteive chemoradiotherapy with sensitizing cisplatin, last radiation therapy ___, who presents with nausea and vomiting similar to previous episodes which have been attributed to reactions to radiation. He had no fever, leukocytosis, or abdominal pain concerning for infectious etiology. His symptoms improved after intravenous hydration and were subsequently controlled with oral medication. On discharge, he was able to take PO food and drink without difficulty. # Nausea and vomiting: Likely radiation-induced nausea and vomiting, as patient lacks other infectious symptoms and has no abdominal pain to suggest obstruction, no neurological deficit or headache to suggest intracranial metastasis. Received fosaprepitant, ondansetron, and dexamethasone IV for resistant nausea on admission, as well as 3L IVF. QTc ___. Olanzapine ODT 5 mg PO was started (patient had been taking tablet at home). Patient has no further episodes of vomiting while admitted, and was able to take PO food and drink without vomiting. His symptoms were much improved on discharge. # HPV+ oropharyngeal SCC: S/p definitive chemoradiotherapy with curative intent. He will need monitoring to confirm remission per primary oncologists. # Pyuria: in the setting of stone without evidence of infection, will hold on antibiotics. Urine culture was negative. # Graves disease: Continued home Methimazole 10 mg PO QHS # Mucositis: Continued home Maalox/Diphenhydramine/Lidocaine 30 mL PO QID # Depression: Continued home Citalopram 20 mg PO QHS Transitional issues: []Scopolamine patch discontinued this admission []Patient was started on ODT olanzapine for management of nausea, which improved his symptom control. As nausea and vomiting is likely related to radiation therapy and may subside in the future, please consider stopping the medication when appropriate. []Contact: ___ Phone number: ___ Cell phone: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 20 mg PO QHS 2. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 3. Docusate Sodium 100 mg PO BID 4. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 5. LORazepam 0.5-1 mg SL Q4H:PRN nausea 6. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID 7. Methimazole 10 mg PO QHS 8. Multivitamins 5 mL PO DAILY 9. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY:PRN nausea 10. Scopolamine Patch 1 PTCH TD ONCE 11. Senna 8.6 mg PO BID 12. Aquaphor Ointment 1 Appl TP TID:PRN radiation burn neck 13. Ondansetron ODT 8 mg PO Q8H 14. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Discharge Medications: 1. Aquaphor Ointment 1 Appl TP TID:PRN radiation burn neck 2. Citalopram 20 mg PO QHS 3. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 4. Docusate Sodium 100 mg PO BID 5. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 6. LORazepam 0.5-1 mg SL Q4H:PRN nausea 7. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID 8. Methimazole 10 mg PO QHS 9. Multivitamins 5 mL PO DAILY 10. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY:PRN nausea RX olanzapine 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 11. Ondansetron ODT 8 mg PO Q8H 12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 13. Senna 8.6 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Nausea and vomiting likely secondary to radiation therapy Secondary diagnosis: HPV positive oropharyngeal squamous cell carcinoma 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 treating you at ___! Why was I admitted to the hospital? -You were admitted because you were having severe nausea and vomiting and couldn't keep down food. What happened while I was admitted? -We gave you intravenous hydration because you were dehydrated. -We treated your nausea with medication, and your nausea and vomiting improved so that you were able to eat and drink without vomiting. What should I do when I return home? -Please continue to eat and drink as you are able. -Please return to the hospital if your vomiting returns and you are unable to eat and drink. Followup Instructions: ___	[ "R112", "E860", "C109", "E440", "Z6825", "K1230", "F329", "Z006" ]	Allergies: Iodine-Iodine Containing / Iodinated Contrast Media - IV Dye Chief Complaint: Nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: This is a [MASKED] with locally advanced HPV positive oropharyngeal squamous cell carcinoma s/p definitive chemoradiotherapy with sensitizing cisplatin (curative intent) who presents with nausea and vomiting x 5 days. Was doing alright after his recent discharge on [MASKED] for a similar episode where his symptoms were attributed to passage of a kidney stone, but he disagres with this assessment. Feels that his symptoms are related to the severe mucositis he is suffering from that leads to mouth irritation, dry mouth, chocking and gagging and then retching. Denies fevers, chills, or sweats, but endorses chills. He tried Zofran, lidocaine, magic mouthwash, Ativan at home without relief. He denies any lightheadness or near syncope. In the ED, initial vital signs were 97.6 123 [MASKED] 99% RA. He received NS x 3 L with improved in his tachycardia as well as ondansetron 4 mg IV x 2. A UA was notable for WBC>182. Past Medical History: Mr. [MASKED] is a very pleasant [MASKED] gentleman with history of Grave's disease, kidney stones and anxiety, who first noticed some sore throat in mid [MASKED]. At that time he saw his PCP but no lesions were found on physical exam and he was oriented to monitor symptoms and seek further evaluation in case of no resolution. Over time the sore throat did not improve and he went to see Dr. [MASKED] in [MASKED] for further evaluation. He was found to have a right oropharyngeal mass and upon biopsy was diagnosed with invasive squamous cell carcinoma, moderately differentiated, invading into skeletal muscle, positive for p16, suggestive of HPV associated ([MASKED]). He underwent staging testing with CT neck on [MASKED] which showed a 3.5 x 2.5 mass in the right tonsillar region and bilateral enlarged level 2 a lymph nodes with intrinsic hyperdensities indicative of metastasis. On [MASKED] he underwent a PET scan which showed that the right oropharyngeal mass had an SUV max of 24.56 and the bilateral cervical LNs also had increased SUV ranging from 6.91 to 15.00. No distant metastatic disease was identified. The patient was referred to our clinic to discuss treatment options for his locally advanced HPV positive oropharyngeal cancer, for which we recommended definitive radiation therapy combined with cisplatin q3weeks. - [MASKED] he was started on Cisplatin and RT. - [MASKED] - [MASKED] - Admission for nausea, vomiting and bleeding from oral cavity - [MASKED] C2 Cisplatin - [MASKED] - [MASKED] - Admission for throat pain, inability to take PO and vomiting PAST MEDICAL HISTORY: 1. Graves disease 2. Kidney stones 3. Sleep apnea 4. Anxiety with OCD features Past Surgical History: 1. Carpal tunnel syndrome Social History: [MASKED] Family History: Mother has [MASKED] disease, father has emphysema, uncle recently diagnosed with head and neck cancer. Physical Exam: ADMISSION PHYSICAL EXAM ==================================== 98, 86, 130/90, 18, 99RA General: NAD HEENT: severe mucositis and errythem in the posterior oropharynx and buccal mucosa, halitosis CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB ABD: BS+, soft, NTND, no masses or hepatosplenomegaly, no CVA tenderness LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed, no nystagmus; strength is [MASKED] of the proximal and distal upper and lower extremities; reflexes are 2+ of the biceps, triceps, patellar DISCHARGE PHYSICAL EXAM ==================================== VS: 97.9PO [MASKED] 18 98 RA GEN: Sitting comfortably in bed, pleasant, no acute distress HEENT: Oropharynx without erythema or erosions. No cervical, supraclavicular, or axillary LAD Cards: RR S1/S2 normal. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [MASKED] sign Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes or bruising Neuro: AOx3, CNs II-XII intact. [MASKED] strength in U/L extremities. DTRs 2+ [MASKED]. sensation intact to LT, cerebellar fxn intact (FTN, HTS). gait WNL. Pertinent Results: ADMISSION LABS ======================================== [MASKED] 09:23AM BLOOD WBC-5.6# RBC-4.24# Hgb-13.0# Hct-38.0# MCV-90 MCH-30.7 MCHC-34.2 RDW-15.2 RDWSD-49.4 Plt [MASKED] [MASKED] 09:23AM BLOOD Neuts-83.6* Lymphs-4.9* Monos-10.1 Eos-0.2* Baso-0.7 Im [MASKED] AbsNeut-4.64# AbsLymp-0.27* AbsMono-0.56 AbsEos-0.01* AbsBaso-0.04 [MASKED] 09:23AM BLOOD Glucose-99 UreaN-21* Creat-1.0 Na-137 K-4.8 Cl-94* HCO3-18* AnGap-30* [MASKED] 09:23AM BLOOD Calcium-9.8 Phos-3.0 Mg-1.9 DISCHARGE LABS ========================================= [MASKED] 06:55AM BLOOD WBC-5.6# RBC-3.41* Hgb-10.4* Hct-30.7* MCV-90 MCH-30.5 MCHC-33.9 RDW-15.6* RDWSD-50.4* Plt [MASKED] [MASKED] 06:55AM BLOOD Glucose-105* UreaN-17 Creat-0.6 Na-138 K-4.3 Cl-102 HCO3-25 AnGap-15 [MASKED] 06:55AM BLOOD Calcium-9.5 Phos-3.1 Mg-2.0 MICROBIOLOGY ========================================= [MASKED] 12:00 pm URINE *FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. IMAGING ========================================== CXR [MASKED] IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: This is a [MASKED] with locally advanced HPV+ oropharyngeal SCC s/p definiteive chemoradiotherapy with sensitizing cisplatin, last radiation therapy [MASKED], who presents with nausea and vomiting similar to previous episodes which have been attributed to reactions to radiation. He had no fever, leukocytosis, or abdominal pain concerning for infectious etiology. His symptoms improved after intravenous hydration and were subsequently controlled with oral medication. On discharge, he was able to take PO food and drink without difficulty. # Nausea and vomiting: Likely radiation-induced nausea and vomiting, as patient lacks other infectious symptoms and has no abdominal pain to suggest obstruction, no neurological deficit or headache to suggest intracranial metastasis. Received fosaprepitant, ondansetron, and dexamethasone IV for resistant nausea on admission, as well as 3L IVF. QTc [MASKED]. Olanzapine ODT 5 mg PO was started (patient had been taking tablet at home). Patient has no further episodes of vomiting while admitted, and was able to take PO food and drink without vomiting. His symptoms were much improved on discharge. # HPV+ oropharyngeal SCC: S/p definitive chemoradiotherapy with curative intent. He will need monitoring to confirm remission per primary oncologists. # Pyuria: in the setting of stone without evidence of infection, will hold on antibiotics. Urine culture was negative. # Graves disease: Continued home Methimazole 10 mg PO QHS # Mucositis: Continued home Maalox/Diphenhydramine/Lidocaine 30 mL PO QID # Depression: Continued home Citalopram 20 mg PO QHS Transitional issues: []Scopolamine patch discontinued this admission []Patient was started on ODT olanzapine for management of nausea, which improved his symptom control. As nausea and vomiting is likely related to radiation therapy and may subside in the future, please consider stopping the medication when appropriate. []Contact: [MASKED] Phone number: [MASKED] Cell phone: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 20 mg PO QHS 2. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 3. Docusate Sodium 100 mg PO BID 4. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 5. LORazepam 0.5-1 mg SL Q4H:PRN nausea 6. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID 7. Methimazole 10 mg PO QHS 8. Multivitamins 5 mL PO DAILY 9. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY:PRN nausea 10. Scopolamine Patch 1 PTCH TD ONCE 11. Senna 8.6 mg PO BID 12. Aquaphor Ointment 1 Appl TP TID:PRN radiation burn neck 13. Ondansetron ODT 8 mg PO Q8H 14. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Discharge Medications: 1. Aquaphor Ointment 1 Appl TP TID:PRN radiation burn neck 2. Citalopram 20 mg PO QHS 3. ClonazePAM 0.5-1 mg PO QHS:PRN insomnia 4. Docusate Sodium 100 mg PO BID 5. Lidocaine Viscous 2% 15 mL PO QID:PRN pain 6. LORazepam 0.5-1 mg SL Q4H:PRN nausea 7. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID 8. Methimazole 10 mg PO QHS 9. Multivitamins 5 mL PO DAILY 10. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY:PRN nausea RX olanzapine 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 11. Ondansetron ODT 8 mg PO Q8H 12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 13. Senna 8.6 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Nausea and vomiting likely secondary to radiation therapy Secondary diagnosis: HPV positive oropharyngeal squamous cell carcinoma 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 treating you at [MASKED]! Why was I admitted to the hospital? -You were admitted because you were having severe nausea and vomiting and couldn't keep down food. What happened while I was admitted? -We gave you intravenous hydration because you were dehydrated. -We treated your nausea with medication, and your nausea and vomiting improved so that you were able to eat and drink without vomiting. What should I do when I return home? -Please continue to eat and drink as you are able. -Please return to the hospital if your vomiting returns and you are unable to eat and drink. Followup Instructions: [MASKED]	[]	[ "F329" ]	[ "R112: Nausea with vomiting, unspecified", "E860: Dehydration", "C109: Malignant neoplasm of oropharynx, unspecified", "E440: Moderate protein-calorie malnutrition", "Z6825: Body mass index [BMI] 25.0-25.9, adult", "K1230: Oral mucositis (ulcerative), unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]
10,091,997	24,962,428	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PLASTIC Allergies: Prozac / Lamictal / seasonal allergy Attending: ___. Chief Complaint: postoperative bleeding Major Surgical or Invasive Procedure: chest wall hematoma evacuation History of Present Illness: ___ s/p top surgery ___. Reportedly had somewhat high drain output in PACU. Went home and syncopized in bathroom while performing drain care. He had not had anything to eat or drink. Presented to ___ and transferred here. Not on anticoagulation. Since yesterday night the drain outputs and swelling has been relatively stable. Social History: ___ Family History: n/a Physical Exam: Gen: NAD, A&Ox3, lying on stretcher. HEENT: Normocephalic. CV: RRR R: Breathing comfortably on room air. No wheezing. Right chest stable ecchymosis, flat, no hematoma JP thin serosanguineous Left chest flat, no ecchymosis JP serous Pertinent Results: ___ 08:25AM BLOOD WBC-10.3* RBC-3.65* Hgb-10.2* Hct-32.6* MCV-89 MCH-27.9 MCHC-31.3* RDW-13.5 RDWSD-43.9 Plt ___ Brief Hospital Course: Presented to ED for right chest wall hematoma. He had syncopized at home. He was taken to OR for washout, where 300cc of blood clot was evacuated. Postoperatively he recovered without issue. His hemoglobin remained stable. He was discharged home with 2 JP drains. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. cefaDROXil 500 mg oral BID 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Discharge Disposition: Home Discharge Diagnosis: postoperative bleeding Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Do not shower; sponge bathe only Take antibiotics as prescribed Wear compression for 2 days as much as possible; be careful not to disrupt nipple dressings Followup Instructions: ___	[ "L7632", "Y838", "Y929", "Z87890" ]	Allergies: Prozac / Lamictal / seasonal allergy Chief Complaint: postoperative bleeding Major Surgical or Invasive Procedure: chest wall hematoma evacuation History of Present Illness: [MASKED] s/p top surgery [MASKED]. Reportedly had somewhat high drain output in PACU. Went home and syncopized in bathroom while performing drain care. He had not had anything to eat or drink. Presented to [MASKED] and transferred here. Not on anticoagulation. Since yesterday night the drain outputs and swelling has been relatively stable. Social History: [MASKED] Family History: n/a Physical Exam: Gen: NAD, A&Ox3, lying on stretcher. HEENT: Normocephalic. CV: RRR R: Breathing comfortably on room air. No wheezing. Right chest stable ecchymosis, flat, no hematoma JP thin serosanguineous Left chest flat, no ecchymosis JP serous Pertinent Results: [MASKED] 08:25AM BLOOD WBC-10.3* RBC-3.65* Hgb-10.2* Hct-32.6* MCV-89 MCH-27.9 MCHC-31.3* RDW-13.5 RDWSD-43.9 Plt [MASKED] Brief Hospital Course: Presented to ED for right chest wall hematoma. He had syncopized at home. He was taken to OR for washout, where 300cc of blood clot was evacuated. Postoperatively he recovered without issue. His hemoglobin remained stable. He was discharged home with 2 JP drains. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. cefaDROXil 500 mg oral BID 3. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate Discharge Disposition: Home Discharge Diagnosis: postoperative bleeding Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Do not shower; sponge bathe only Take antibiotics as prescribed Wear compression for 2 days as much as possible; be careful not to disrupt nipple dressings Followup Instructions: [MASKED]	[]	[ "Y929" ]	[ "L7632: Postprocedural hematoma of skin and subcutaneous tissue following other procedure", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "Z87890: Personal history of sex reassignment" ]
10,092,020	22,096,323	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Allergies/ADRs on File Attending: ___ Chief Complaint: AMS Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ man with history of A. fib on Eliquis, recent diagnosis of TIA (altered awareness and aphasia in ___ presented to the ED with complaints of an episode of loss of consciousness and right arm pain. Patient does not recall the episode and history is provided by his wife at bedside. As per the patient and wife he returned from work around 11 ___ after an 8-hour shift. He went to bed at 1130 and fell asleep soon after. At around 3:45 AM patient heard his husband screaming loud which woke her up. She tried to call his name but he was not responding to her. After the screaming, he made gurgling/howling loud sounds with heavy breathing which lasted for up to a minute and his head was turned to left. She noticed that his fists were clenched but his arms were lying next to him flaccid. Following this he remained unconscious, trembling in bed for up to 15 minutes. He then started to wake up, she noticed him blinking but was not acknowledging or responding to her. He was holding his right arm and is in pain with movement. EMS arrived by this time and brought him to the ED. Right upper extremity weakness was suspected and a code stroke was called but upon arrival to the ED he was noted to have significant right shoulder extremity pain suspected to be from right humeral dislocation/fracture. His mental status returned to baseline and no other noted deficits were observed. CT head was negative for acute process. Blood work showed an elevated lactate of 4 given the suspicion of right humeral dislocation and seizure was suspected. Patient denies any recollection of this event. He remembers going to bed at night and woke up in the ambulance. He does complain of right shoulder pain and it is difficult for him to move it. He reports of having bilateral rotator cuff problems and he had a repair done on his left shoulder and has been monitoring his right. He denies any recent fevers or chills or nausea or vomiting or abdominal pain no chest pain or shortness of breath or recent medications. No bowel or bladder problems. No prior history of similar episode. He has been missing some of his Eliquis doses as he keeps forgetting to take it. Wife does report of him acting out his dreams and sleep talking at times but she has never seen him have an episode similar to above in the past. Patient notes that him and his wife had a huge fight the day before and he attributes current episode to that. Past Medical History: Afib. Has been on Eliquis for the past month Prostate cancer Social History: ___ Family History: Daughter with migraines No other family hx of seizure disorder, stroke, muscular, movement, or neurological disorders Physical Exam: On admission: Mental status: He is awake, alert, and oriented to time place and person. He is attentive, able to say months of the year backwards. Fund of knowledge is intact. Language is fluent. Normal prosody, no paraphasic errors. Able to name and repeat with intact comprehension. Memory for recent and remote history is intact. Following both midline and appendicular commands. No evidence of apraxia or neglect Cranial nerves: Pupils are equal and reactive to light. Extraocular movements are full. Facial sensation and movement are intact and symmetric. Hearing is intact to finger rub bilaterally. Palate elevates symmetrically. SCM and trapezius are full strength bilaterally. Tongue is midline. Motor: Tone is normal. He has no pronator drift. Strength is full in all muscle groups in 4 extremities. Sensation: Sensation is intact to pinprick, light touch. Joint position sense is intact. Coordination: No dysmetria to finger-nose bilaterally Reflexes: 2 at biceps, triceps, brachioradialis, patella and 1 at the ankle bilaterally. toes are downgoing bilaterally. Gait: Deferred On discharge: Mental status: He is awake, alert, and oriented to time place and person. He is attentive, able to say months of the year backwards. Fund of knowledge is intact. Language is fluent. Normal prosody, no paraphasic errors. Able to name and repeat with intact comprehension. Memory for recent and remote history is intact. Following both midline and appendicular commands. No evidence of apraxia or neglect Cranial nerves: Pupils are equal and reactive to light. Extraocular movements are full. Facial sensation and movement are intact and symmetric. Hearing is intact to finger rub bilaterally. Palate elevates symmetrically. SCM and trapezius are full strength bilaterally. Tongue is midline. Motor: Tone is normal. He has no pronator drift. Strength is full in all muscle groups in 4 extremities. Sensation: Sensation is intact to pinprick, light touch. Joint position sense is intact. Coordination: No dysmetria to finger-nose bilaterally Reflexes: 2 at biceps, triceps, brachioradialis, patella and 1 at the ankle bilaterally. toes are downgoing bilaterally. Gait: Deferred Pertinent Results: ___ 05:38AM BLOOD WBC-7.3 RBC-4.17* Hgb-13.1* Hct-39.4* MCV-95 MCH-31.4 MCHC-33.2 RDW-12.3 RDWSD-42.7 Plt ___ ___ 05:38AM BLOOD Glucose-100 UreaN-13 Creat-0.8 Na-143 K-4.1 Cl-109* HCO3-23 AnGap-11 ___ 04:35AM BLOOD ALT-17 AST-24 AlkPhos-49 TotBili-0.3 ___ 05:38AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1 ___ 08:24AM BLOOD VitB12-382 ___ 08:24AM BLOOD TSH-1.9 ___ 04:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 11:23AM BLOOD Lactate-1.4 EEG: This is an abnormal continuous video-EEG monitoring study due to: 1. Seizure arising from the left temporally, characterized clinically by mouth automatism (chewing) and other brief and non-specific movements (brief head turn to the left and brief hand movements). There are no pushbutton events. No definite epileptiform discharges MRI brain w and w/o There is no evidence of acute intracranial process or hemorrhage. 2. There is no evidence of abnormal enhancement after contrast administration. Brief Hospital Course: ___ M with PMH of A. fib on Eliquis, recent history of transient lack of awareness and aphasia suspected to be TIA, presented to the ED with complaints of an episode of impaired consciousness(screaming, guttural sounds, clenched fists generalized trembling followed by 15-min period of unresponsiveness) associated with possible right shoulder pain (suspicious for dislocation) and labs significant for lactic acidosis. Exam in the ED without any neurological deficits. Possible etiology of the episode was suspected to be seizure. He was admitted for further evaluation, underwent continuous video EEG monitoring. No metabolic/infectious/trauma etiologies identified. MRI with and without contrast did not show any abnormalities. Video EEG revealed 90 second seizure with L temporal onset associated with staring and chewing. He was subsequently started on Keppra 1g BID and continuous EEG did not show any further seizure activity. Lumbar puncture was not performed as MRI brain was unrevealing, seizures were well controlled with Keppra, and clinical suspicion for an infectious/inflammatory process was therefore low. His clinical status and neurological exam remained stable and he was ambulating in the hallways without issues. He was discharged home to follow-up with outpatient neurology as above. We recommended that he do not drive for at least 6 months and to avoid handling heavy/mechanical equipment/baths when he is by himself. Right shoulder pain was evaluated with an x-ray which did not reveal any fracture or dislocation. Suspect chronic degenerative changes and rotator cuff issues with possible acute injury?. He is to follow-up with his PCP ___ 1 week and to follow-up with his orthopedic surgeon for further evaluation. Transitional issues: -Follow-up with orthopedic team for evaluation of right shoulder pain, likely due to rotator cuff pathology. Referral for outpatient ___ was provided to him. -Follow-up with neurology-will require further outpatient work-up to determine the cause of seizure (no structural/metabolic/infectious causes identified so far and no history of memory loss to suggest temporal sclerosis). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Pravastatin 20 mg PO QPM Discharge Medications: 1. LevETIRAcetam 1000 mg PO BID RX levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:*3 2. Apixaban 5 mg PO BID 3. Pravastatin 20 mg PO QPM 4.Outpatient Physical Therapy Evaluate and treat Diagnosis: Rotator cuff strain, right Discharge Disposition: Home Discharge Diagnosis: Seizure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were hospitalized d for evaluation of an episode of impaired consciousness. Based on the description of the event, we suspected that you may have had a seizure prior to arrival. You underwent continuous video electrical brainwave activity monitoring (called EEG) and you were found to have abnormal changes during an episode of chewing and staring consistent with a seizure. You were started on levetiracetam (Keppra) and antiseizure medication with continuous monitoring of brain wave activity. You did not have any further seizures for 24 hours after initiation of medication. You are being discharged home to follow-up with neurology as outpatient. You also complained of right shoulder pain, x-ray did not show fracture or dislocation and showed some degenerative changes. It is possible that you have a rotator cuff injury and we recommend you follow-up with your outpatient orthopedic surgeon for further management. According to ___ law, you cannot drive for 6 months after your last seizure. You should also avoid heights/ladders, bathing or swimming unsupervised, or power tools/dangerous machinery. New medication added Keppra 1000mg oral twice daily Please continue home apixaban as previous Please follow-up with Dr. ___, neurologist ___ ___ as previously scheduled ___. Also follow-up with primary care physician ___ 1 to 2 weeks. It is a pleasure taking care of you! Your sincerely, ___ Neurology team Followup Instructions: ___	[ "G4089", "I4820", "E872", "M25512", "Z7901", "Z8546", "Z87891", "Z8673" ]	Allergies: No Allergies/ADRs on File Chief Complaint: AMS Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] man with history of A. fib on Eliquis, recent diagnosis of TIA (altered awareness and aphasia in [MASKED] presented to the ED with complaints of an episode of loss of consciousness and right arm pain. Patient does not recall the episode and history is provided by his wife at bedside. As per the patient and wife he returned from work around 11 [MASKED] after an 8-hour shift. He went to bed at 1130 and fell asleep soon after. At around 3:45 AM patient heard his husband screaming loud which woke her up. She tried to call his name but he was not responding to her. After the screaming, he made gurgling/howling loud sounds with heavy breathing which lasted for up to a minute and his head was turned to left. She noticed that his fists were clenched but his arms were lying next to him flaccid. Following this he remained unconscious, trembling in bed for up to 15 minutes. He then started to wake up, she noticed him blinking but was not acknowledging or responding to her. He was holding his right arm and is in pain with movement. EMS arrived by this time and brought him to the ED. Right upper extremity weakness was suspected and a code stroke was called but upon arrival to the ED he was noted to have significant right shoulder extremity pain suspected to be from right humeral dislocation/fracture. His mental status returned to baseline and no other noted deficits were observed. CT head was negative for acute process. Blood work showed an elevated lactate of 4 given the suspicion of right humeral dislocation and seizure was suspected. Patient denies any recollection of this event. He remembers going to bed at night and woke up in the ambulance. He does complain of right shoulder pain and it is difficult for him to move it. He reports of having bilateral rotator cuff problems and he had a repair done on his left shoulder and has been monitoring his right. He denies any recent fevers or chills or nausea or vomiting or abdominal pain no chest pain or shortness of breath or recent medications. No bowel or bladder problems. No prior history of similar episode. He has been missing some of his Eliquis doses as he keeps forgetting to take it. Wife does report of him acting out his dreams and sleep talking at times but she has never seen him have an episode similar to above in the past. Patient notes that him and his wife had a huge fight the day before and he attributes current episode to that. Past Medical History: Afib. Has been on Eliquis for the past month Prostate cancer Social History: [MASKED] Family History: Daughter with migraines No other family hx of seizure disorder, stroke, muscular, movement, or neurological disorders Physical Exam: On admission: Mental status: He is awake, alert, and oriented to time place and person. He is attentive, able to say months of the year backwards. Fund of knowledge is intact. Language is fluent. Normal prosody, no paraphasic errors. Able to name and repeat with intact comprehension. Memory for recent and remote history is intact. Following both midline and appendicular commands. No evidence of apraxia or neglect Cranial nerves: Pupils are equal and reactive to light. Extraocular movements are full. Facial sensation and movement are intact and symmetric. Hearing is intact to finger rub bilaterally. Palate elevates symmetrically. SCM and trapezius are full strength bilaterally. Tongue is midline. Motor: Tone is normal. He has no pronator drift. Strength is full in all muscle groups in 4 extremities. Sensation: Sensation is intact to pinprick, light touch. Joint position sense is intact. Coordination: No dysmetria to finger-nose bilaterally Reflexes: 2 at biceps, triceps, brachioradialis, patella and 1 at the ankle bilaterally. toes are downgoing bilaterally. Gait: Deferred On discharge: Mental status: He is awake, alert, and oriented to time place and person. He is attentive, able to say months of the year backwards. Fund of knowledge is intact. Language is fluent. Normal prosody, no paraphasic errors. Able to name and repeat with intact comprehension. Memory for recent and remote history is intact. Following both midline and appendicular commands. No evidence of apraxia or neglect Cranial nerves: Pupils are equal and reactive to light. Extraocular movements are full. Facial sensation and movement are intact and symmetric. Hearing is intact to finger rub bilaterally. Palate elevates symmetrically. SCM and trapezius are full strength bilaterally. Tongue is midline. Motor: Tone is normal. He has no pronator drift. Strength is full in all muscle groups in 4 extremities. Sensation: Sensation is intact to pinprick, light touch. Joint position sense is intact. Coordination: No dysmetria to finger-nose bilaterally Reflexes: 2 at biceps, triceps, brachioradialis, patella and 1 at the ankle bilaterally. toes are downgoing bilaterally. Gait: Deferred Pertinent Results: [MASKED] 05:38AM BLOOD WBC-7.3 RBC-4.17* Hgb-13.1* Hct-39.4* MCV-95 MCH-31.4 MCHC-33.2 RDW-12.3 RDWSD-42.7 Plt [MASKED] [MASKED] 05:38AM BLOOD Glucose-100 UreaN-13 Creat-0.8 Na-143 K-4.1 Cl-109* HCO3-23 AnGap-11 [MASKED] 04:35AM BLOOD ALT-17 AST-24 AlkPhos-49 TotBili-0.3 [MASKED] 05:38AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1 [MASKED] 08:24AM BLOOD VitB12-382 [MASKED] 08:24AM BLOOD TSH-1.9 [MASKED] 04:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 11:23AM BLOOD Lactate-1.4 EEG: This is an abnormal continuous video-EEG monitoring study due to: 1. Seizure arising from the left temporally, characterized clinically by mouth automatism (chewing) and other brief and non-specific movements (brief head turn to the left and brief hand movements). There are no pushbutton events. No definite epileptiform discharges MRI brain w and w/o There is no evidence of acute intracranial process or hemorrhage. 2. There is no evidence of abnormal enhancement after contrast administration. Brief Hospital Course: [MASKED] M with PMH of A. fib on Eliquis, recent history of transient lack of awareness and aphasia suspected to be TIA, presented to the ED with complaints of an episode of impaired consciousness(screaming, guttural sounds, clenched fists generalized trembling followed by 15-min period of unresponsiveness) associated with possible right shoulder pain (suspicious for dislocation) and labs significant for lactic acidosis. Exam in the ED without any neurological deficits. Possible etiology of the episode was suspected to be seizure. He was admitted for further evaluation, underwent continuous video EEG monitoring. No metabolic/infectious/trauma etiologies identified. MRI with and without contrast did not show any abnormalities. Video EEG revealed 90 second seizure with L temporal onset associated with staring and chewing. He was subsequently started on Keppra 1g BID and continuous EEG did not show any further seizure activity. Lumbar puncture was not performed as MRI brain was unrevealing, seizures were well controlled with Keppra, and clinical suspicion for an infectious/inflammatory process was therefore low. His clinical status and neurological exam remained stable and he was ambulating in the hallways without issues. He was discharged home to follow-up with outpatient neurology as above. We recommended that he do not drive for at least 6 months and to avoid handling heavy/mechanical equipment/baths when he is by himself. Right shoulder pain was evaluated with an x-ray which did not reveal any fracture or dislocation. Suspect chronic degenerative changes and rotator cuff issues with possible acute injury?. He is to follow-up with his PCP [MASKED] 1 week and to follow-up with his orthopedic surgeon for further evaluation. Transitional issues: -Follow-up with orthopedic team for evaluation of right shoulder pain, likely due to rotator cuff pathology. Referral for outpatient [MASKED] was provided to him. -Follow-up with neurology-will require further outpatient work-up to determine the cause of seizure (no structural/metabolic/infectious causes identified so far and no history of memory loss to suggest temporal sclerosis). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Pravastatin 20 mg PO QPM Discharge Medications: 1. LevETIRAcetam 1000 mg PO BID RX levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:*3 2. Apixaban 5 mg PO BID 3. Pravastatin 20 mg PO QPM 4.Outpatient Physical Therapy Evaluate and treat Diagnosis: Rotator cuff strain, right Discharge Disposition: Home Discharge Diagnosis: Seizure 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 d for evaluation of an episode of impaired consciousness. Based on the description of the event, we suspected that you may have had a seizure prior to arrival. You underwent continuous video electrical brainwave activity monitoring (called EEG) and you were found to have abnormal changes during an episode of chewing and staring consistent with a seizure. You were started on levetiracetam (Keppra) and antiseizure medication with continuous monitoring of brain wave activity. You did not have any further seizures for 24 hours after initiation of medication. You are being discharged home to follow-up with neurology as outpatient. You also complained of right shoulder pain, x-ray did not show fracture or dislocation and showed some degenerative changes. It is possible that you have a rotator cuff injury and we recommend you follow-up with your outpatient orthopedic surgeon for further management. According to [MASKED] law, you cannot drive for 6 months after your last seizure. You should also avoid heights/ladders, bathing or swimming unsupervised, or power tools/dangerous machinery. New medication added Keppra 1000mg oral twice daily Please continue home apixaban as previous Please follow-up with Dr. [MASKED], neurologist [MASKED] [MASKED] as previously scheduled [MASKED]. Also follow-up with primary care physician [MASKED] 1 to 2 weeks. It is a pleasure taking care of you! Your sincerely, [MASKED] Neurology team Followup Instructions: [MASKED]	[]	[ "E872", "Z7901", "Z87891", "Z8673" ]	[ "G4089: Other seizures", "I4820: Chronic atrial fibrillation, unspecified", "E872: Acidosis", "M25512: Pain in left shoulder", "Z7901: Long term (current) use of anticoagulants", "Z8546: Personal history of malignant neoplasm of prostate", "Z87891: Personal history of nicotine dependence", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]
10,092,175	27,558,426	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dyspnea Major Surgical or Invasive Procedure: arterial line placed and removed History of Present Illness: Ms. ___ is a ___ yo F with PMH significant for morbid obesity, lymphedema, depression and a pelvic mass who presented with dyspnea as a transfer from ___. She initially presented with a ___ week history of increasing dyspnea to the point where she was unable to complete daily tasks at home. Also reported orthopnea, PND, weight gain, and increasing ___ edema. She denied fever, chills, night sweats, N/V/D, constipation, dysuria, or skin changes. At ___, she was found to be hypoxic with SpO2 64% on RA. She was started on BiPAP with improvement in her oxygenation. On presentation, there was concern for PE, but she was was unable to fit into the CT scanner at the OSH, and was transferred to ___ to rule out PE and for further care. In the ___ ED, she received Lasix 20mg IV with good response (diuresed 2 L), and was weaned off BiPAP to ___ mask. She initially tolerated the ___ mask well, though her SpO2 eventually dropped to 90% with increasing dyspnea and was put back on BiPAP. She was also started on a heparin gtt for suspected ACS. She was transferred to the CCU for further care. In the CCU, she was actively diuresed with Lasix and has since put over 40L. Also, on telemetry overnight ___ she demonstrated paroxysmal atrial fibrillation w/RVT and was started on metoprolol and warfarin with heparin bridging. After stabilizing and continuing diuresis, she transferred to the Heart Failure Service for continued diuresis. Towards the end of her course, she underwent a right heart catheterization which showed moderate-severe pulmonary hypertension and a normal PCWP. She was seen by pulmonology who recommended continuing oxygen therapy, wearing a BiPAP at night, and following up with them in ___ weeks. Past Medical History: -morbid obesity -lymphedema of unknown etiology -pelvic mass w/ uterine bleeding s/p hysteroscopy, polypectomy, d & c and placement of Mirena intrauterine device -depression Social History: ___ Family History: Father: deceased MI @ age ___ Sister: stroke @ age ___ Physical Exam: ADMISSION EXAM: =============== General: Obese woman lying in bed, sleepy but easily arousable, speaking full sentences on BiPAP, in NAD. Heent: Normocephalic atraumatic. Sclera anicteric. Neck: Supple. JVP appears elevated but difficult to assess given body habitus. Cardiac: Normal rate, regular rhythm. Normal S1 and S2. No murmurs, rubs or gallops appreciated. Faint heart sounds. Lungs: Exam limited by body habitus. No obvious wheezes, rales or rhonchi. Abdomen: Obese. Soft, non-tender. Protuberant. Unable to assess hepatomegaly or splenomegaly due to body habitus. Firm 2+ pitting oedema of the pannus. Extremities: Warm and well-perfused. 4+ firm and pitting oedema of the lower extremities, L > R. Unable to palpate pulses. Skin: No significant skin lesions or rashes. DISCHARGE EXAM: ================ General: Pleasant middle-aged woman, morbidly obese, NAD, A/Ox3. Head: NC/AT. Neck: JVP obscured by obesity. Cardiac: RRR, normal S1, S2 w/ systolic flow murmur. Respiratory: CTABL, normal effort. Abdomen: Obese, non-tender. Extremities: L leg lymphedema, otherwise no pitting edema. WWP, dusky color of palms, feet, and shins. Pertinent Results: ADMISSION LABS: =============== ___ 05:50AM BLOOD WBC-7.8 RBC-5.51* Hgb-12.2 Hct-47.3* MCV-86 MCH-22.1* MCHC-25.8* RDW-20.8* RDWSD-62.1* Plt ___ ___ 05:50AM BLOOD Neuts-66.7 ___ Monos-8.9 Eos-1.9 Baso-0.4 NRBC-0.8* Im ___ AbsNeut-5.22 AbsLymp-1.69 AbsMono-0.70 AbsEos-0.15 AbsBaso-0.03 ___ 05:50AM BLOOD ___ PTT-25.6 ___ ___ 05:50AM BLOOD Glucose-85 UreaN-10 Creat-0.8 Na-140 K-5.5* Cl-99 HCO3-30 AnGap-17 ___ 05:50AM BLOOD ALT-19 AST-56* AlkPhos-77 TotBili-0.9 ___ 05:50AM BLOOD Lipase-28 ___ 05:50AM BLOOD ___ 05:50AM BLOOD cTropnT-0.15* ___ 12:50PM BLOOD cTropnT-0.11* ___ 05:50AM BLOOD Albumin-3.1* Calcium-7.9* Phos-4.3 Mg-2.2 ___ 06:00AM BLOOD %HbA1c-PND ___ 04:30PM BLOOD Triglyc-PND HDL-PND ___ 04:30PM BLOOD TSH-PND ___ 04:30PM BLOOD ASA-PND Ethanol-PND Acetmnp-PND Bnzodzp-PND Barbitr-PND Tricycl-PND ___ 05:57AM BLOOD ___ pO2-115* pCO2-54* pH-7.41 calTCO2-35* Base XS-8 Comment-GREEN TOP OTHER PERTINENT LABS: ===================== ___ 05:50AM BLOOD ALT-19 AST-56* AlkPhos-77 TotBili-0.9 ___ 04:43AM BLOOD ALT-28 AST-42* AlkPhos-150* TotBili-1.2 ___ 05:50AM BLOOD Lipase-28 ___ 05:50AM BLOOD ___ 05:50AM BLOOD cTropnT-0.15* ___ 12:50PM BLOOD cTropnT-0.11* ___ 10:37AM BLOOD D-Dimer-3900* ___ 06:00AM BLOOD %HbA1c-6.5* eAG-140* ___ 04:30PM BLOOD Triglyc-113 HDL-18 CHOL/HD-4.4 LDLcalc-39 ___ 04:30PM BLOOD TSH-3.8 ___ 08:05AM BLOOD HIV Ab-NEG ___ 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG IMAGING: ======== CXR -___: Cardiomegaly and moderate pulmonary edema with moderate to large layering left pleural effusion at least a small right pleural effusion. Likely mild shift of the mediastinum to the right side by mass effect from the large left pleural effusion. -___: In comparison with the study ___, the lower portion of the chest has been cut from the image. There is substantial enlargement the cardiac silhouette with moderate pulmonary edema. The degree of pleural effusion cannot be adequately assessed on this limited study. -___: Comparison to ___. Lung volumes have increased. A rounded perihilar right-sided parenchymal opacity, seen on the previous chest x-ray, is no longer visualized. Moderate cardiomegaly. Moderate right pleural effusion. Mild fluid overload but no overt pulmonary edema. No pneumothorax TTE: ___ CONCLUSIONS: The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is moderately dilated with depressed free wall contractility. There is abnormal septal motion/position. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Very suboptimal image quality. Right ventricular cavity dilation with free wall hypokinesis. Left ventricular cavity dilation with preserved global systolic function. Mild pulmonary artery systolic hypertension. Cardiac Cath: ___ Normal biventricular filling pressures. Moderate to severe pulmonary hypertension with normal left-side filling pressures. Improvement in pulmonary hypertension with oxygen. MICROBIOLOGY: ============= ___ Urine Culture: NEG, FINAL ___ Blood Culture: NEG, FINAL MOST RECENT LABS ON DISCHARGE: ============================== ___ 08:50AM BLOOD WBC-6.2 RBC-5.31* Hgb-12.6 Hct-45.6* MCV-86 MCH-23.7* MCHC-27.6* RDW-20.9* RDWSD-64.2* Plt ___ ___ 03:59AM BLOOD Glucose-117* UreaN-20 Creat-0.9 Na-140 K-3.8 Cl-93* HCO3-31 AnGap-16 ___ 03:59AM BLOOD Calcium-9.1 Phos-4.9* Mg-2.___rief Hospital Course: ======================= Ms. ___ is a ___ yo F with PMH significant for morbid obesity, lymphedema, depression and a pelvic mass who presents with dyspnea as a transfer from ___. She initially presented with a ___ week history of increasing dyspnea to the point where she was unable to complete daily tasks at home. Also reported orthopnea, PND, weight gain, and increasing ___ edema. She denied fever, chills, night sweats, N/V/D, constipation, dysuria, or skin changes. At ___, she was found to be hypoxic with SpO2 64% on RA. She was started on BiPAP with improvement in her oxygenation. On presentation, there was concern for PE, but she was was unable to fit into the CT scanner at the OSH, and was transferred to ___ to rule out PE and for further care. In the ___ ED, she received Lasix 20mg IV with good response (diuresed 2 L), and was weaned off BiPAP to ___ mask. She initially tolerated the ___ mask well, though her SpO2 eventually dropped to 90% with increasing dyspnea and was put back on BiPAP. She was also started on a heparin gtt for suspected ACS. She was transferred to the CCU for further care. In the CCU, she was actively diuresed with Lasix and has since put over 40L. Also, on telemetry overnight ___ she demonstrated paroxysmal atrial fibrillation w/RVT and was started on metoprolol and warfarin with heparin bridging. After stabilizing and continuing diuresis, she transferred to the Heart Failure Service for continued diuresis. Towards the end of her course, she underwent a right heart catheterization which showed moderate-severe pulmonary hypertension and a normal PCWP. She was seen by pulmonology who recommended continuing oxygen therapy, wearing a BiPAP at night, and following up with them in ___ weeks. Acute Medical Issues Addressed: =============================== Ms ___ is a ___ yo F with PMH significant for morbid obesity, lymphedema, depression and a pelvic mass who presents with dyspnea as a transfer from ___, found to have acute on chronic CHF with significant pulmonary edema treated with diuretics and severe sleep apnea requiring in-house BiPAP titration. # CORONARIES: unknown # PUMP: Normal EF (>55%) # RHYTHM: NSR # Hypoxemic Respiratory Failure Ms. ___ presented with hypoxia requiring BiPAP, worsening ___ edema, orthopnea, an elevated proBNP and CXR with pulmonary edema and pleural effusions, consistent with HF. Her overall respiratory failure was thought to be ___ to HF ___ to OHS & OSA. She was aggressively diuresed (see below) w/ improvement in oxygenation status. She required oxygen and work a BiPAP every night and will continue to do so on discharge. # Newly diagnosed heart failure with preserved ejection fraction As above, hypoxia, dyspnea on exertion, orthopnea, ___ edema, elevated proBNP and a CXR with pulmonary edema and bilateral pleural effusions suggested new HF exacerbation. Troponins were mildly elevated and downtrended (0.15 to 0.11) and ECG was without ischemic changes, so there was a low suspicion for active ischemia. TTE ___ demonstrated RV dilation without segmental wall motion abnormalities and LVEF >55%. Thus, a new diagnosis of HFpEF was made. She was diuresed aggressively on a Lasix drip for a total of negative >60 liters with significant improvement in her respiratory status. She underwent a right heart cath as below which showed pulmonary hypertension, and is likely the major contributor to her heart failure. At discharge, her diuretic regimen was torsemide 100 mg BID, and weight was 167.7 kg. # Pulmonary hypertension: Prior to discharge, she underwent a right heart catheterization which showed moderate-to-severe pulmonary hypertension and a normal PCWP. Her PA pressures improved significantly with oxygen and nitrates. This was felt to be due to OSA and OHS, though an outpatient V/Q scan was recommended to evaluate for CTEPH (currently anticoagulated for other reasons). Pulmonology was consulted, and recommended continued home O2 and BiPAP at night. They did not feel sildenafil would be helpful at this time. She will need to follow up with pulmonology and have a repeat RHC in ___ months. # Severe obstructive sleep apnea with in-house BiPAP titration She had significant overnight desaturations while sleeping. Sleep was consulted and performed an in house BiPAP titration with arterial line placed for frqeuent arterial blood gas monitoring. Her settings on discharge were: - Model: Resp dream station Bipap - Settings: I-18, E-10, PS 8 - Mask size: Simplus FFMASK medium # Hypokalemia: She had significant hypokalemia with diuresis, thus was started on spironolactone 100 mg daily and potassium 40 mEq po BID. # New Atrial Fibrillation: On ___ telemetry demonstrated paroxysmal atrial fibrillation with rates in the 150s bpm range with stable BPs. CHA2DS2-VASc = 3, so heparin gtt (started for DVT, see below) was transitioned to warfarin with goal INR = ___ (warfarin chosen due to lack of evidence of efficacy for NOACs in morbid obesity). Metoprolol 6.25 mg PO Q6H was started for rate control, and transitioned to metoprolol succinate 50 mg PO daily by time of discharge. Consider whether there is a need for lifelong anticoagulation for this given that it occurred in the setting of acute respiratory failure. # Venous Thrombosis: LENIs on ___ demonstrated a thrombus in either the gastrocnemius vein or a superficial lesser saphenous vein with inability to distinguish due to poor image quality. She was anticoagulated for this, as well as for atrial fibrillation, as above. Due to her hypoxia we desired to obtain CTA chest to rule out PE, however the patient was unable to fit through the bore of the CT scanner. It is likely that this clot was provoked given that she reports being very sedentary, although we cannot rule out underlying hypercoagulability. # New T2DM: Found to have HbA1c = 6.5 %. Consider starting metformin as an outpatient. She inquired about an outpatient referral with Bariatric Surgery which should be followed up. # R Breast Cellulitis: Pt complained of R breast rash on ___. On further exam, R breast was diffusely red with vague borders, tender to palpation. No breast discharge. She was treated for cellulitis with cephalexin 500mg PO for a 7 day course (last day: ___. # Microscopic Haematuria: This was a chronic stable problem, per Ms ___, since her gynaecologic procedure in ___. We trended daily CBCs with no evidence of active gross bleeding. Urine cultures demonstrated no growth. # Elevated LFTs: Presented with mildly elevated LFTs, likely in the setting of congestion and CHF exacerbation. They normalized within 36 hours of admission after diuresis. Transitional Issues: ==================== [ ] Will need potassium checked on ___ and then as needed to maintain potassium within normal range. [ ] PULM HYPERTENSION: Discharged on home O2 and CPAP. Consider outpatient V/Q scan to evaluate for CTEPH, though patient is already anticoagulated. [ ] DIABETES: New diagnosis, A1c of 6.5. Consider starting metformin as an outpatient. [ ] BARIATRIC SURGERY: Patient inquired about bariatric surgery to help with her heart, diabetes, and progressive medical problems. We discussed this possibility. We gave her the phone number to schedule an appointment with this clinic. Please continue discussion of bariatric surgery. [ ] HEART FAILURE REGIMEN: - Preload: Torsemide 100 mg BID [ ] HYPOKALEMIA: Started KCL 40 mg BID and spironolactone 100 mg daily. Will need potassium closely monitored. [ ] ATRIAL FIBRILLATION: metoprolol succinate XL 50 mg PO daily. Anticoagulation with warfarin, goal INR ___. Consider long-term monitoring for AF (Linq device) with possible discontinuation of warfarin if no AF seen given that this occurred in the setting of acute respiratory failure and severe volume overload. [ ] DVT: Likely provoked given sedentary lifestyle, so may only need 3 months of anticoagulation. Her obesity puts her at high risk of recurrent clots (through elevated estrogen and sedentary lifestyle), so the risks of continued anticoagulation may outweigh benefits (also consider AF as above) [ ] SLEEP APNEA: severe desaturations with sleep. Patient underwent in house bipap titration, discharge settings are: I-18, E-10, PS-8. Requires ongoing follow up with Sleep. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild RX acetaminophen 650 mg 1 tablet(s) by mouth every six (6) hours Disp #100 Tablet Refills:0 2. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID constipation RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 4. Magnesium Oxide 400 mg PO DAILY RX magnesium oxide 400 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 5. Metoprolol Succinate XL 50 mg PO DAILY RX metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe RX oxycodone 5 mg 1 tablet(s) by mouth q4-6h Disp #30 Tablet Refills:0 7. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 [Miralax] 17 gram/dose 17 grams by mouth daily Refills:0 8. Senna 8.6 mg PO BID constipation RX sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #60 Tablet Refills:0 9. Spironolactone 100 mg PO DAILY RX spironolactone 100 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 10. Sucralfate 1 gm PO Q6H:PRN GI upset RX sucralfate [Carafate] 1 gram/10 mL 10 ml by mouth every six (6) hours Refills:0 11. Torsemide 100 mg PO BID RX torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 12. Warfarin 3.5 mg PO DAILY16 RX warfarin [Coumadin] 3 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 RX warfarin [Coumadin] 1 mg 0.5 (One half) tablet(s) by mouth daily Disp #30 Tablet Refills:*0 13.Outpatient Lab Work Chem 10, ICD10 E87.6. Please fax results to Dr. ___ at ___ for adjustment of potassium dose. Discharge Disposition: Home with Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Hypoxemic respiratory failure Acute decompensated heart failure with preserved ejection fraction Pulmonary hypertension Secondary Diagnosis: paroxysmal atrial fibrillation Type 2 diabetes deep vein thrombosis obstructive sleep apnea obesity hypoventilation syndrome obesity transaminitis right breast cellulitis 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 ___ for difficulty breathing in the setting of fluid overload. While here, you underwent an ultrasound of your heart, which showed dilation in the setting of excess fluid, as well as intact squeeze (a condition called heart failure with preserved ejection fraction, or HFpEF). We gave you IV medications in order to take fluid off, and as fluid was removed, your breathing improved. When you left the hospital, a total of 136 pounds of fluid were removed. Your "dry weight" was 369.7 lbs. You were discharged home with a medication called torsemide at a dose of 100 milligrams two times a day. This medication will help you keep fluid off. Because of low potassium caused by this drug, we started you on a drug called spironolactone to keep your potassium up and you will need to take oral potassium as well. Please weigh yourself at home every day, and if your weight increases by more than 2 lbs in a day or by more than 5 lbs in a week, please call your doctor. You also had an ultrasound of your legs, which showed a possible blood clot. In addition, you were noted on the heart monitor to have an abnormal fast heart rhythm called atrial fibrillation. For the blood clot and for the abnormal heart rhythm, you were started on blood thinner medications (initially heparin through an IV, and later an oral medication called warfarin). In addition, in order to prevent your heart from beating too fast, you were started on a medication to slow the heart rate called metoprolol. Finally, given the blood clot we saw, it shall be important for you to follow-up with your primary care physician for blood tests for a condition called hypercoagulability, which is the tendency to form blood clots. During routine blood tests, you also tested positive for type 2, or adult-onset, diabetes (more specifically, your HbA1c test was 6.5 %, and 6.5 % is the cut-off for being positive for diabetes, with higher numbers indicating higher average blood sugars). In addition, you were started on a medication called atorvastatin, which prevents heart disease and lowers cholesterol. You might also consider starting a medication called metformin for the diabetes, and your PCP can decide whether to do this. In addition, we discussed how weight loss and exercise (even exercise in the absence of weight loss) will be key to controlling your blood sugars and diabetes in the future. Throughout your admission, you were noted to have low oxygen levels. These oxygen levels improved with a breathing machine and mask called BiPAP. We suspect that you may have a condition called obstructive sleep apnea as well as "obesity hypoventilation syndrome", which causes your lungs to not fill adequately. You underwent a "right heart catheterization" to measure pressures in your lungs, and we found that you have high lung pressures called "pulmonary hypertension". Because of this, you will need to wear your oxygen every day and your CPAP every night to help you reduce your lung pressures. You will need to see a pulmonologist (lung doctor) as an outpatient when you leave. You expressed interest in Bariatric Surgery during this admission, which is a type of surgery that can help patients lose weight. Diabetes, heart disease, sleep apnea and overall general health can all be improved with weight loss. Please talk to your PCP to receive ___ referral to Bariatric Surgery. It was a pleasure taking care of you, - Your ___ Team Followup Instructions: ___	[ "I5033", "J9601", "I272", "N179", "E662", "E870", "Z6844", "I824Z1", "I480", "E119", "R740", "N610", "I890", "M170", "E876", "K5900", "R3129", "F329", "R7989", "Z87891" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: dyspnea Major Surgical or Invasive Procedure: arterial line placed and removed History of Present Illness: Ms. [MASKED] is a [MASKED] yo F with PMH significant for morbid obesity, lymphedema, depression and a pelvic mass who presented with dyspnea as a transfer from [MASKED]. She initially presented with a [MASKED] week history of increasing dyspnea to the point where she was unable to complete daily tasks at home. Also reported orthopnea, PND, weight gain, and increasing [MASKED] edema. She denied fever, chills, night sweats, N/V/D, constipation, dysuria, or skin changes. At [MASKED], she was found to be hypoxic with SpO2 64% on RA. She was started on BiPAP with improvement in her oxygenation. On presentation, there was concern for PE, but she was was unable to fit into the CT scanner at the OSH, and was transferred to [MASKED] to rule out PE and for further care. In the [MASKED] ED, she received Lasix 20mg IV with good response (diuresed 2 L), and was weaned off BiPAP to [MASKED] mask. She initially tolerated the [MASKED] mask well, though her SpO2 eventually dropped to 90% with increasing dyspnea and was put back on BiPAP. She was also started on a heparin gtt for suspected ACS. She was transferred to the CCU for further care. In the CCU, she was actively diuresed with Lasix and has since put over 40L. Also, on telemetry overnight [MASKED] she demonstrated paroxysmal atrial fibrillation w/RVT and was started on metoprolol and warfarin with heparin bridging. After stabilizing and continuing diuresis, she transferred to the Heart Failure Service for continued diuresis. Towards the end of her course, she underwent a right heart catheterization which showed moderate-severe pulmonary hypertension and a normal PCWP. She was seen by pulmonology who recommended continuing oxygen therapy, wearing a BiPAP at night, and following up with them in [MASKED] weeks. Past Medical History: -morbid obesity -lymphedema of unknown etiology -pelvic mass w/ uterine bleeding s/p hysteroscopy, polypectomy, d & c and placement of Mirena intrauterine device -depression Social History: [MASKED] Family History: Father: deceased MI @ age [MASKED] Sister: stroke @ age [MASKED] Physical Exam: ADMISSION EXAM: =============== General: Obese woman lying in bed, sleepy but easily arousable, speaking full sentences on BiPAP, in NAD. Heent: Normocephalic atraumatic. Sclera anicteric. Neck: Supple. JVP appears elevated but difficult to assess given body habitus. Cardiac: Normal rate, regular rhythm. Normal S1 and S2. No murmurs, rubs or gallops appreciated. Faint heart sounds. Lungs: Exam limited by body habitus. No obvious wheezes, rales or rhonchi. Abdomen: Obese. Soft, non-tender. Protuberant. Unable to assess hepatomegaly or splenomegaly due to body habitus. Firm 2+ pitting oedema of the pannus. Extremities: Warm and well-perfused. 4+ firm and pitting oedema of the lower extremities, L > R. Unable to palpate pulses. Skin: No significant skin lesions or rashes. DISCHARGE EXAM: ================ General: Pleasant middle-aged woman, morbidly obese, NAD, A/Ox3. Head: NC/AT. Neck: JVP obscured by obesity. Cardiac: RRR, normal S1, S2 w/ systolic flow murmur. Respiratory: CTABL, normal effort. Abdomen: Obese, non-tender. Extremities: L leg lymphedema, otherwise no pitting edema. WWP, dusky color of palms, feet, and shins. Pertinent Results: ADMISSION LABS: =============== [MASKED] 05:50AM BLOOD WBC-7.8 RBC-5.51* Hgb-12.2 Hct-47.3* MCV-86 MCH-22.1* MCHC-25.8* RDW-20.8* RDWSD-62.1* Plt [MASKED] [MASKED] 05:50AM BLOOD Neuts-66.7 [MASKED] Monos-8.9 Eos-1.9 Baso-0.4 NRBC-0.8* Im [MASKED] AbsNeut-5.22 AbsLymp-1.69 AbsMono-0.70 AbsEos-0.15 AbsBaso-0.03 [MASKED] 05:50AM BLOOD [MASKED] PTT-25.6 [MASKED] [MASKED] 05:50AM BLOOD Glucose-85 UreaN-10 Creat-0.8 Na-140 K-5.5* Cl-99 HCO3-30 AnGap-17 [MASKED] 05:50AM BLOOD ALT-19 AST-56* AlkPhos-77 TotBili-0.9 [MASKED] 05:50AM BLOOD Lipase-28 [MASKED] 05:50AM BLOOD [MASKED] 05:50AM BLOOD cTropnT-0.15* [MASKED] 12:50PM BLOOD cTropnT-0.11* [MASKED] 05:50AM BLOOD Albumin-3.1* Calcium-7.9* Phos-4.3 Mg-2.2 [MASKED] 06:00AM BLOOD %HbA1c-PND [MASKED] 04:30PM BLOOD Triglyc-PND HDL-PND [MASKED] 04:30PM BLOOD TSH-PND [MASKED] 04:30PM BLOOD ASA-PND Ethanol-PND Acetmnp-PND Bnzodzp-PND Barbitr-PND Tricycl-PND [MASKED] 05:57AM BLOOD [MASKED] pO2-115* pCO2-54* pH-7.41 calTCO2-35* Base XS-8 Comment-GREEN TOP OTHER PERTINENT LABS: ===================== [MASKED] 05:50AM BLOOD ALT-19 AST-56* AlkPhos-77 TotBili-0.9 [MASKED] 04:43AM BLOOD ALT-28 AST-42* AlkPhos-150* TotBili-1.2 [MASKED] 05:50AM BLOOD Lipase-28 [MASKED] 05:50AM BLOOD [MASKED] 05:50AM BLOOD cTropnT-0.15* [MASKED] 12:50PM BLOOD cTropnT-0.11* [MASKED] 10:37AM BLOOD D-Dimer-3900* [MASKED] 06:00AM BLOOD %HbA1c-6.5* eAG-140* [MASKED] 04:30PM BLOOD Triglyc-113 HDL-18 CHOL/HD-4.4 LDLcalc-39 [MASKED] 04:30PM BLOOD TSH-3.8 [MASKED] 08:05AM BLOOD HIV Ab-NEG [MASKED] 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG IMAGING: ======== CXR -[MASKED]: Cardiomegaly and moderate pulmonary edema with moderate to large layering left pleural effusion at least a small right pleural effusion. Likely mild shift of the mediastinum to the right side by mass effect from the large left pleural effusion. -[MASKED]: In comparison with the study [MASKED], the lower portion of the chest has been cut from the image. There is substantial enlargement the cardiac silhouette with moderate pulmonary edema. The degree of pleural effusion cannot be adequately assessed on this limited study. -[MASKED]: Comparison to [MASKED]. Lung volumes have increased. A rounded perihilar right-sided parenchymal opacity, seen on the previous chest x-ray, is no longer visualized. Moderate cardiomegaly. Moderate right pleural effusion. Mild fluid overload but no overt pulmonary edema. No pneumothorax TTE: [MASKED] CONCLUSIONS: The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is moderately dilated with depressed free wall contractility. There is abnormal septal motion/position. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Very suboptimal image quality. Right ventricular cavity dilation with free wall hypokinesis. Left ventricular cavity dilation with preserved global systolic function. Mild pulmonary artery systolic hypertension. Cardiac Cath: [MASKED] Normal biventricular filling pressures. Moderate to severe pulmonary hypertension with normal left-side filling pressures. Improvement in pulmonary hypertension with oxygen. MICROBIOLOGY: ============= [MASKED] Urine Culture: NEG, FINAL [MASKED] Blood Culture: NEG, FINAL MOST RECENT LABS ON DISCHARGE: ============================== [MASKED] 08:50AM BLOOD WBC-6.2 RBC-5.31* Hgb-12.6 Hct-45.6* MCV-86 MCH-23.7* MCHC-27.6* RDW-20.9* RDWSD-64.2* Plt [MASKED] [MASKED] 03:59AM BLOOD Glucose-117* UreaN-20 Creat-0.9 Na-140 K-3.8 Cl-93* HCO3-31 AnGap-16 [MASKED] 03:59AM BLOOD Calcium-9.1 Phos-4.9* Mg-2. rief Hospital Course: ======================= Ms. [MASKED] is a [MASKED] yo F with PMH significant for morbid obesity, lymphedema, depression and a pelvic mass who presents with dyspnea as a transfer from [MASKED]. She initially presented with a [MASKED] week history of increasing dyspnea to the point where she was unable to complete daily tasks at home. Also reported orthopnea, PND, weight gain, and increasing [MASKED] edema. She denied fever, chills, night sweats, N/V/D, constipation, dysuria, or skin changes. At [MASKED], she was found to be hypoxic with SpO2 64% on RA. She was started on BiPAP with improvement in her oxygenation. On presentation, there was concern for PE, but she was was unable to fit into the CT scanner at the OSH, and was transferred to [MASKED] to rule out PE and for further care. In the [MASKED] ED, she received Lasix 20mg IV with good response (diuresed 2 L), and was weaned off BiPAP to [MASKED] mask. She initially tolerated the [MASKED] mask well, though her SpO2 eventually dropped to 90% with increasing dyspnea and was put back on BiPAP. She was also started on a heparin gtt for suspected ACS. She was transferred to the CCU for further care. In the CCU, she was actively diuresed with Lasix and has since put over 40L. Also, on telemetry overnight [MASKED] she demonstrated paroxysmal atrial fibrillation w/RVT and was started on metoprolol and warfarin with heparin bridging. After stabilizing and continuing diuresis, she transferred to the Heart Failure Service for continued diuresis. Towards the end of her course, she underwent a right heart catheterization which showed moderate-severe pulmonary hypertension and a normal PCWP. She was seen by pulmonology who recommended continuing oxygen therapy, wearing a BiPAP at night, and following up with them in [MASKED] weeks. Acute Medical Issues Addressed: =============================== Ms [MASKED] is a [MASKED] yo F with PMH significant for morbid obesity, lymphedema, depression and a pelvic mass who presents with dyspnea as a transfer from [MASKED], found to have acute on chronic CHF with significant pulmonary edema treated with diuretics and severe sleep apnea requiring in-house BiPAP titration. # CORONARIES: unknown # PUMP: Normal EF (>55%) # RHYTHM: NSR # Hypoxemic Respiratory Failure Ms. [MASKED] presented with hypoxia requiring BiPAP, worsening [MASKED] edema, orthopnea, an elevated proBNP and CXR with pulmonary edema and pleural effusions, consistent with HF. Her overall respiratory failure was thought to be [MASKED] to HF [MASKED] to OHS & OSA. She was aggressively diuresed (see below) w/ improvement in oxygenation status. She required oxygen and work a BiPAP every night and will continue to do so on discharge. # Newly diagnosed heart failure with preserved ejection fraction As above, hypoxia, dyspnea on exertion, orthopnea, [MASKED] edema, elevated proBNP and a CXR with pulmonary edema and bilateral pleural effusions suggested new HF exacerbation. Troponins were mildly elevated and downtrended (0.15 to 0.11) and ECG was without ischemic changes, so there was a low suspicion for active ischemia. TTE [MASKED] demonstrated RV dilation without segmental wall motion abnormalities and LVEF >55%. Thus, a new diagnosis of HFpEF was made. She was diuresed aggressively on a Lasix drip for a total of negative >60 liters with significant improvement in her respiratory status. She underwent a right heart cath as below which showed pulmonary hypertension, and is likely the major contributor to her heart failure. At discharge, her diuretic regimen was torsemide 100 mg BID, and weight was 167.7 kg. # Pulmonary hypertension: Prior to discharge, she underwent a right heart catheterization which showed moderate-to-severe pulmonary hypertension and a normal PCWP. Her PA pressures improved significantly with oxygen and nitrates. This was felt to be due to OSA and OHS, though an outpatient V/Q scan was recommended to evaluate for CTEPH (currently anticoagulated for other reasons). Pulmonology was consulted, and recommended continued home O2 and BiPAP at night. They did not feel sildenafil would be helpful at this time. She will need to follow up with pulmonology and have a repeat RHC in [MASKED] months. # Severe obstructive sleep apnea with in-house BiPAP titration She had significant overnight desaturations while sleeping. Sleep was consulted and performed an in house BiPAP titration with arterial line placed for frqeuent arterial blood gas monitoring. Her settings on discharge were: - Model: Resp dream station Bipap - Settings: I-18, E-10, PS 8 - Mask size: Simplus FFMASK medium # Hypokalemia: She had significant hypokalemia with diuresis, thus was started on spironolactone 100 mg daily and potassium 40 mEq po BID. # New Atrial Fibrillation: On [MASKED] telemetry demonstrated paroxysmal atrial fibrillation with rates in the 150s bpm range with stable BPs. CHA2DS2-VASc = 3, so heparin gtt (started for DVT, see below) was transitioned to warfarin with goal INR = [MASKED] (warfarin chosen due to lack of evidence of efficacy for NOACs in morbid obesity). Metoprolol 6.25 mg PO Q6H was started for rate control, and transitioned to metoprolol succinate 50 mg PO daily by time of discharge. Consider whether there is a need for lifelong anticoagulation for this given that it occurred in the setting of acute respiratory failure. # Venous Thrombosis: LENIs on [MASKED] demonstrated a thrombus in either the gastrocnemius vein or a superficial lesser saphenous vein with inability to distinguish due to poor image quality. She was anticoagulated for this, as well as for atrial fibrillation, as above. Due to her hypoxia we desired to obtain CTA chest to rule out PE, however the patient was unable to fit through the bore of the CT scanner. It is likely that this clot was provoked given that she reports being very sedentary, although we cannot rule out underlying hypercoagulability. # New T2DM: Found to have HbA1c = 6.5 %. Consider starting metformin as an outpatient. She inquired about an outpatient referral with Bariatric Surgery which should be followed up. # R Breast Cellulitis: Pt complained of R breast rash on [MASKED]. On further exam, R breast was diffusely red with vague borders, tender to palpation. No breast discharge. She was treated for cellulitis with cephalexin 500mg PO for a 7 day course (last day: [MASKED]. # Microscopic Haematuria: This was a chronic stable problem, per Ms [MASKED], since her gynaecologic procedure in [MASKED]. We trended daily CBCs with no evidence of active gross bleeding. Urine cultures demonstrated no growth. # Elevated LFTs: Presented with mildly elevated LFTs, likely in the setting of congestion and CHF exacerbation. They normalized within 36 hours of admission after diuresis. Transitional Issues: ==================== [ ] Will need potassium checked on [MASKED] and then as needed to maintain potassium within normal range. [ ] PULM HYPERTENSION: Discharged on home O2 and CPAP. Consider outpatient V/Q scan to evaluate for CTEPH, though patient is already anticoagulated. [ ] DIABETES: New diagnosis, A1c of 6.5. Consider starting metformin as an outpatient. [ ] BARIATRIC SURGERY: Patient inquired about bariatric surgery to help with her heart, diabetes, and progressive medical problems. We discussed this possibility. We gave her the phone number to schedule an appointment with this clinic. Please continue discussion of bariatric surgery. [ ] HEART FAILURE REGIMEN: - Preload: Torsemide 100 mg BID [ ] HYPOKALEMIA: Started KCL 40 mg BID and spironolactone 100 mg daily. Will need potassium closely monitored. [ ] ATRIAL FIBRILLATION: metoprolol succinate XL 50 mg PO daily. Anticoagulation with warfarin, goal INR [MASKED]. Consider long-term monitoring for AF (Linq device) with possible discontinuation of warfarin if no AF seen given that this occurred in the setting of acute respiratory failure and severe volume overload. [ ] DVT: Likely provoked given sedentary lifestyle, so may only need 3 months of anticoagulation. Her obesity puts her at high risk of recurrent clots (through elevated estrogen and sedentary lifestyle), so the risks of continued anticoagulation may outweigh benefits (also consider AF as above) [ ] SLEEP APNEA: severe desaturations with sleep. Patient underwent in house bipap titration, discharge settings are: I-18, E-10, PS-8. Requires ongoing follow up with Sleep. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild RX acetaminophen 650 mg 1 tablet(s) by mouth every six (6) hours Disp #100 Tablet Refills:0 2. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID constipation RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 4. Magnesium Oxide 400 mg PO DAILY RX magnesium oxide 400 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 5. Metoprolol Succinate XL 50 mg PO DAILY RX metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe RX oxycodone 5 mg 1 tablet(s) by mouth q4-6h Disp #30 Tablet Refills:0 7. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 [Miralax] 17 gram/dose 17 grams by mouth daily Refills:0 8. Senna 8.6 mg PO BID constipation RX sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #60 Tablet Refills:0 9. Spironolactone 100 mg PO DAILY RX spironolactone 100 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 10. Sucralfate 1 gm PO Q6H:PRN GI upset RX sucralfate [Carafate] 1 gram/10 mL 10 ml by mouth every six (6) hours Refills:0 11. Torsemide 100 mg PO BID RX torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 12. Warfarin 3.5 mg PO DAILY16 RX warfarin [Coumadin] 3 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 RX warfarin [Coumadin] 1 mg 0.5 (One half) tablet(s) by mouth daily Disp #30 Tablet Refills:*0 13.Outpatient Lab Work Chem 10, ICD10 E87.6. Please fax results to Dr. [MASKED] at [MASKED] for adjustment of potassium dose. Discharge Disposition: Home with Service Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis: Hypoxemic respiratory failure Acute decompensated heart failure with preserved ejection fraction Pulmonary hypertension Secondary Diagnosis: paroxysmal atrial fibrillation Type 2 diabetes deep vein thrombosis obstructive sleep apnea obesity hypoventilation syndrome obesity transaminitis right breast cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms [MASKED], You were admitted to [MASKED] for difficulty breathing in the setting of fluid overload. While here, you underwent an ultrasound of your heart, which showed dilation in the setting of excess fluid, as well as intact squeeze (a condition called heart failure with preserved ejection fraction, or HFpEF). We gave you IV medications in order to take fluid off, and as fluid was removed, your breathing improved. When you left the hospital, a total of 136 pounds of fluid were removed. Your "dry weight" was 369.7 lbs. You were discharged home with a medication called torsemide at a dose of 100 milligrams two times a day. This medication will help you keep fluid off. Because of low potassium caused by this drug, we started you on a drug called spironolactone to keep your potassium up and you will need to take oral potassium as well. Please weigh yourself at home every day, and if your weight increases by more than 2 lbs in a day or by more than 5 lbs in a week, please call your doctor. You also had an ultrasound of your legs, which showed a possible blood clot. In addition, you were noted on the heart monitor to have an abnormal fast heart rhythm called atrial fibrillation. For the blood clot and for the abnormal heart rhythm, you were started on blood thinner medications (initially heparin through an IV, and later an oral medication called warfarin). In addition, in order to prevent your heart from beating too fast, you were started on a medication to slow the heart rate called metoprolol. Finally, given the blood clot we saw, it shall be important for you to follow-up with your primary care physician for blood tests for a condition called hypercoagulability, which is the tendency to form blood clots. During routine blood tests, you also tested positive for type 2, or adult-onset, diabetes (more specifically, your HbA1c test was 6.5 %, and 6.5 % is the cut-off for being positive for diabetes, with higher numbers indicating higher average blood sugars). In addition, you were started on a medication called atorvastatin, which prevents heart disease and lowers cholesterol. You might also consider starting a medication called metformin for the diabetes, and your PCP can decide whether to do this. In addition, we discussed how weight loss and exercise (even exercise in the absence of weight loss) will be key to controlling your blood sugars and diabetes in the future. Throughout your admission, you were noted to have low oxygen levels. These oxygen levels improved with a breathing machine and mask called BiPAP. We suspect that you may have a condition called obstructive sleep apnea as well as "obesity hypoventilation syndrome", which causes your lungs to not fill adequately. You underwent a "right heart catheterization" to measure pressures in your lungs, and we found that you have high lung pressures called "pulmonary hypertension". Because of this, you will need to wear your oxygen every day and your CPAP every night to help you reduce your lung pressures. You will need to see a pulmonologist (lung doctor) as an outpatient when you leave. You expressed interest in Bariatric Surgery during this admission, which is a type of surgery that can help patients lose weight. Diabetes, heart disease, sleep apnea and overall general health can all be improved with weight loss. Please talk to your PCP to receive [MASKED] referral to Bariatric Surgery. It was a pleasure taking care of you, - Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "J9601", "N179", "I480", "E119", "K5900", "F329", "Z87891" ]	[ "I5033: Acute on chronic diastolic (congestive) heart failure", "J9601: Acute respiratory failure with hypoxia", "I272: Other secondary pulmonary hypertension", "N179: Acute kidney failure, unspecified", "E662: Morbid (severe) obesity with alveolar hypoventilation", "E870: Hyperosmolality and hypernatremia", "Z6844: Body mass index [BMI] 60.0-69.9, adult", "I824Z1: Acute embolism and thrombosis of unspecified deep veins of right distal lower extremity", "I480: Paroxysmal atrial fibrillation", "E119: Type 2 diabetes mellitus without complications", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "N610: Mastitis without abscess", "I890: Lymphedema, not elsewhere classified", "M170: Bilateral primary osteoarthritis of knee", "E876: Hypokalemia", "K5900: Constipation, unspecified", "R3129: Other microscopic hematuria", "F329: Major depressive disorder, single episode, unspecified", "R7989: Other specified abnormal findings of blood chemistry", "Z87891: Personal history of nicotine dependence" ]
10,092,201	28,030,798	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Breakthrough seizure activity Major Surgical or Invasive Procedure: Cerebral angiogram History of Present Illness: Mr. ___ is a ___ old right-handed man with a past medical history of IV drug use, chronic back ___ c/b Gabapentin abuse, remote febrile seizure who presents with two events concerning for seizure. Patient reports waking up with a headache yesterday morning. It is described as bifrontal pressure, with associated nausea and phonophobia, initially mild and then progressively worsened over the course of the day. He took Tylenol with some relief. This was in the setting of a few days of feeling "off," with poor appetite, nausea and chills but no fever. Around 1am, he and his girlfriend were lying on the couch and had just fallen asleep. His girlfriend awoke to a grunting noise. She looked over and saw the patient stiff, with eyelid fluttering, grinding his teeth and completely rigid for one minute without incontinence. He was sleepy and quiet afterwards. EMS arrived 5 minutes later and the patient became combative and agitated, confused about why people were in the house. He returned to normal about 30 minutes later after arrival to the OSH ED. At ___, he had basic labs checked, including BG 122, wbc 10.4, Cr 1.3. He had a second seizure, lasting about 1 minute, which resolved prior to Ativan administration. He was then loaded with Dilantin 15mg/kg around 2:30am. He was post-ictal for about 10 mins. He had a head CT which showed a hyperdense focus in the left parietal lobe concerning for venous anomaly. He was therefore transferred for further management. On arrival, he was evaluated by neurosurgery who recommended CTA and MRI. Neurology was consulted for management of his seizures. Of note, there are documentations of patient taking Wellbutrin recently, but he has not taken this medication in ___ months. Additionally, he reports abusing Gabapentin due to significant back ___. He will buy it on the street and take approximately 10 pills per day of Gabapentin 800mg. On the day of the seizure, he thinks he took slightly less Gabapentin than usual, though he is not sure how much. He denies any other drug use. He has not used heroin in over ___ years. Seizure risk factors: -Febrile seizure: only 1 when he was ___ year old. He was placed on Phenobarbital x ___ year. No other seizure medications required and he has never had another seizure. -Head trauma: reports multiple fights with blows to the head and probable concussions in the past -No meningitis or encephalitis -Reports a "bleed" in his brain found on imaging approximately ___ years ago. Presented to doctor for episodes of dizziness and had head imaging which apparently initially looked like a tumor, then told it was a "bleed." There is a head CT in our system from ___ showing a left parietal hemorrhage with mild surrounding edema in the same location. Past Medical History: Back ___ secondary to lumbar disc disease s/p L5 surgery (unclear what was done) Substance abuse (Gabapentin as outlined above) History of IV drug use, quit ___ years ago Depression ADHD Febrile sz s/p appendectomy Social History: ___ Family History: No seizures. Physical Exam: ADMISSION EXAM: General: Sleepy but arousable HEENT: NC/AT, no scleral icterus noted, dry MM, no lesions noted in oropharynx Neck: Supple. No nuchal rigidity Pulmonary: Normal work of breathing Cardiac: RRR, warm, well-perfused Abdomen: soft, non-distended Back: ___ on palpation of thoracic paraspinals R > L, mild midline ___ Extremities: No ___ edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x to self, ___ ___ Able to name his girlfriend in the room. Inattentive, unable to ___ backwards. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. 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, proprioception throughout. -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. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. -Gait: Deferred due to ___ DISCHARGE EXAM: Difficulty w/ MOYB, otherwise nonfocal Pertinent Results: ___ 05:00AM BLOOD WBC-6.8 RBC-5.03 Hgb-15.4 Hct-45.7 MCV-91 MCH-30.6 MCHC-33.7 RDW-11.8 RDWSD-39.3 Plt ___ ___ 03:51AM BLOOD WBC-20.7* RBC-4.78 Hgb-15.2 Hct-42.9 MCV-90 MCH-31.8 MCHC-35.4 RDW-11.9 RDWSD-39.0 Plt ___ ___ 05:00AM BLOOD ___ PTT-27.8 ___ ___ 05:00AM BLOOD Glucose-90 UreaN-15 Creat-0.8 Na-139 K-4.1 Cl-100 HCO3-27 AnGap-16 ___ 03:51AM BLOOD Glucose-136* UreaN-11 Creat-1.0 Na-137 K-3.7 Cl-102 HCO3-19* AnGap-20 ___ 03:51AM BLOOD ALT-26 AST-33 AlkPhos-25* TotBili-0.2 ___ 05:00AM BLOOD Calcium-9.5 Phos-4.7* Mg-2.0 ___ 08:10AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.3 ___ 03:51AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ H&N 1. Curvilinear hyperdense lesion within the left parietal lobe, with extension to the left parafalcine region is likely secondary to calcification, which may be secondary to a partially thrombosed AVM, cavernous malformation, or sequelae of prior hemorrhage. No definite acute intracranial hemorrhage or acute large territorial infarction. 2. Unremarkable CTA of the head without evidence of stenosis or aneurysm. No evidence of vascular malformation. ___ Head w/ and w/o contrast 1. THe left parietal lesions is most likely an occult vascular malformation. ___ Angiogram 5 vessels diagnostic cerebral angiogram did not demonstrate any vascular abnormalities. Brief Hospital Course: Mr. ___ was hospitalized at ___ due to two tonic events concerning for seizure activity. He underwent imaging including CTA Head and Neck and MRI Brain which were concerning for R parietal vascular malformation. He was evaluated on EEG and started on Keppra which was uptitrated due to persistent events. Due to hx of Gabapentin abuse, he was started on gabapentin regimen to prevent withdrawal. He underwent cerebral angiogram by NSGY on ___ which did not show a vascular abnormality. Per Neurosurgery, likely that pt does not have vascular abnormality but rather has abnormalities seen on imaging related to previous TBI in ___. Due to appearing clinically stable, patient was discharged from the hospital. ******************* Transition Issues: -Pt will need to follow up with new PCP and ___ -Pt will need to follow up in First Time Seizure Clinic -Pt will need to continue taking Keppra 1500mg BID -Pt will need to take Gabapentin taper starting at 800mg TID and tapering down by 100mg every week -Pt will need to obtain MRI in 6 months to ensure that vascular anomaly seen on previous imaging is not apparent Medications on Admission: Gabapentin 800mg TID (often up to 10 pills per day) Prozac Adderall ___ pills per day Discharge Medications: 1. Gabapentin 800 mg PO TID 2. LevETIRAcetam 1500 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Breakthrough seizure activity 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 ___ and treated by Neurology due to events concerning for seizure activity. You underwent neuroimaging of the brain as well as EEG which suggested occult vascular anomaly in brain. However, cerebral angiogram did not reveal this abnormality. Due to appearing stable on Keppra started on admission with no continued seizures, you will be discharged from the hospital. Please continue taking Keppra 1500mg twice daily. Please continue to taper down on Gabapentin as follows: Gabapentin 800mg (1 800mg tablet) three times daily x 1 week, then Gabapentin 700mg (1 600mg tablet+1 100mg tablet) three times daily x 1 week, then Gabapentin 600mg (1 600mg tablet) three times daily x 1 week, then Gabapentin 500mg (1 400mg tablet+1 100mg tablet) three times daily x 1 week, then Gabapentin 400mg (1 400mg tablet) three times daily x 1 week, then Gabapentin 300mg (3 x 100mg tablets) three times daily x 1 week, then Gabapentin 200mg (2 x 100mg tablets) three times daily x 1 week, then Gabapentin 100mg (1 x 100mg tablet) three times daily x 1 week, then stop Please follow up in First Time Seizure Clinic in near future (to be contacted with appointment information). Please plan for follow up MRI Brain in 6 months to determine if intracerebral vascular anomaly has resolved. Please follow up with new PCP and ___ based on information provided by social worker. It was pleasure taking care of you, ___ Neurology Team Followup Instructions: ___	[ "G40409", "F329", "F558", "F909", "M545", "G8929", "F419", "F17210" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Breakthrough seizure activity Major Surgical or Invasive Procedure: Cerebral angiogram History of Present Illness: Mr. [MASKED] is a [MASKED] old right-handed man with a past medical history of IV drug use, chronic back [MASKED] c/b Gabapentin abuse, remote febrile seizure who presents with two events concerning for seizure. Patient reports waking up with a headache yesterday morning. It is described as bifrontal pressure, with associated nausea and phonophobia, initially mild and then progressively worsened over the course of the day. He took Tylenol with some relief. This was in the setting of a few days of feeling "off," with poor appetite, nausea and chills but no fever. Around 1am, he and his girlfriend were lying on the couch and had just fallen asleep. His girlfriend awoke to a grunting noise. She looked over and saw the patient stiff, with eyelid fluttering, grinding his teeth and completely rigid for one minute without incontinence. He was sleepy and quiet afterwards. EMS arrived 5 minutes later and the patient became combative and agitated, confused about why people were in the house. He returned to normal about 30 minutes later after arrival to the OSH ED. At [MASKED], he had basic labs checked, including BG 122, wbc 10.4, Cr 1.3. He had a second seizure, lasting about 1 minute, which resolved prior to Ativan administration. He was then loaded with Dilantin 15mg/kg around 2:30am. He was post-ictal for about 10 mins. He had a head CT which showed a hyperdense focus in the left parietal lobe concerning for venous anomaly. He was therefore transferred for further management. On arrival, he was evaluated by neurosurgery who recommended CTA and MRI. Neurology was consulted for management of his seizures. Of note, there are documentations of patient taking Wellbutrin recently, but he has not taken this medication in [MASKED] months. Additionally, he reports abusing Gabapentin due to significant back [MASKED]. He will buy it on the street and take approximately 10 pills per day of Gabapentin 800mg. On the day of the seizure, he thinks he took slightly less Gabapentin than usual, though he is not sure how much. He denies any other drug use. He has not used heroin in over [MASKED] years. Seizure risk factors: -Febrile seizure: only 1 when he was [MASKED] year old. He was placed on Phenobarbital x [MASKED] year. No other seizure medications required and he has never had another seizure. -Head trauma: reports multiple fights with blows to the head and probable concussions in the past -No meningitis or encephalitis -Reports a "bleed" in his brain found on imaging approximately [MASKED] years ago. Presented to doctor for episodes of dizziness and had head imaging which apparently initially looked like a tumor, then told it was a "bleed." There is a head CT in our system from [MASKED] showing a left parietal hemorrhage with mild surrounding edema in the same location. Past Medical History: Back [MASKED] secondary to lumbar disc disease s/p L5 surgery (unclear what was done) Substance abuse (Gabapentin as outlined above) History of IV drug use, quit [MASKED] years ago Depression ADHD Febrile sz s/p appendectomy Social History: [MASKED] Family History: No seizures. Physical Exam: ADMISSION EXAM: General: Sleepy but arousable HEENT: NC/AT, no scleral icterus noted, dry MM, no lesions noted in oropharynx Neck: Supple. No nuchal rigidity Pulmonary: Normal work of breathing Cardiac: RRR, warm, well-perfused Abdomen: soft, non-distended Back: [MASKED] on palpation of thoracic paraspinals R > L, mild midline [MASKED] Extremities: No [MASKED] edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x to self, [MASKED] [MASKED] Able to name his girlfriend in the room. Inattentive, unable to [MASKED] backwards. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall [MASKED] at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. 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] [MASKED] 5 5 5 5 R 5 [MASKED] [MASKED] 5 5 5 5 -Sensory: No deficits to light touch, pinprick, proprioception throughout. -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. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. -Gait: Deferred due to [MASKED] DISCHARGE EXAM: Difficulty w/ MOYB, otherwise nonfocal Pertinent Results: [MASKED] 05:00AM BLOOD WBC-6.8 RBC-5.03 Hgb-15.4 Hct-45.7 MCV-91 MCH-30.6 MCHC-33.7 RDW-11.8 RDWSD-39.3 Plt [MASKED] [MASKED] 03:51AM BLOOD WBC-20.7* RBC-4.78 Hgb-15.2 Hct-42.9 MCV-90 MCH-31.8 MCHC-35.4 RDW-11.9 RDWSD-39.0 Plt [MASKED] [MASKED] 05:00AM BLOOD [MASKED] PTT-27.8 [MASKED] [MASKED] 05:00AM BLOOD Glucose-90 UreaN-15 Creat-0.8 Na-139 K-4.1 Cl-100 HCO3-27 AnGap-16 [MASKED] 03:51AM BLOOD Glucose-136* UreaN-11 Creat-1.0 Na-137 K-3.7 Cl-102 HCO3-19* AnGap-20 [MASKED] 03:51AM BLOOD ALT-26 AST-33 AlkPhos-25* TotBili-0.2 [MASKED] 05:00AM BLOOD Calcium-9.5 Phos-4.7* Mg-2.0 [MASKED] 08:10AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.3 [MASKED] 03:51AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] H&N 1. Curvilinear hyperdense lesion within the left parietal lobe, with extension to the left parafalcine region is likely secondary to calcification, which may be secondary to a partially thrombosed AVM, cavernous malformation, or sequelae of prior hemorrhage. No definite acute intracranial hemorrhage or acute large territorial infarction. 2. Unremarkable CTA of the head without evidence of stenosis or aneurysm. No evidence of vascular malformation. [MASKED] Head w/ and w/o contrast 1. THe left parietal lesions is most likely an occult vascular malformation. [MASKED] Angiogram 5 vessels diagnostic cerebral angiogram did not demonstrate any vascular abnormalities. Brief Hospital Course: Mr. [MASKED] was hospitalized at [MASKED] due to two tonic events concerning for seizure activity. He underwent imaging including CTA Head and Neck and MRI Brain which were concerning for R parietal vascular malformation. He was evaluated on EEG and started on Keppra which was uptitrated due to persistent events. Due to hx of Gabapentin abuse, he was started on gabapentin regimen to prevent withdrawal. He underwent cerebral angiogram by NSGY on [MASKED] which did not show a vascular abnormality. Per Neurosurgery, likely that pt does not have vascular abnormality but rather has abnormalities seen on imaging related to previous TBI in [MASKED]. Due to appearing clinically stable, patient was discharged from the hospital. ******************* Transition Issues: -Pt will need to follow up with new PCP and [MASKED] -Pt will need to follow up in First Time Seizure Clinic -Pt will need to continue taking Keppra 1500mg BID -Pt will need to take Gabapentin taper starting at 800mg TID and tapering down by 100mg every week -Pt will need to obtain MRI in 6 months to ensure that vascular anomaly seen on previous imaging is not apparent Medications on Admission: Gabapentin 800mg TID (often up to 10 pills per day) Prozac Adderall [MASKED] pills per day Discharge Medications: 1. Gabapentin 800 mg PO TID 2. LevETIRAcetam 1500 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Breakthrough seizure activity 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] and treated by Neurology due to events concerning for seizure activity. You underwent neuroimaging of the brain as well as EEG which suggested occult vascular anomaly in brain. However, cerebral angiogram did not reveal this abnormality. Due to appearing stable on Keppra started on admission with no continued seizures, you will be discharged from the hospital. Please continue taking Keppra 1500mg twice daily. Please continue to taper down on Gabapentin as follows: Gabapentin 800mg (1 800mg tablet) three times daily x 1 week, then Gabapentin 700mg (1 600mg tablet+1 100mg tablet) three times daily x 1 week, then Gabapentin 600mg (1 600mg tablet) three times daily x 1 week, then Gabapentin 500mg (1 400mg tablet+1 100mg tablet) three times daily x 1 week, then Gabapentin 400mg (1 400mg tablet) three times daily x 1 week, then Gabapentin 300mg (3 x 100mg tablets) three times daily x 1 week, then Gabapentin 200mg (2 x 100mg tablets) three times daily x 1 week, then Gabapentin 100mg (1 x 100mg tablet) three times daily x 1 week, then stop Please follow up in First Time Seizure Clinic in near future (to be contacted with appointment information). Please plan for follow up MRI Brain in 6 months to determine if intracerebral vascular anomaly has resolved. Please follow up with new PCP and [MASKED] based on information provided by social worker. It was pleasure taking care of you, [MASKED] Neurology Team Followup Instructions: [MASKED]	[]	[ "F329", "G8929", "F419", "F17210" ]	[ "G40409: Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus", "F329: Major depressive disorder, single episode, unspecified", "F558: Abuse of other non-psychoactive substances", "F909: Attention-deficit hyperactivity disorder, unspecified type", "M545: Low back pain", "G8929: Other chronic pain", "F419: Anxiety disorder, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
10,092,227	23,138,040	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: CVL placement (removed) PICC line placed (removed on ___ Bronchoscopy History of Present Illness: ___ with unclear medical history (?COPD) presenting from out of hospital for unresponsiveness. Patient had a fall yesterday. EMS was called; however, the patient declined transfer at that time. Patient today was found unresponsive by friend. Brought to outside hospital where she was in respiratory distress. Hypotensive with systolics in the ___. Patient was intubated and started on norepinephrine. Patient found to have transaminitis (2000s); trop 0.04. Pan scan results showed concern for temporal and occipital stroke. ___ pancreatic inflammation on CT scan although with normal lipase level. Patient received vancomycin and Zosyn for concern for pneumonia. OG tube with coffee ground material returning. Patient given pantoprazole. Transferred here for further management. Right femoral line placed at outside hospital (___). In the ED, initial vitals: 98.0, 87, 129/77, 15, 100%vent Labs were significant for: VBG: 7.13, 86, O2 44, HCO3 30 CBC: 18.4>14.9/51.2<98 Chem (whole blood): Na 148, K 4.4, Cl 106, Glu 149, freeCa 1.08 Lactate: 2.9 INR 2.2, ___ ___ Fibrinogen 168 ALT 2550, AST 5098, AP 124, Tbili 2.1, Alb 3.2 Lipase: 12 Serum tox: negative APAP tox: negative Imaging was significant for: CXR 1. Standard positioning of endotracheal tube. 2. Enteric tube tip is likely within the stomach, however the side port is just proximal to the gastroesophageal junction, and slight interval advancement by approximately 4 cm is suggested. 3. Opacification of the right upper lobe concerning for collapse given the presence of rightward tracheal deviation. Consider contrast-enhanced chest CT to assess for an underlying obstructive lesion. 4. Small right pleural effusion and right basilar opacity, potentially compressive atelectasis. 5. Mild pulmonary vascular congestion. Her imaging is notable for right lung collapse, possible pneumonia, pulmonary nodule, and ___ stranding in addition to the reported subacute right temporal occipital stroke seen on head CT (currently unable to access). CT head non-con (___): 1. There are late subacute to chronic infarcts in the right occipital, temporal lobes. If there is clinical concern for acute component, MRI would be helpful. 2. There is 2.5 cm well-circumscribed right pre antral mass, abutting right nares. 3. There is left scalp, right temporal scalp edema. There is mild edema about partially seen upper right parotid gland, indeterminate come consider parotitis. Consults: Neuro, toxicology, RT On transfer, vitals were: On arrival to the MICU, Review of systems: unable to obtain as patient is intubated. (+) Per HPI Past Medical History: COPD; ?skin cancer of nose (no other hx available) Social History: ___ Family History: Unknown Physical Exam: ADMISSION EXAM: --------------- Vitals: T: 98.2 NR BP: 80/62 P: 78 R: 42 O2: 99%Vent GENERAL: Intubated/sedated HEENT: Sclera anicteric NECK: supple LUNGS: coarse breath sounds bilaterally, no wheezes CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley in place EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis; 2+ edema bilaterally in lower extremities SKIN: large macular rash underneath breasts. NEURO: Intubated/sedated -- deferred ACCESS: PIVs DISCHARGE EXAM: --------------- General: No acute distress. AOx3. HEENT: sclera anicteric, MMM, oropharynx clear Neck: supple. No JVD Lungs: Clear lung in left. Decreased breath sounds of RLL fields CV: RRR, normal S1 + S2, no significant murmurs, rubs or gallops. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, trace edema around legs bilaterally. Neuro: moving all 4 extremities Skin: 4cm circular scar on back from prior procedure. R nare with 1cm round lesion with pearly red borders, R thigh with dressing over erythematous skin lesion. Pertinent Results: ADMISSION LABS: --------------- ___ 04:45PM BLOOD WBC-18.4* RBC-5.37* Hgb-14.9 Hct-51.2* MCV-95 MCH-27.7 MCHC-29.1* RDW-17.9* RDWSD-58.8* Plt Ct-98* ___ 04:45PM BLOOD ___ PTT-24.7* ___ ___ 04:45PM BLOOD Plt Smr-LOW Plt Ct-98* ___ 04:45PM BLOOD UreaN-35* Creat-1.6* ___ 04:45PM BLOOD ALT-2550* AST-5098* AlkPhos-124* TotBili-2.1* ___ 04:45PM BLOOD Albumin-3.2* ___ 05:08PM BLOOD pO2-44* pCO2-86* pH-7.13* calTCO2-30 Base XS--3 ___ 05:08PM BLOOD Glucose-149* Lactate-2.9* Na-148* K-4.4 Cl-106 ___ 05:08PM BLOOD freeCa-1.08* DISCHARGE LABS: --------------- ___ 05:32AM BLOOD WBC-10.4* RBC-2.98* Hgb-8.5* Hct-27.7* MCV-93 MCH-28.5 MCHC-30.7* RDW-18.1* RDWSD-60.6* Plt ___ ___ 05:32AM BLOOD Plt ___ ___ 05:32AM BLOOD Glucose-112* UreaN-21* Creat-1.1 Na-144 K-3.6 Cl-101 HCO3-35* AnGap-12 ___ 04:16AM BLOOD ALT-84* AST-17 LD(LDH)-303* AlkPhos-103 TotBili-0.9 ___ 06:34PM BLOOD CK-MB-1 cTropnT-0.01 ___ 05:32AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.0 IMAGING: -------- CXR ___: IMPRESSION: In comparison with the study of ___, there is little overall change. Again there is extensive opacification at the right base consistent with pleural fluid and substantial volume loss in the right lower lobe. The cardiomediastinal silhouette is unchanged and there again is tortuosity of the descending aorta. There may be mild elevation of pulmonary venous pressure. The tip of the central catheter again extends into the right atrium. CXR ___: FINDINGS: Compared to ___, there is re-expansion of the right lung with some residual right pleural effusion and adjacent volume loss at the right base. The left lung and left PICC line position are unchanged. IMPRESSION: Compared to ___, re-expansion of the right lung with some residual right pleural effusion and adjacent volume loss at the right base. CT Chest ___: 1. Complete collapse of the right lung with rightward mediastinal shift secondary to volume loss. Extensive intraluminal airway secretions with near complete distal airway opacification on the right. Suggestion of 2 cm low-attenuation nodule in the right lower lobe. 2 rounded areas of aerated lung parenchyma in the right upper lung, or, if there is clinical symptoms of pneumonia, cavitated pneumonia could have similar appearance. Right hilar or perihilar Masse cannot be excluded on a noncontrast scan. 2. Probable pulmonary hypertension. 3. Moderate right pleural effusion. 4. Unchanged 11 mm left upper lobe nodule. 5. Nonspecific old surgical skin defect overlying the upper-mid thoracic spine. MRI/MRA Head/Neck ___: 1. Chronic right temporo-occipital infarct and chronic small vessel ischemic changes. No evidence of acute or subacute vascular territorial infarction. 2. 18 x 23 mm indeterminate mass at the junction of the nose and right upper lip as described above, unchanged from the recent CT scan of ___. 3. Moderately motion degraded brain MRI shows grossly patent circle of ___. 4. Nondiagnostic contrast enhanced neck MRA, but appears grossly patent on moderately motion degraded time-of-flight MRA of the neck. Portable CXR IMPRESSION: 1. Standard positioning of endotracheal tube. 2. Enteric tube tip is likely within the stomach, however the side port is just proximal to the gastroesophageal junction, and slight interval advancement by approximately 4 cm is suggested. 3. Opacification of the right upper lobe concerning for collapse given the presence of rightward tracheal deviation. Consider contrast-enhanced chest CT to assess for an underlying obstructive lesion. 4. Small right pleural effusion and right basilar opacity, potentially compressive atelectasis. 5. Mild pulmonary vascular congestion. Non-con Head CT ___: 1. There are late subacute to chronic infarcts in the right occipital, temporal lobes. If there is clinical concern for acute component, MRI would be helpful. 2. There is 2.5 cm well-circumscribed right pre antral mass, abutting right nares. 3. There is left scalp, right temporal scalp edema. There is mild edema about partially seen upper right parotid gland, indeterminate come consider parotitis. ___ Non-con Neck CT: IMPRESSION: 1. Significant amount of debris and secretions in the lower trachea and extending to the imaged portion of the proximal right main bronchus. The imaged portion of the right lung is collapsed, as seen earlier today. Bilateral pleural effusions, greater on the right. 2. Approximately 2.6 cm right thyroid nodule. Thyroid ultrasound recommended. 3. 8 mm left upper lobe pulmonary nodule. 4. Marked enlargement of main pulmonary artery, consistent with pulmonary artery hypertension. 5. Indeterminate 2.4 cm right pre antral soft tissue mass. RECOMMENDATION(S): 1. The ___ pulmonary nodule recommendations are intended as guidelines for follow-up and management of newly incidentally detected pulmonary nodules smaller than 8 mm, in patients ___ years of age or older. Low risk patients have minimal or absent history of smoking or other known risk factors for primary lung neoplasm. High risk patients have a history of smoking or other known risk factors for primary lung neoplasm. In the case of nodule size >6 - 8 mm: For low risk patients, initial follow-up CT at ___ months and then at ___ months if no change. For high risk patients - initial follow-up CT at ___ months and then at ___ and 24 months if no change. 2. Nonurgent thyroid ultrasound. MICROBIOLOGY ============== No growth on any cultures ___ BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} INPATIENT GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. YEAST. 10,000-100,000 CFU/mL. ___ MRSA SCREEN MRSA SCREEN-FINAL INPATIENT ___ SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT Brief Hospital Course: SUMMARY: ___ h/o COPD, depression, likely ___ transferred from outside hospital for unresponsiveness, found to be in shock with respiratory failure. She was initially admitted to the MICU where she required three pressors for shock and was intubated. For her respiratory failure, she was treated for a COPD exacerbation, HCAP, and pulmonary edema with eventual extubation and weaning to 3L. For her shock, thought to be septic, she was treated with antibiotics and improved. After transfer to the floor, she was additionally managed for complete right lung collapse with chest ___, as well as atrial fibrillation with RVR using rate control agents. A MRI of her head showed old infarcts and she was started on anticoagulation with apixaban. She was discharged to a rehab facility for continued chest ___ and rehabilitation. A bronchoscopy was deferred given improvement with chest ___. She will need repeat CXR in ___ weeks to assess for resolution of RLL collapse along with CT to revaluate for possible malignancy causing lung collapse. #Respiratory failure: As above, patient presented in mixed hypoxemic and hypercarbic respiratory failure requiring intubation. She quickly improved after intubation. She was treated for a COPD exacerbation with methylprednisone, azithromycin 5-day course, and nebulizers. She was also treated for pneumonia with HCAP coverage, completing an 8-day course of vanc/zosyn then levofloxacin. She was also treated for pulmonary edema with boluses of IV furosemide and albumin (her albumin was 2.5). With these interventions she improved and stabilized on nasal canula. She was found to have collapse in her R lung, thought to be in the setting of mucus plugging versus obstructive mass. Pulmonology was consulted and bronchoscopy was deferred in setting of improvement with chest ___, which patient had initially refused. She remained on 2L O2 on nasal canula. She will need continued chest ___ at rehab along with repeat CXR in ___ weeks to assess for resolution in right lower lung collapse. She will need repeat CT after resolution of lung collapse to evaluation for possible mass causing collapse. She did not have cytology performed on initial bronchoscopy in the ICU. # Afib with RVR: Patient with no prior diagnosis of Afib, found to be in Afib with RVR on several occasions during this admission. She was placed on a rate control agent with verapamil, which was uptitrated to 120mg q8h. Her heart rates stabilized on this dose. She was also started on anticoagulation with apixaban 2.5mg BID, which was increased to apixaban 5mg BID after kidney function improved. # Shock: Resolved. As above, suspected to most likely be septic shock. CVL was placed at OSH. She initially required 3 pressors, but eventually weaned off completely. Blood, urine and sputum cultures were unremarkable. Patient had some shock-related laboratory abnormalities including troponin elevation, transaminase elevation, coagulopathy however these improved/resolved as she improved clinically. CVL was removed. # ___: Patient came in with Cr 1.6 and peaked at 3.6. Urine sediment showed muddy brown casts suggestive of ATN. Her Cr was monitored closely and over time downtrended to baseline of ___. # Skin lesions: Patient has a large nodule abutting her right nares which is suspicious for a BCC. Will require biopsy and further follow up as outpatient. # Sub-acute/chronic strokes: CT head showed late subacute to chronic infarcts in the right occipital, temporal lobes. Neurology was consulted. Stroke risk factors were unremarkable. A MRI/MRA was subsequently performed which showed areas of chronic infarcts. Patient was started on ASA 81mg and anticoagulation. No residual deficits on exam. # UGIB: Coffee ground material seen from OG tube at OSH. Patient started on IV PPI and a type/screen was maintained. Ultimately Hb remained stable and clinical suspicion for bleed was low. PPI was discontinued in setting of unlikely bleed. TRANSITIONAL ISSUES: [] Afib with RVR - Patient with new diagnosis of Afib with RVR - Started on verapamil 120mg q8h for rate control, apixaban 5mg BID for anticoagulation. Switched to verapamil SR 360mg daily as outpatient - SHOULD received 360mg SR starting ___. [] Chronic strokes - Chronic infarcts in R occipital and temporal lobes seen with no residual deficits - Will follow up with neurology in clinic in ___ weeks - this appointment needs to be made [] Skin lesion - R nares lesion likely ___ will require outpatient dermatology biopsy and follow-up in ___ weeks (this appointment needs to be made) [] Right lung collapse - Patient with right lung collapse, bronch deferred given improvement with CHEST ___ - Patient will need to continue aggressive chest ___ in rehab. - Repeat CXR in ___ weeks to assess for resolution and f/u with pulmonary at that time. Suggestion of 2 cm low-attenuation nodule in the right lower lobe which requires further evaluation. - Patient remained on 2L of oxygen during inpatient. Continue to wean as tolerated while patient undergoing aggressive chest ___. - Patient should follow up with Pulmonology in ___ weeks (this appointment needs to be made). - Patient should have a repeat CT Chest in 3 months to assess for right lung collapse after chest ___ and acute issues resolve [] Incidental imaging findings - 2.6cm right thyroid nodule, recommended THYROID ULTRASOUND as soon as possible - 8mm left upper lobe pulmonary nodule, will require 6-month follow-up CT scan- - Suggestion of 2 cm low-attenuation nodule in the right lower lobe which requires f/u CT scan of chest in ___ weeks after resolution of right lower lung collapse. # Code status: DNR/DNI # Contact: Proxy name: ___ Relationship: friend Phone: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing 2. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN Pain - Moderate 3. FLUoxetine 20 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH ___ BID Discharge Medications: 1. Apixaban 5 mg PO BID 2. Aspirin 81 mg PO DAILY 3. Verapamil SR 360 mg PO Q24H 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing 5. FLUoxetine 20 mg PO DAILY 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Sepsis Pneumonia Right lung collapse Acute tubular necrosis Atrial fibrillation Stroke Skin lesion SECONDARY DIAGNOSIS: COPD Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___: You were admitted to ___ after being unresponsive and very sick. WHAT HAPPENED TO YOU IN THE HOSPITAL? - You were first in the ICU. You were intubated and we gave you support for your blood pressures - You improved and were taken care of on the regular medical floor - We treated you with antibiotics, nebulizers, and steroids to improve your lung status - We did a bronchoscopy which showed collapse of your right lung, without evidence of masses or tumor, although you will need another chest x-ray and CT scan of your chest to better evaluate once your lung opens back up. - You developed a fast heart rhythm called Afib. We slowed your heart rate with a medication called verapamil and put you on a blood thinner called Eliquis. - On a MRI, we saw that you had old strokes. The blood thinner will help prevent strokes in the future. You should see a neurologist in clinic - We saw that you have a lesion on the right side of your nose that is concerning for a basal cell tumor. You should follow up with dermatology for evaluation once you leave the hospital. WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL? - You must follow up with dermatology to have your nose lesion biopsied - You must continue taking your medications, including the new medications we have prescribed. These are very important - You should follow up with a neurologist and your primary care doctor - You will need to have another chest X-ray in ___ weeks to make sure that your right lung has opened back up. Once the lung has opened up, we will need to repeat a CT scan of your chest to check for any masses or tumors in the lungs that may have caused the lung to collapse. It is very important that you follow up with the lung doctors for this ___. We wish you all the best! - Your ___ care team Followup Instructions: ___	[ "A419", "K7200", "N170", "I639", "R6521", "J189", "J9601", "G92", "J9602", "E874", "D689", "J9819", "B368", "J441", "E870", "K922", "I248", "I480", "I272", "F329", "F419", "L89892", "Z85820", "Z66", "C44311", "D649", "D6959", "C44712", "E041", "R911" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: CVL placement (removed) PICC line placed (removed on [MASKED] Bronchoscopy History of Present Illness: [MASKED] with unclear medical history (?COPD) presenting from out of hospital for unresponsiveness. Patient had a fall yesterday. EMS was called; however, the patient declined transfer at that time. Patient today was found unresponsive by friend. Brought to outside hospital where she was in respiratory distress. Hypotensive with systolics in the [MASKED]. Patient was intubated and started on norepinephrine. Patient found to have transaminitis (2000s); trop 0.04. Pan scan results showed concern for temporal and occipital stroke. [MASKED] pancreatic inflammation on CT scan although with normal lipase level. Patient received vancomycin and Zosyn for concern for pneumonia. OG tube with coffee ground material returning. Patient given pantoprazole. Transferred here for further management. Right femoral line placed at outside hospital ([MASKED]). In the ED, initial vitals: 98.0, 87, 129/77, 15, 100%vent Labs were significant for: VBG: 7.13, 86, O2 44, HCO3 30 CBC: 18.4>14.9/51.2<98 Chem (whole blood): Na 148, K 4.4, Cl 106, Glu 149, freeCa 1.08 Lactate: 2.9 INR 2.2, [MASKED] [MASKED] Fibrinogen 168 ALT 2550, AST 5098, AP 124, Tbili 2.1, Alb 3.2 Lipase: 12 Serum tox: negative APAP tox: negative Imaging was significant for: CXR 1. Standard positioning of endotracheal tube. 2. Enteric tube tip is likely within the stomach, however the side port is just proximal to the gastroesophageal junction, and slight interval advancement by approximately 4 cm is suggested. 3. Opacification of the right upper lobe concerning for collapse given the presence of rightward tracheal deviation. Consider contrast-enhanced chest CT to assess for an underlying obstructive lesion. 4. Small right pleural effusion and right basilar opacity, potentially compressive atelectasis. 5. Mild pulmonary vascular congestion. Her imaging is notable for right lung collapse, possible pneumonia, pulmonary nodule, and [MASKED] stranding in addition to the reported subacute right temporal occipital stroke seen on head CT (currently unable to access). CT head non-con ([MASKED]): 1. There are late subacute to chronic infarcts in the right occipital, temporal lobes. If there is clinical concern for acute component, MRI would be helpful. 2. There is 2.5 cm well-circumscribed right pre antral mass, abutting right nares. 3. There is left scalp, right temporal scalp edema. There is mild edema about partially seen upper right parotid gland, indeterminate come consider parotitis. Consults: Neuro, toxicology, RT On transfer, vitals were: On arrival to the MICU, Review of systems: unable to obtain as patient is intubated. (+) Per HPI Past Medical History: COPD; ?skin cancer of nose (no other hx available) Social History: [MASKED] Family History: Unknown Physical Exam: ADMISSION EXAM: --------------- Vitals: T: 98.2 NR BP: 80/62 P: 78 R: 42 O2: 99%Vent GENERAL: Intubated/sedated HEENT: Sclera anicteric NECK: supple LUNGS: coarse breath sounds bilaterally, no wheezes CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley in place EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis; 2+ edema bilaterally in lower extremities SKIN: large macular rash underneath breasts. NEURO: Intubated/sedated -- deferred ACCESS: PIVs DISCHARGE EXAM: --------------- General: No acute distress. AOx3. HEENT: sclera anicteric, MMM, oropharynx clear Neck: supple. No JVD Lungs: Clear lung in left. Decreased breath sounds of RLL fields CV: RRR, normal S1 + S2, no significant murmurs, rubs or gallops. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, trace edema around legs bilaterally. Neuro: moving all 4 extremities Skin: 4cm circular scar on back from prior procedure. R nare with 1cm round lesion with pearly red borders, R thigh with dressing over erythematous skin lesion. Pertinent Results: ADMISSION LABS: --------------- [MASKED] 04:45PM BLOOD WBC-18.4* RBC-5.37* Hgb-14.9 Hct-51.2* MCV-95 MCH-27.7 MCHC-29.1* RDW-17.9* RDWSD-58.8* Plt Ct-98* [MASKED] 04:45PM BLOOD [MASKED] PTT-24.7* [MASKED] [MASKED] 04:45PM BLOOD Plt Smr-LOW Plt Ct-98* [MASKED] 04:45PM BLOOD UreaN-35* Creat-1.6* [MASKED] 04:45PM BLOOD ALT-2550* AST-5098* AlkPhos-124* TotBili-2.1* [MASKED] 04:45PM BLOOD Albumin-3.2* [MASKED] 05:08PM BLOOD pO2-44* pCO2-86* pH-7.13* calTCO2-30 Base XS--3 [MASKED] 05:08PM BLOOD Glucose-149* Lactate-2.9* Na-148* K-4.4 Cl-106 [MASKED] 05:08PM BLOOD freeCa-1.08* DISCHARGE LABS: --------------- [MASKED] 05:32AM BLOOD WBC-10.4* RBC-2.98* Hgb-8.5* Hct-27.7* MCV-93 MCH-28.5 MCHC-30.7* RDW-18.1* RDWSD-60.6* Plt [MASKED] [MASKED] 05:32AM BLOOD Plt [MASKED] [MASKED] 05:32AM BLOOD Glucose-112* UreaN-21* Creat-1.1 Na-144 K-3.6 Cl-101 HCO3-35* AnGap-12 [MASKED] 04:16AM BLOOD ALT-84* AST-17 LD(LDH)-303* AlkPhos-103 TotBili-0.9 [MASKED] 06:34PM BLOOD CK-MB-1 cTropnT-0.01 [MASKED] 05:32AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.0 IMAGING: -------- CXR [MASKED]: IMPRESSION: In comparison with the study of [MASKED], there is little overall change. Again there is extensive opacification at the right base consistent with pleural fluid and substantial volume loss in the right lower lobe. The cardiomediastinal silhouette is unchanged and there again is tortuosity of the descending aorta. There may be mild elevation of pulmonary venous pressure. The tip of the central catheter again extends into the right atrium. CXR [MASKED]: FINDINGS: Compared to [MASKED], there is re-expansion of the right lung with some residual right pleural effusion and adjacent volume loss at the right base. The left lung and left PICC line position are unchanged. IMPRESSION: Compared to [MASKED], re-expansion of the right lung with some residual right pleural effusion and adjacent volume loss at the right base. CT Chest [MASKED]: 1. Complete collapse of the right lung with rightward mediastinal shift secondary to volume loss. Extensive intraluminal airway secretions with near complete distal airway opacification on the right. Suggestion of 2 cm low-attenuation nodule in the right lower lobe. 2 rounded areas of aerated lung parenchyma in the right upper lung, or, if there is clinical symptoms of pneumonia, cavitated pneumonia could have similar appearance. Right hilar or perihilar Masse cannot be excluded on a noncontrast scan. 2. Probable pulmonary hypertension. 3. Moderate right pleural effusion. 4. Unchanged 11 mm left upper lobe nodule. 5. Nonspecific old surgical skin defect overlying the upper-mid thoracic spine. MRI/MRA Head/Neck [MASKED]: 1. Chronic right temporo-occipital infarct and chronic small vessel ischemic changes. No evidence of acute or subacute vascular territorial infarction. 2. 18 x 23 mm indeterminate mass at the junction of the nose and right upper lip as described above, unchanged from the recent CT scan of [MASKED]. 3. Moderately motion degraded brain MRI shows grossly patent circle of [MASKED]. 4. Nondiagnostic contrast enhanced neck MRA, but appears grossly patent on moderately motion degraded time-of-flight MRA of the neck. Portable CXR IMPRESSION: 1. Standard positioning of endotracheal tube. 2. Enteric tube tip is likely within the stomach, however the side port is just proximal to the gastroesophageal junction, and slight interval advancement by approximately 4 cm is suggested. 3. Opacification of the right upper lobe concerning for collapse given the presence of rightward tracheal deviation. Consider contrast-enhanced chest CT to assess for an underlying obstructive lesion. 4. Small right pleural effusion and right basilar opacity, potentially compressive atelectasis. 5. Mild pulmonary vascular congestion. Non-con Head CT [MASKED]: 1. There are late subacute to chronic infarcts in the right occipital, temporal lobes. If there is clinical concern for acute component, MRI would be helpful. 2. There is 2.5 cm well-circumscribed right pre antral mass, abutting right nares. 3. There is left scalp, right temporal scalp edema. There is mild edema about partially seen upper right parotid gland, indeterminate come consider parotitis. [MASKED] Non-con Neck CT: IMPRESSION: 1. Significant amount of debris and secretions in the lower trachea and extending to the imaged portion of the proximal right main bronchus. The imaged portion of the right lung is collapsed, as seen earlier today. Bilateral pleural effusions, greater on the right. 2. Approximately 2.6 cm right thyroid nodule. Thyroid ultrasound recommended. 3. 8 mm left upper lobe pulmonary nodule. 4. Marked enlargement of main pulmonary artery, consistent with pulmonary artery hypertension. 5. Indeterminate 2.4 cm right pre antral soft tissue mass. RECOMMENDATION(S): 1. The [MASKED] pulmonary nodule recommendations are intended as guidelines for follow-up and management of newly incidentally detected pulmonary nodules smaller than 8 mm, in patients [MASKED] years of age or older. Low risk patients have minimal or absent history of smoking or other known risk factors for primary lung neoplasm. High risk patients have a history of smoking or other known risk factors for primary lung neoplasm. In the case of nodule size >6 - 8 mm: For low risk patients, initial follow-up CT at [MASKED] months and then at [MASKED] months if no change. For high risk patients - initial follow-up CT at [MASKED] months and then at [MASKED] and 24 months if no change. 2. Nonurgent thyroid ultrasound. MICROBIOLOGY ============== No growth on any cultures [MASKED] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} INPATIENT GRAM STAIN (Final [MASKED]: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Final [MASKED]: Commensal Respiratory Flora Absent. YEAST. 10,000-100,000 CFU/mL. [MASKED] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [MASKED] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [MASKED] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [MASKED] URINE URINE CULTURE-FINAL INPATIENT Brief Hospital Course: SUMMARY: [MASKED] h/o COPD, depression, likely [MASKED] transferred from outside hospital for unresponsiveness, found to be in shock with respiratory failure. She was initially admitted to the MICU where she required three pressors for shock and was intubated. For her respiratory failure, she was treated for a COPD exacerbation, HCAP, and pulmonary edema with eventual extubation and weaning to 3L. For her shock, thought to be septic, she was treated with antibiotics and improved. After transfer to the floor, she was additionally managed for complete right lung collapse with chest [MASKED], as well as atrial fibrillation with RVR using rate control agents. A MRI of her head showed old infarcts and she was started on anticoagulation with apixaban. She was discharged to a rehab facility for continued chest [MASKED] and rehabilitation. A bronchoscopy was deferred given improvement with chest [MASKED]. She will need repeat CXR in [MASKED] weeks to assess for resolution of RLL collapse along with CT to revaluate for possible malignancy causing lung collapse. #Respiratory failure: As above, patient presented in mixed hypoxemic and hypercarbic respiratory failure requiring intubation. She quickly improved after intubation. She was treated for a COPD exacerbation with methylprednisone, azithromycin 5-day course, and nebulizers. She was also treated for pneumonia with HCAP coverage, completing an 8-day course of vanc/zosyn then levofloxacin. She was also treated for pulmonary edema with boluses of IV furosemide and albumin (her albumin was 2.5). With these interventions she improved and stabilized on nasal canula. She was found to have collapse in her R lung, thought to be in the setting of mucus plugging versus obstructive mass. Pulmonology was consulted and bronchoscopy was deferred in setting of improvement with chest [MASKED], which patient had initially refused. She remained on 2L O2 on nasal canula. She will need continued chest [MASKED] at rehab along with repeat CXR in [MASKED] weeks to assess for resolution in right lower lung collapse. She will need repeat CT after resolution of lung collapse to evaluation for possible mass causing collapse. She did not have cytology performed on initial bronchoscopy in the ICU. # Afib with RVR: Patient with no prior diagnosis of Afib, found to be in Afib with RVR on several occasions during this admission. She was placed on a rate control agent with verapamil, which was uptitrated to 120mg q8h. Her heart rates stabilized on this dose. She was also started on anticoagulation with apixaban 2.5mg BID, which was increased to apixaban 5mg BID after kidney function improved. # Shock: Resolved. As above, suspected to most likely be septic shock. CVL was placed at OSH. She initially required 3 pressors, but eventually weaned off completely. Blood, urine and sputum cultures were unremarkable. Patient had some shock-related laboratory abnormalities including troponin elevation, transaminase elevation, coagulopathy however these improved/resolved as she improved clinically. CVL was removed. # [MASKED]: Patient came in with Cr 1.6 and peaked at 3.6. Urine sediment showed muddy brown casts suggestive of ATN. Her Cr was monitored closely and over time downtrended to baseline of [MASKED]. # Skin lesions: Patient has a large nodule abutting her right nares which is suspicious for a BCC. Will require biopsy and further follow up as outpatient. # Sub-acute/chronic strokes: CT head showed late subacute to chronic infarcts in the right occipital, temporal lobes. Neurology was consulted. Stroke risk factors were unremarkable. A MRI/MRA was subsequently performed which showed areas of chronic infarcts. Patient was started on ASA 81mg and anticoagulation. No residual deficits on exam. # UGIB: Coffee ground material seen from OG tube at OSH. Patient started on IV PPI and a type/screen was maintained. Ultimately Hb remained stable and clinical suspicion for bleed was low. PPI was discontinued in setting of unlikely bleed. TRANSITIONAL ISSUES: [] Afib with RVR - Patient with new diagnosis of Afib with RVR - Started on verapamil 120mg q8h for rate control, apixaban 5mg BID for anticoagulation. Switched to verapamil SR 360mg daily as outpatient - SHOULD received 360mg SR starting [MASKED]. [] Chronic strokes - Chronic infarcts in R occipital and temporal lobes seen with no residual deficits - Will follow up with neurology in clinic in [MASKED] weeks - this appointment needs to be made [] Skin lesion - R nares lesion likely [MASKED] will require outpatient dermatology biopsy and follow-up in [MASKED] weeks (this appointment needs to be made) [] Right lung collapse - Patient with right lung collapse, bronch deferred given improvement with CHEST [MASKED] - Patient will need to continue aggressive chest [MASKED] in rehab. - Repeat CXR in [MASKED] weeks to assess for resolution and f/u with pulmonary at that time. Suggestion of 2 cm low-attenuation nodule in the right lower lobe which requires further evaluation. - Patient remained on 2L of oxygen during inpatient. Continue to wean as tolerated while patient undergoing aggressive chest [MASKED]. - Patient should follow up with Pulmonology in [MASKED] weeks (this appointment needs to be made). - Patient should have a repeat CT Chest in 3 months to assess for right lung collapse after chest [MASKED] and acute issues resolve [] Incidental imaging findings - 2.6cm right thyroid nodule, recommended THYROID ULTRASOUND as soon as possible - 8mm left upper lobe pulmonary nodule, will require 6-month follow-up CT scan- - Suggestion of 2 cm low-attenuation nodule in the right lower lobe which requires f/u CT scan of chest in [MASKED] weeks after resolution of right lower lung collapse. # Code status: DNR/DNI # Contact: Proxy Relationship: friend Phone: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing 2. OxyCODONE--Acetaminophen (5mg-325mg) [MASKED] TAB PO Q6H:PRN Pain - Moderate 3. FLUoxetine 20 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH [MASKED] BID Discharge Medications: 1. Apixaban 5 mg PO BID 2. Aspirin 81 mg PO DAILY 3. Verapamil SR 360 mg PO Q24H 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing 5. FLUoxetine 20 mg PO DAILY 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: Sepsis Pneumonia Right lung collapse Acute tubular necrosis Atrial fibrillation Stroke Skin lesion SECONDARY DIAGNOSIS: COPD Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [MASKED]: You were admitted to [MASKED] after being unresponsive and very sick. WHAT HAPPENED TO YOU IN THE HOSPITAL? - You were first in the ICU. You were intubated and we gave you support for your blood pressures - You improved and were taken care of on the regular medical floor - We treated you with antibiotics, nebulizers, and steroids to improve your lung status - We did a bronchoscopy which showed collapse of your right lung, without evidence of masses or tumor, although you will need another chest x-ray and CT scan of your chest to better evaluate once your lung opens back up. - You developed a fast heart rhythm called Afib. We slowed your heart rate with a medication called verapamil and put you on a blood thinner called Eliquis. - On a MRI, we saw that you had old strokes. The blood thinner will help prevent strokes in the future. You should see a neurologist in clinic - We saw that you have a lesion on the right side of your nose that is concerning for a basal cell tumor. You should follow up with dermatology for evaluation once you leave the hospital. WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL? - You must follow up with dermatology to have your nose lesion biopsied - You must continue taking your medications, including the new medications we have prescribed. These are very important - You should follow up with a neurologist and your primary care doctor - You will need to have another chest X-ray in [MASKED] weeks to make sure that your right lung has opened back up. Once the lung has opened up, we will need to repeat a CT scan of your chest to check for any masses or tumors in the lungs that may have caused the lung to collapse. It is very important that you follow up with the lung doctors for this [MASKED]. We wish you all the best! - Your [MASKED] care team Followup Instructions: [MASKED]	[]	[ "J9601", "I480", "F329", "F419", "Z66", "D649" ]	[ "A419: Sepsis, unspecified organism", "K7200: Acute and subacute hepatic failure without coma", "N170: Acute kidney failure with tubular necrosis", "I639: Cerebral infarction, unspecified", "R6521: Severe sepsis with septic shock", "J189: Pneumonia, unspecified organism", "J9601: Acute respiratory failure with hypoxia", "G92: Toxic encephalopathy", "J9602: Acute respiratory failure with hypercapnia", "E874: Mixed disorder of acid-base balance", "D689: Coagulation defect, unspecified", "J9819: Other pulmonary collapse", "B368: Other specified superficial mycoses", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "E870: Hyperosmolality and hypernatremia", "K922: Gastrointestinal hemorrhage, unspecified", "I248: Other forms of acute ischemic heart disease", "I480: Paroxysmal atrial fibrillation", "I272: Other secondary pulmonary hypertension", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "L89892: Pressure ulcer of other site, stage 2", "Z85820: Personal history of malignant melanoma of skin", "Z66: Do not resuscitate", "C44311: Basal cell carcinoma of skin of nose", "D649: Anemia, unspecified", "D6959: Other secondary thrombocytopenia", "C44712: Basal cell carcinoma of skin of right lower limb, including hip", "E041: Nontoxic single thyroid nodule", "R911: Solitary pulmonary nodule" ]
10,092,572	29,709,457	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ___ Major Surgical or Invasive Procedure: None History of Present Illness: ___ Critical is a ___ female who presents to ___ on ___ with a moderate TBI. Per report patient fell in the bathroom at 0415, with + LOC and head strike. Patient was initially unresponsive and EMS was called. Per EMS patient became responsive around 0505 but was unable to answer questions about the fall. She was transferred to ___ where CT revealed SAH. Patient takes Plavix and ASA for atrial fibrillation. She is demented at baseline, only oriented x2. At ___ became more altered and was intubated for airway protection. She was transferred to ___ for Neurosurgical evaluation. Mechanism of trauma: fall Past Medical History: Atrial Fibrillation Cancer Dementia R foot drop GERD Hyperlipidemia Diabetes Social History: ___ Family History: NC Physical Exam: Upon admission: Intubated No EO PERRL ___ +Corneal/gag/cough Briskly withdraws all four extremities to noxious No commands Some intermittent purposeful movement with BUE Pertinent Results: Please see OMR for pertinent results Brief Hospital Course: Ms. ___ was admitted to the Neurosurgical service after a fall on Plavix and ASA, NCHCT revealed SAH. She was transferred from ___ to ___. Intubated at the OSH for airway protection. #___ Patient was admitted to the ICU ___. She was started on Keppra 500mg BID for seizure prophylaxis. Repeat CT 6 hours after initial was stable. CTA was done which revealed carotid stenosis but no aneurysm. Mental status remained poor. She was extubated on ___ and transferred to the ___. On ___ mental status somewhat improved. He exam continued to wax and wane. On ___, a family meeting was held and it was decided to proceed with comfort measures only and discharge home with hospice. The patient was discharged to home in stable condition for the ambulance ride on ___. #Respiratory Failure Patient was intubated at the OSH for airway protection secondary to altered mental status. Her ABG on arrival was normal. She was successfully extubated ___. #Dysphagia ___ patient failed a S&S evaluation. The evaluation was repeated on ___ and again was felt to be inappropriate for a PO diet. Given her advanced dementia and the likelihood for her dysphagia to worsen significantly, the patient's family had a goal of care meeting and made her NPO. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Vitamin D ___ UNIT PO DAILY 2. Atorvastatin 40 mg PO Q24H 3. Clopidogrel 75 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. RisperiDONE 1 mg PO DAILY 7. RisperiDONE 2 mg PO QHS 8. Vesicare (solifenacin) 5 mg oral DAILY 9. galantamine 8 mg oral DAILY 10. Sotalol 80 mg PO BID 11. TraZODone 50 mg PO QHS:PRN Insomnia Discharge Medications: 1. Atropine Sulfate 1% ___ DROP SL ASDIR Secretions 2. Haloperidol ___ mg PO Q4H:PRN agitation 3. LORazepam 0.5 mg PO Q6H RX lorazepam 0.5 mg 1 tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 4. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___ mg PO Q1H:PRN Pain - Moderate RX morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth every one (1) hour Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Subarachnoid Hemorrhage Altered mental status Dementia Hypertension UTI Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Ms. ___, You were admitted to ___ Neurosurgery after sustaining a fall which resulted in an traumatic subarachnoid hemorrhage. Your hospital course was complicated by altered mental status, hypertension, a UTI, and inability to meet nutritional goals. Disposition: Discharge home with hospice care and family. Followup Instructions: ___	[ "S066X9A", "J9600", "N390", "W1830XA", "Y92002", "R4182", "G309", "F0280", "I10", "R1310", "I4891", "E785", "I2510", "Z515" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: [MASKED] Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] Critical is a [MASKED] female who presents to [MASKED] on [MASKED] with a moderate TBI. Per report patient fell in the bathroom at 0415, with + LOC and head strike. Patient was initially unresponsive and EMS was called. Per EMS patient became responsive around 0505 but was unable to answer questions about the fall. She was transferred to [MASKED] where CT revealed SAH. Patient takes Plavix and ASA for atrial fibrillation. She is demented at baseline, only oriented x2. At [MASKED] became more altered and was intubated for airway protection. She was transferred to [MASKED] for Neurosurgical evaluation. Mechanism of trauma: fall Past Medical History: Atrial Fibrillation Cancer Dementia R foot drop GERD Hyperlipidemia Diabetes Social History: [MASKED] Family History: NC Physical Exam: Upon admission: Intubated No EO PERRL [MASKED] +Corneal/gag/cough Briskly withdraws all four extremities to noxious No commands Some intermittent purposeful movement with BUE Pertinent Results: Please see OMR for pertinent results Brief Hospital Course: Ms. [MASKED] was admitted to the Neurosurgical service after a fall on Plavix and ASA, NCHCT revealed SAH. She was transferred from [MASKED] to [MASKED]. Intubated at the OSH for airway protection. #[MASKED] Patient was admitted to the ICU [MASKED]. She was started on Keppra 500mg BID for seizure prophylaxis. Repeat CT 6 hours after initial was stable. CTA was done which revealed carotid stenosis but no aneurysm. Mental status remained poor. She was extubated on [MASKED] and transferred to the [MASKED]. On [MASKED] mental status somewhat improved. He exam continued to wax and wane. On [MASKED], a family meeting was held and it was decided to proceed with comfort measures only and discharge home with hospice. The patient was discharged to home in stable condition for the ambulance ride on [MASKED]. #Respiratory Failure Patient was intubated at the OSH for airway protection secondary to altered mental status. Her ABG on arrival was normal. She was successfully extubated [MASKED]. #Dysphagia [MASKED] patient failed a S&S evaluation. The evaluation was repeated on [MASKED] and again was felt to be inappropriate for a PO diet. Given her advanced dementia and the likelihood for her dysphagia to worsen significantly, the patient's family had a goal of care meeting and made her NPO. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Vitamin D [MASKED] UNIT PO DAILY 2. Atorvastatin 40 mg PO Q24H 3. Clopidogrel 75 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. RisperiDONE 1 mg PO DAILY 7. RisperiDONE 2 mg PO QHS 8. Vesicare (solifenacin) 5 mg oral DAILY 9. galantamine 8 mg oral DAILY 10. Sotalol 80 mg PO BID 11. TraZODone 50 mg PO QHS:PRN Insomnia Discharge Medications: 1. Atropine Sulfate 1% [MASKED] DROP SL ASDIR Secretions 2. Haloperidol [MASKED] mg PO Q4H:PRN agitation 3. LORazepam 0.5 mg PO Q6H RX lorazepam 0.5 mg 1 tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 4. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL [MASKED] mg PO Q1H:PRN Pain - Moderate RX morphine concentrate 100 mg/5 mL (20 mg/mL) [MASKED] mg by mouth every one (1) hour Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Subarachnoid Hemorrhage Altered mental status Dementia Hypertension UTI Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Ms. [MASKED], You were admitted to [MASKED] Neurosurgery after sustaining a fall which resulted in an traumatic subarachnoid hemorrhage. Your hospital course was complicated by altered mental status, hypertension, a UTI, and inability to meet nutritional goals. Disposition: Discharge home with hospice care and family. Followup Instructions: [MASKED]	[]	[ "N390", "I10", "I4891", "E785", "I2510", "Z515" ]	[ "S066X9A: Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, initial encounter", "J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia", "N390: Urinary tract infection, site not specified", "W1830XA: Fall on same level, unspecified, initial encounter", "Y92002: Bathroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause", "R4182: Altered mental status, unspecified", "G309: Alzheimer's disease, unspecified", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "I10: Essential (primary) hypertension", "R1310: Dysphagia, unspecified", "I4891: Unspecified atrial fibrillation", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z515: Encounter for palliative care" ]
10,092,879	26,114,447	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: planned allo-SCT admission D0 ___ Major Surgical or Invasive Procedure: ___ Temporary Tunneled Central Venous Line Placement ___ Central Venous Line Replacement ___ Colonoscopy with biopsies 6 8 ___ Port-A-Cath placement History of Present Illness: Ms. ___ is a ___ woman with history of breast cancer status post chemo/radiation and right mastectomy found to have high risk MDS, here for allo SCT with Flu/Mel reduced intensity conditioning (___). See below for relevant information about pt's onc history. Pre-transplant Workup (full reports below): Repeat bone marrow biopsy shows 4% blasts on aspirate, echo ejection fraction 75%, pulmonary function test final results pending but DLCO over 80%. She was evaluated by dentist earlier this week without problems and infectious disease Dr. ___ on ___. Over the last several months pt has noted increased bruising w/o hematochezia, melena, epistaxis, gum bleeding, hematuria. During same time frame has noted exertional dyspnea, which has not greatly impacted her daily life. She continues to workout 5d per week without difficulties. Denies associated chest pain, SOB at rest, n/v. Past Medical History: PAST ONCOLOGIC HISTORY: =========================== Breast cancer: treated with chemotherapy, radiation and mastectomy. Date of Diagnosis: ___ Stage: Stage IIIA (T3N2M0), ___ nodes; ER+/Her2-; LVI+ Treatment: Mastectomy; dose dense Cytoxan/Adriamycin/Taxol; Radiation Therapy, Tamoxifen x ___ years (intolerant of aromatase inhibitors) Last Mammogram: ___ BRCA-/Myriad MyRisk- ___ CBCD showed pancytopenia that led to BMB on ___. Pt noted fatigue and DOE and bruising. Bone marrow biopsy is consistent with therapy related myelodysplastic syndrome. PAST MEDICAL/SURGICAL HISTORY: =============================== Breast Cancer; R mastectomy, chemo and radiation. Last Mammogram ___ was normal. Last pap ___ normal Abnormal Chest CT; q 6 month monitoring; next due ___ Right Shoulder pain Hemorrhoids Knee osteoarthritis Seasonal allergies Insomnia Social History: ___ Family History: FHx of stomach cancer, HTN, and stroke, but denies hx of blood cancers or immune deficiencies. Brother died of suicide in his ___. Physical Exam: ADMISSION PHYSICAL EXAM: ====================== Vitals: ___ 1256 Temp: 98.4 PO BP: 136/60 HR: 60 RR: 18 O2 sat: 97% O2 delivery: RA Gen: sitting upright in NA NEURO: A&Ox3. gait intact. CN II-XII intact. HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: supple, full ROM LYMPH: No cervical or supraclav LAD CV: Nl rate, regular rhythm. No MRG. LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. ABD: ND, nl bowel sounds, NT, no HSM. EXT: WWP. No ___ edema. SKIN: No rashes/lesions, petechiae. Scattered ecchymoses on ___ DISCHARGE PHYSICAL EXAM: ======================== VITALS: T97.7 100/62, 69, 18, 99% RA weight 65.14kg (143.6 lbs) General: Sitting upright in no acute distress Neuro: No focal neuro deficits, alert oriented x3, gait normal HEENT: No conjunctival pallor, no icterus, mucous remains moist with clear oropharynx. Mild erythema on chin and behind ears with some excoriation. Lymph: No cervical lymphadenopathy Cardiovascular: Regular rate and rhythm, S1-S2, no MRG Pulm: Clear to oxygen bilaterally with good air entry Abdomen: + Bowel sounds, soft nontender nondistended, no hepatomegaly Extremities: No petechiae, no edema, warm Access: Left chest wall port, CDI, no erythema, no swelling Pertinent Results: =============== ADMISSION LABS: =============== ___ 04:20PM BLOOD WBC-2.8* RBC-2.58* Hgb-7.6* Hct-25.2* MCV-98 MCH-29.5 MCHC-30.2* RDW-16.3* RDWSD-57.8* Plt ___ ___ 04:20PM BLOOD Neuts-35 Lymphs-63* Monos-1* Eos-0* Baso-1 AbsNeut-0.98* AbsLymp-1.76 AbsMono-0.03* AbsEos-0.00* AbsBaso-0.03 ___ 04:20PM BLOOD ___ PTT-26.9 ___ ___ 04:20PM BLOOD Glucose-144* UreaN-18 Creat-1.1 Na-143 K-3.9 Cl-106 HCO3-27 AnGap-10 ___ 04:20PM BLOOD ALT-10 AST-15 LD(___)-175 AlkPhos-49 TotBili-0.2 DirBili-<0.2 IndBili-0.2 ___ 04:20PM BLOOD TotProt-6.5 Albumin-4.3 Globuln-2.2 Calcium-9.2 Phos-3.2 Mg-2.4 UricAcd-5.0 ======================= RELEVANT INTERVAL LABS: ======================= ___ 12:00AM BLOOD WBC-0.1* RBC-2.60* Hgb-7.7* Hct-23.6* MCV-91 MCH-29.6 MCHC-32.6 RDW-14.1 RDWSD-46.9* Plt Ct-6* ___ 12:00AM BLOOD ALT-202* AST-191* LD(LDH)-436* AlkPhos-159* TotBili-0.7 ___ 12:00AM BLOOD ALT-336* AST-298* LD(LDH)-415* AlkPhos-182* TotBili-0.7 ___ 12:00AM BLOOD Lipase-26 ___ 12:00AM BLOOD GGT-26 ___ 12:00AM BLOOD TotProt-5.7* Albumin-3.4* Globuln-2.3 Calcium-8.9 Phos-3.4 Mg-1.7 UricAcd-2.1* ___ 12:00AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-POS* IgM HAV-NEG ___ 12:00AM BLOOD CMV IgG-NEG CMV IgM-NEG CMVI-There is n ___ 12:00AM BLOOD HCV Ab-NEG ___ 12:00AM BLOOD HCV VL-NOT DETECT ___ 12:00AM BLOOD CMV VL-NOT DETECT ___ Test Result Reference Range/Units SOURCE Plasma HSV 1 DNA, QN PCR <100 <100 copies/mL HSV 2 DNA, QN PCR <100 <100 copies/mL ___ Test Result Reference Range/Units SOURCE Whole Blood VARICELLA ZOSTER VIRUS (VZV) Not Detected Not Detected DNA, QL RT PCR Test Result Reference Range/Units SOURCE Whole Blood EBV DNA, QN PCR <200 <200 copies/mL Test Result Reference Range/Units INDEX VALUE 0.03 <0.50 ASPERGILLUS AG,EIA,SERUM Not Detected Not Detected Test Result Reference Range/Units FUNGITELL(R) ___ <31 <60 pg/mL GLUCAN ASSAY INTERPRETATION Negative ___ RESPIRATORY VIRAL PANEL NEGATIVE ================ DISCHARGE LABS: ================ ___ 12:00AM BLOOD WBC-5.9 RBC-2.72* Hgb-8.2* Hct-26.1* MCV-96 MCH-30.1 MCHC-31.4* RDW-18.2* RDWSD-62.1* Plt ___ ___ 12:00AM BLOOD Neuts-63.5 Lymphs-17.3* Monos-17.3* Eos-0.5* Baso-0.7 Im ___ AbsNeut-3.76 AbsLymp-1.02* AbsMono-1.02* AbsEos-0.03* AbsBaso-0.04 ___ 12:00AM BLOOD ___ PTT-26.0 ___ ___ 12:00AM BLOOD Glucose-96 UreaN-10 Creat-1.2* Na-143 K-4.5 Cl-106 HCO3-22 AnGap-15 ___ 12:00AM BLOOD ALT-55* AST-19 AlkPhos-103 TotBili-0.4 ___ 12:00AM BLOOD Calcium-9.5 Phos-4.2 Mg-1.9 ======== IMAGING: ======== CT Chest ___: NECK, THORACIC INLET, AXILLAE AND CHEST WALL: The partially visualized shows no incidental findings. No enlarged lymph nodes in either axilla or thoracic inlet. The patient is post right mastectomy.. No atherosclerotic calcifications in the head and neck arteries. MEDIASTINUM AND HILA: The esophagus is unremarkable. Small mediastinal lymph nodes, none pathologically enlarged by CT size criteria. No hilar lymphadenopathy. HEART AND VASCULATURE: The heart is normal in size and shape. No pericardial effusion. No atherosclerotic calcifications in the coronary arteries, cardiac valves or aorta. The aorta and pulmonary arteries are normal in caliber throughout. Low density of the blood pool suggests underlying anemia. LUNGS AND PLEURA: The airways are patent to the subsegmental levels. Lungs are well expanded and clear, with no bronchial wall thickening, bronchiectasis or mucus plugging. Mild bilateral apical scarring. Multiple tiny nodules are seen bilaterally as follows: -2 mm nodule in the right upper lobe (5:61). -2 mm endobronchial nodule in a subsegmental branch for the anterior segment of the right upper lobe (5:100). -3 mm nodule in the right lower lobe (5:205). -4 mm nodule in the left lower lobe (5:205). -4 mm nodule in the right lower lobe (5: 210). -3 mm nodule in the left lower lobe (5:216). -2 mm nodule in the left lower lobe (5:241). CHEST CAGE: No acute fractures. Mild dorsal spondylosis. No suspicious lytic or sclerotic lesions. UPPER ABDOMEN: The limited sections of the upper abdomen show no significant abnormal findings. There is an incompletely visualized right renal lower pole cyst. CT Sinus ___: 1. Paranasal sinus disease as described above, with opacification of the left frontal ethmoidal recess, mild mucosal thickening of the ethmoid air cells and aerosolized opacification of a right posterior ethmoid air cell. Aerosolized mucous in the posterior right ethmoid air cells suggests acute inflammatory process. 2. No evidence of abscess or abnormal enhancement following contrast administration. CT Chest ___: 1. No pleural effusions or acute intrathoracic abnormality. 2. A 1.9 cm ground-glass opacity in the left upper lobe, unchanged from the prior study from ___, likely represents small airways disease. 3. Overall stable multiple pulmonary nodules measuring up to 3 mm. Continued attention on follow-up imaging is recommended. RUQUS ___: Gallbladder wall thickening with edema and hyperemia may be related to hepatitis in the absence of abnormal gallbladder distension. However, in the setting of neutropenia, acute acalculous cholecystitis would be difficult to exclude. MRI with contrast or HIDA scan may be obtained for further evaluation. RUQUS ___: 1. Normal hepatic echotexture. No evidence of intrahepatic or extrahepatic biliary dilatation. 2. Interval improvement in gallbladder wall thickening. Unremarkable gallbladder. CT ABD and PELVIS w/ CONTRAST ___: Diffuse mucosal thickening of the ascending, transverse and descending colons with associated mild pericolonic fat stranding most prominent in the splenic flexure. Findings are suggestive of diffuse colitis related to an infectious/inflammatory process. ___: RUQUS 1. Normal sonographic appearance of the liver. 2. Common hepatic duct is prominent measuring 0.8 cm with relative increased echogenicity intraluminally. In correlation with the CT abdomen pelvis dated ___ which demonstrated wall thickening and enhancement of the common hepatic duct wall, further evaluation with MRCP should be performed for further assessment. ___: MRCP 1. No intra or extrahepatic bile duct dilation. The gallbladder appears normal. No ductal stones. 2. No focal liver lesion. 3. No ascites. 4. Signal abnormality throughout the pancreas suggestive of chronic pancreatitis. No active pancreatitis. Pancreatic neck cystic lesions measuring up to 5 mm likely represent side branch IPMN versus chronic pseudocysts. No dedicated followup required. ===================== COLONOSCOPY ___: Normal mucosa was noted in the whole colon. With cold forceps biopsies were performed for histology and ascending, transverse, descending and rectosigmoid. Normal mucosa was noted in the distal terminal ileum. 3 polyps were found in the transverse colon (2 mm), descending colon (4 mm) and pedunculated in the descending colon (8 mm). Not removed due to Lovenox and indication Colonic mucosal biopsies 4 1. Ascending colon: Colonic mucosa within normal limits 2. Transverse colon: Colonic mucosa within normal limits 3. Descending colon: Colonic mucosa within normal limits 4. Rectosigmoid colon: Colonic mucosa within normal limits ====================== ================ OTHER PATHOLOGY: ================ TEST RESULT FLAG UNITS REF RANGE ST2 (serum)* 87.5 H ng/mL <30.0 TEST RESULT FLAG UNITS REF RANGE Reg3A (serum)* 54.6 ng/mL <74.___RIEF HOSPITAL COURSE ================================= ___ is a ___ woman with a history of breast cancer s/p chemo/radiation and right mastectomy found to have high risk therapy related MDS, who was admitted for planned MUD Allo SCT with Flu/Mel reduced intensity conditioning (___). Pre-transplant course complicated by acute sinusitis, treated with cefepime. Post transplant course complicated by cytopenias, opioid induced constipation, anorexia, & elevated LFTs. The transaminitis was initially thought to be due to posaconazole and was briefly switched to micafungin, however her liver enzymes continue to uptrend, and hepatology was consulted who thought this was a methotrexate effect. Prior to discharge her liver enzymes were normalizing and she was switched back to Posaconazole. She also had diarrhea and abdominal pain which was concerning for GVHD, was briefly on steroids. GI was consulted for colonoscopy however biopsies were normal and her steroids were discontinued. She did have a facial rash which improved with hydrocortisone cream. Ms. ___ successfully engrafted ___ D+14. She will be discharged on infection prophylaxis regimen of acyclovir, fluconazole (rather than Posaconazole), TMP/SMX, immune suppression regimen with tacrolimus 0.5 mg twice a day, and VOD/SOS prophylaxis with ursodiol. She was discharged on day +28. Her weight on discharge was 65.14 kg (143.61 LBS). Her ANC on discharge was 2330. Her hemoglobin hematocrit on discharge were 7.9 and 25.6 respectively. Her platelet count on discharge was 250. Creatinine discharge was 1.2. A single lumen chest power Port-a-cath was placed via L jugular vein access and was ready to use at the time of discharge. TRANSITIONAL ISSUES: ================================= Heme-Onc: [ ] Please follow pulmonary nodules with repeat chest CT in 6 months (___). Has had a positive beta glucan on ___, however all subsequent tests have been negative. [ ] A tacrolimus level was drawn on ___, goal is ___. She is being discharged on 0.5 mg twice daily, which will need to continue to be titrated. [ ] Please repeat CMP and LFTs on discharge to ensure resolution. [ ] Please consider repeat CT abdomen/pelvis in ___ weeks to ensure resolution of colonic thickening [ ] Please repeat an EKG in the week following discharge Gastroenterology: [] 3 polyps were found on your colonoscopy. Please follow-up with gastroenterology in ___ year ___ (Dr. ___ ___ ___: [] Please follow up for monocular diplopia in s/o presbyopia + refractive error # CODE: Full code # CONTACT: ___ (HCP & SO)\| ___ ACTIVE PROBLEMS: ====================== #high risk MDS ___ in s/o pt's hx of chemo for breast cancer many years ago, thus characterized as therapy related MDS. ___ here for MUD allo-SCT w/ Flu/Mel reduced intensity conditioning. (___) s/p MTX course. Engraftment ___ (D+14). Will be discharged on immunosuppressive regimen of: tacrolimus 0.5mg BID. Continuing ursodiol for VOD ppx. #Infection Prophylaxis Provided levofloxacin initially for neutropenia ppx, but developed achilles tendonitis, thus transitioned to cefpodoxime. Furthermore, initially on posaconazole rather than fluconazole d/t her initially positive beta glucan in s/o known pulmonary nodules. Due to elevated LFTs, transitioned to micafungin, but was later return to posaconazole as her transaminases normalized. After discussion with her primary oncologist, it was decided to ultimately discharge her on fluconazole. Will be discharged on: acyclovir 400mg TID and Fluconazole 400mg daily. Of note, pt is toxo+ therefore will require TMP-SMX indefinitely without transitioning to other agents. #Abdominal Pain #Concern for GVHD Patient had diffuse crampy abdominal pain along with loose stools, this is concerning for GVHD. A CT of the abdomen pelvis revealed diffuse colonic wall thickening. C. difficile/norovirus/stool culture all negative. She was empirically started on steroids. GI was called for colonoscopy which revealed normal mucosa and biopsies were negative for GVHD and subsequently her steroids were stopped. Of note 3 polyps were found on colonoscopy which were not removed this patient was on anticoagulation. ST2 was high, but REG3A was low. TI: Follow-up with GI in ___ year for repeat colonoscopy. #Transaminitis More hepatocellular rather than cholestatic. Suspect d/t posaconazole & drug induced liver injury, but DDx also included DILI ___ chemo vs. VOD/SOS. Regarding VOD/SOS, lack of ascites, hepatomegaly, and hyperbili argued against this dx. RUQUS unrevealing. Transitioned from posaconazole to micafungin, but later switched back to Posaconazole as above. Viral HBV/HCV/CMV/EBV/VZV/HSV were negative. Additionally on ursodiol for VOD/SOS. MRCP was performed which suggested chronic pancreatitis. #Access s/p tunneled line removal w/ insertion of LIJ ___ d/t likely infiltration. Port-O-cath inserted on ___. #Atelectasis #Pulmonary Effusion Noted on CT imaging. Intermittently low O2 sats in AM. Incentive spirometry provided. Also responded well to furosemide for several days post-transplant. #Constipation Given good effect of methylnaltrexone previously, suspect opioid induced. Will be discharged on regimen of: senna and miralax as needed #Anorexia Many days of anorexia and poor PO post-transplant. Followed by nutrition & intiated on marinol. #Hypertension Likely side of tacrolimus, intitiated amlodipine 7.5mg PO daily. #Monocular Diplopia of Left Eye (refractive error + presbyopia) Opthalmology consult determined refractive error & presbyopia. Provided artificial tears. TI: follow-up with optometrist #Acute Sinusitis-RESOLVED CT e/o acute frontal sinusitis. Completed course of cefepime. CHRONIC/STABLE ISSUES: ======================= #Hx of Positive B-glucan Infectious workup on ___ as part of pre-transplant screening notable for positive B-glucan, but reassured that repeat levels were negative. Remainder of fungal workup negative. Was on ___ & micafungin per above. She was eventually switched to fluconazole upon discharge. #Insomnia Continued home trazodone 50mg PO QHS and used ambien as needed at night. #Mental Health Continued home citalopram 10mg PO Qday #Pulmonary Nodules Receives q6mo CT for monitoring. CT chest on ___ new baseline. Recommend continue q6mo imaging for active surveillance given Ms. ___ hx of former tobacco use & BCa s/p chemo/radiation. #Hx Hemorrhoids Stable. Bowel regimen per above. Used hydrocortisone cream with good effect. #Tremor-RESOLVED Very fine and only intermittent on exam. Suspect in s/o recent tacrolimus initiation. #Risky EtOH Use Appears pt on occasion drinks more than the recommended 14 drinks per week & no more than ___ drinks per day for women. Does not appear to be causing negative harm in pts life. Recommend continued conversations with PCP. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Zolpidem Tartrate 2.5 mg PO QHS:PRN insomnia 2. TraZODone 50 mg PO QHS 3. Citalopram 10 mg PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q8H RX acyclovir 400 mg 1 capsule(s) by mouth every eight (8) hours Disp #90 Tablet Refills:0 2. amLODIPine 7.5 mg PO DAILY RX amlodipine 2.5 mg 3 tablet(s) by mouth once a day Disp #90 Tablet Refills:0 3. Dronabinol 2.5 mg PO BID:PRN poor appetite 4. Famotidine 40 mg PO DAILY RX famotidine 40 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 5. Fluconazole 400 mg PO DAILY RX fluconazole 200 mg 2 tablet(s) by mouth once a day Disp #60 Tablet Refills:3 6. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 7. Hydrocortisone (Rectal) 2.5% Cream ___AILY:PRN hemorrhoid pain 8. Hydrocortisone Cream 1% 1 Appl TP QID:PRN facial rash 9. Multivitamins 1 TAB PO DAILY RX multivitamin 1 capsule(s) by mouth once a day Disp #30 Tablet Refills:0 10. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH PAIN RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #10 Tablet Refills:0 11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line RX polyethylene glycol 3350 17 gram 1 dose by mouth once a day Disp #30 Packet Refills:0 12. Senna 8.6 mg PO BID:PRN Constipation - First Line RX sennosides 8.6 mg 1 tablet by mouth twice a day Disp #60 Tablet Refills:0 13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Do not start taking until D+21 on ___ RX sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 14. Tacrolimus 0.5 mg PO Q12H Avoid grapefruit. Do not take AM dose on clinic days. Apply sunscreen daily. Monitor blood pressure RX tacrolimus [Prograf] 0.5 mg 1 capsule(s) by mouth twice a day Disp #120 Capsule Refills:1 15. Ursodiol 300 mg PO BID Please take with food RX ursodiol 300 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 16. Citalopram 10 mg PO DAILY RX citalopram 10 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 17. TraZODone 50 mg PO QHS RX trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime Disp #15 Tablet Refills:0 18. Zolpidem Tartrate 2.5 mg PO QHS:PRN insomnia RX zolpidem 5 mg 0.5 (One half) tablet(s) by mouth at bedtime Disp #15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: ================== Myelodysplastic Syndrome Status post matched unrelated donor CMV positive allo-SCT on ___ Secondary diagnoses: =================== Acute Sinusitis Thrombocytopenia Neutropenia Anemia Opioid induced constipation Insomnia Pulmonary Nodules, positive beta glucan Concern for GVHD Hypertension related to tacrolimus Pleural Effusions Atelectasis Elevated LFTs Hemorrhoids Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted for a bone marrow transplant What was done for me while I was in the hospital? -We gave you chemotherapy prior to her bone marrow transplant -We gave you the bone marrow transplant -We gave you antibiotics, antivirals, and antifungals to prevent and treat any infections -We gave you immune suppressants to decrease your risk for graft versus host disease (GVHD) -We gave you blood products when your counts were low -We gave you medications to treat your pain & constipation -We did a colonoscopy because you were having diarrhea and we were concerned that it might have been some GVHD involvement, however biopsies were normal -We monitored your liver enzymes because they were elevated, however they became more normal before you are discharged -We had you work with the nutritionists & physical therapists -You had a port placed for ongoing blood draws and infusions before you left What should I do when I leave the hospital? -If you have any fevers, new rashes, chest pain, shortness of breath, abdominal pain, worsening diarrhea please call your doctor or go to the emergency department -Follow up with all of your physicians as directed -Take all of your medications as prescribed Sincerely, Your ___ Care Team Followup Instructions: ___	[ "D46Z", "J9811", "B370", "J90", "T451X5S", "Z006", "R109", "R197", "K635", "J0110", "Z87891", "R21", "K5903", "T402X5A", "Y92230", "R630", "Z6828", "G4700", "R918", "I158", "T451X5A", "D701", "Y929", "D6959", "R740", "Z853", "R251", "F99", "M7660", "R5381", "H532", "K649", "E876", "E8342" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: planned allo-SCT admission D0 [MASKED] Major Surgical or Invasive Procedure: [MASKED] Temporary Tunneled Central Venous Line Placement [MASKED] Central Venous Line Replacement [MASKED] Colonoscopy with biopsies 6 8 [MASKED] Port-A-Cath placement History of Present Illness: Ms. [MASKED] is a [MASKED] woman with history of breast cancer status post chemo/radiation and right mastectomy found to have high risk MDS, here for allo SCT with Flu/Mel reduced intensity conditioning ([MASKED]). See below for relevant information about pt's onc history. Pre-transplant Workup (full reports below): Repeat bone marrow biopsy shows 4% blasts on aspirate, echo ejection fraction 75%, pulmonary function test final results pending but DLCO over 80%. She was evaluated by dentist earlier this week without problems and infectious disease Dr. [MASKED] on [MASKED]. Over the last several months pt has noted increased bruising w/o hematochezia, melena, epistaxis, gum bleeding, hematuria. During same time frame has noted exertional dyspnea, which has not greatly impacted her daily life. She continues to workout 5d per week without difficulties. Denies associated chest pain, SOB at rest, n/v. Past Medical History: PAST ONCOLOGIC HISTORY: =========================== Breast cancer: treated with chemotherapy, radiation and mastectomy. Date of Diagnosis: [MASKED] Stage: Stage IIIA (T3N2M0), [MASKED] nodes; ER+/Her2-; LVI+ Treatment: Mastectomy; dose dense Cytoxan/Adriamycin/Taxol; Radiation Therapy, Tamoxifen x [MASKED] years (intolerant of aromatase inhibitors) Last Mammogram: [MASKED] BRCA-/Myriad MyRisk- [MASKED] CBCD showed pancytopenia that led to BMB on [MASKED]. Pt noted fatigue and DOE and bruising. Bone marrow biopsy is consistent with therapy related myelodysplastic syndrome. PAST MEDICAL/SURGICAL HISTORY: =============================== Breast Cancer; R mastectomy, chemo and radiation. Last Mammogram [MASKED] was normal. Last pap [MASKED] normal Abnormal Chest CT; q 6 month monitoring; next due [MASKED] Right Shoulder pain Hemorrhoids Knee osteoarthritis Seasonal allergies Insomnia Social History: [MASKED] Family History: FHx of stomach cancer, HTN, and stroke, but denies hx of blood cancers or immune deficiencies. Brother died of suicide in his [MASKED]. Physical Exam: ADMISSION PHYSICAL EXAM: ====================== Vitals: [MASKED] 1256 Temp: 98.4 PO BP: 136/60 HR: 60 RR: 18 O2 sat: 97% O2 delivery: RA Gen: sitting upright in NA NEURO: A&Ox3. gait intact. CN II-XII intact. HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: supple, full ROM LYMPH: No cervical or supraclav LAD CV: Nl rate, regular rhythm. No MRG. LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. ABD: ND, nl bowel sounds, NT, no HSM. EXT: WWP. No [MASKED] edema. SKIN: No rashes/lesions, petechiae. Scattered ecchymoses on [MASKED] DISCHARGE PHYSICAL EXAM: ======================== VITALS: T97.7 100/62, 69, 18, 99% RA weight 65.14kg (143.6 lbs) General: Sitting upright in no acute distress Neuro: No focal neuro deficits, alert oriented x3, gait normal HEENT: No conjunctival pallor, no icterus, mucous remains moist with clear oropharynx. Mild erythema on chin and behind ears with some excoriation. Lymph: No cervical lymphadenopathy Cardiovascular: Regular rate and rhythm, S1-S2, no MRG Pulm: Clear to oxygen bilaterally with good air entry Abdomen: + Bowel sounds, soft nontender nondistended, no hepatomegaly Extremities: No petechiae, no edema, warm Access: Left chest wall port, CDI, no erythema, no swelling Pertinent Results: =============== ADMISSION LABS: =============== [MASKED] 04:20PM BLOOD WBC-2.8* RBC-2.58* Hgb-7.6* Hct-25.2* MCV-98 MCH-29.5 MCHC-30.2* RDW-16.3* RDWSD-57.8* Plt [MASKED] [MASKED] 04:20PM BLOOD Neuts-35 Lymphs-63* Monos-1* Eos-0* Baso-1 AbsNeut-0.98* AbsLymp-1.76 AbsMono-0.03* AbsEos-0.00* AbsBaso-0.03 [MASKED] 04:20PM BLOOD [MASKED] PTT-26.9 [MASKED] [MASKED] 04:20PM BLOOD Glucose-144* UreaN-18 Creat-1.1 Na-143 K-3.9 Cl-106 HCO3-27 AnGap-10 [MASKED] 04:20PM BLOOD ALT-10 AST-15 LD([MASKED])-175 AlkPhos-49 TotBili-0.2 DirBili-<0.2 IndBili-0.2 [MASKED] 04:20PM BLOOD TotProt-6.5 Albumin-4.3 Globuln-2.2 Calcium-9.2 Phos-3.2 Mg-2.4 UricAcd-5.0 ======================= RELEVANT INTERVAL LABS: ======================= [MASKED] 12:00AM BLOOD WBC-0.1* RBC-2.60* Hgb-7.7* Hct-23.6* MCV-91 MCH-29.6 MCHC-32.6 RDW-14.1 RDWSD-46.9* Plt Ct-6* [MASKED] 12:00AM BLOOD ALT-202* AST-191* LD(LDH)-436* AlkPhos-159* TotBili-0.7 [MASKED] 12:00AM BLOOD ALT-336* AST-298* LD(LDH)-415* AlkPhos-182* TotBili-0.7 [MASKED] 12:00AM BLOOD Lipase-26 [MASKED] 12:00AM BLOOD GGT-26 [MASKED] 12:00AM BLOOD TotProt-5.7* Albumin-3.4* Globuln-2.3 Calcium-8.9 Phos-3.4 Mg-1.7 UricAcd-2.1* [MASKED] 12:00AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-POS* IgM HAV-NEG [MASKED] 12:00AM BLOOD CMV IgG-NEG CMV IgM-NEG CMVI-There is n [MASKED] 12:00AM BLOOD HCV Ab-NEG [MASKED] 12:00AM BLOOD HCV VL-NOT DETECT [MASKED] 12:00AM BLOOD CMV VL-NOT DETECT [MASKED] Test Result Reference Range/Units SOURCE Plasma HSV 1 DNA, QN PCR <100 <100 copies/mL HSV 2 DNA, QN PCR <100 <100 copies/mL [MASKED] Test Result Reference Range/Units SOURCE Whole Blood VARICELLA ZOSTER VIRUS (VZV) Not Detected Not Detected DNA, QL RT PCR Test Result Reference Range/Units SOURCE Whole Blood EBV DNA, QN PCR <200 <200 copies/mL Test Result Reference Range/Units INDEX VALUE 0.03 <0.50 ASPERGILLUS AG,EIA,SERUM Not Detected Not Detected Test Result Reference Range/Units FUNGITELL(R) [MASKED] <31 <60 pg/mL GLUCAN ASSAY INTERPRETATION Negative [MASKED] RESPIRATORY VIRAL PANEL NEGATIVE ================ DISCHARGE LABS: ================ [MASKED] 12:00AM BLOOD WBC-5.9 RBC-2.72* Hgb-8.2* Hct-26.1* MCV-96 MCH-30.1 MCHC-31.4* RDW-18.2* RDWSD-62.1* Plt [MASKED] [MASKED] 12:00AM BLOOD Neuts-63.5 Lymphs-17.3* Monos-17.3* Eos-0.5* Baso-0.7 Im [MASKED] AbsNeut-3.76 AbsLymp-1.02* AbsMono-1.02* AbsEos-0.03* AbsBaso-0.04 [MASKED] 12:00AM BLOOD [MASKED] PTT-26.0 [MASKED] [MASKED] 12:00AM BLOOD Glucose-96 UreaN-10 Creat-1.2* Na-143 K-4.5 Cl-106 HCO3-22 AnGap-15 [MASKED] 12:00AM BLOOD ALT-55* AST-19 AlkPhos-103 TotBili-0.4 [MASKED] 12:00AM BLOOD Calcium-9.5 Phos-4.2 Mg-1.9 ======== IMAGING: ======== CT Chest [MASKED]: NECK, THORACIC INLET, AXILLAE AND CHEST WALL: The partially visualized shows no incidental findings. No enlarged lymph nodes in either axilla or thoracic inlet. The patient is post right mastectomy.. No atherosclerotic calcifications in the head and neck arteries. MEDIASTINUM AND HILA: The esophagus is unremarkable. Small mediastinal lymph nodes, none pathologically enlarged by CT size criteria. No hilar lymphadenopathy. HEART AND VASCULATURE: The heart is normal in size and shape. No pericardial effusion. No atherosclerotic calcifications in the coronary arteries, cardiac valves or aorta. The aorta and pulmonary arteries are normal in caliber throughout. Low density of the blood pool suggests underlying anemia. LUNGS AND PLEURA: The airways are patent to the subsegmental levels. Lungs are well expanded and clear, with no bronchial wall thickening, bronchiectasis or mucus plugging. Mild bilateral apical scarring. Multiple tiny nodules are seen bilaterally as follows: -2 mm nodule in the right upper lobe (5:61). -2 mm endobronchial nodule in a subsegmental branch for the anterior segment of the right upper lobe (5:100). -3 mm nodule in the right lower lobe (5:205). -4 mm nodule in the left lower lobe (5:205). -4 mm nodule in the right lower lobe (5: 210). -3 mm nodule in the left lower lobe (5:216). -2 mm nodule in the left lower lobe (5:241). CHEST CAGE: No acute fractures. Mild dorsal spondylosis. No suspicious lytic or sclerotic lesions. UPPER ABDOMEN: The limited sections of the upper abdomen show no significant abnormal findings. There is an incompletely visualized right renal lower pole cyst. CT Sinus [MASKED]: 1. Paranasal sinus disease as described above, with opacification of the left frontal ethmoidal recess, mild mucosal thickening of the ethmoid air cells and aerosolized opacification of a right posterior ethmoid air cell. Aerosolized mucous in the posterior right ethmoid air cells suggests acute inflammatory process. 2. No evidence of abscess or abnormal enhancement following contrast administration. CT Chest [MASKED]: 1. No pleural effusions or acute intrathoracic abnormality. 2. A 1.9 cm ground-glass opacity in the left upper lobe, unchanged from the prior study from [MASKED], likely represents small airways disease. 3. Overall stable multiple pulmonary nodules measuring up to 3 mm. Continued attention on follow-up imaging is recommended. RUQUS [MASKED]: Gallbladder wall thickening with edema and hyperemia may be related to hepatitis in the absence of abnormal gallbladder distension. However, in the setting of neutropenia, acute acalculous cholecystitis would be difficult to exclude. MRI with contrast or HIDA scan may be obtained for further evaluation. RUQUS [MASKED]: 1. Normal hepatic echotexture. No evidence of intrahepatic or extrahepatic biliary dilatation. 2. Interval improvement in gallbladder wall thickening. Unremarkable gallbladder. CT ABD and PELVIS w/ CONTRAST [MASKED]: Diffuse mucosal thickening of the ascending, transverse and descending colons with associated mild pericolonic fat stranding most prominent in the splenic flexure. Findings are suggestive of diffuse colitis related to an infectious/inflammatory process. [MASKED]: RUQUS 1. Normal sonographic appearance of the liver. 2. Common hepatic duct is prominent measuring 0.8 cm with relative increased echogenicity intraluminally. In correlation with the CT abdomen pelvis dated [MASKED] which demonstrated wall thickening and enhancement of the common hepatic duct wall, further evaluation with MRCP should be performed for further assessment. [MASKED]: MRCP 1. No intra or extrahepatic bile duct dilation. The gallbladder appears normal. No ductal stones. 2. No focal liver lesion. 3. No ascites. 4. Signal abnormality throughout the pancreas suggestive of chronic pancreatitis. No active pancreatitis. Pancreatic neck cystic lesions measuring up to 5 mm likely represent side branch IPMN versus chronic pseudocysts. No dedicated followup required. ===================== COLONOSCOPY [MASKED]: Normal mucosa was noted in the whole colon. With cold forceps biopsies were performed for histology and ascending, transverse, descending and rectosigmoid. Normal mucosa was noted in the distal terminal ileum. 3 polyps were found in the transverse colon (2 mm), descending colon (4 mm) and pedunculated in the descending colon (8 mm). Not removed due to Lovenox and indication Colonic mucosal biopsies 4 1. Ascending colon: Colonic mucosa within normal limits 2. Transverse colon: Colonic mucosa within normal limits 3. Descending colon: Colonic mucosa within normal limits 4. Rectosigmoid colon: Colonic mucosa within normal limits ====================== ================ OTHER PATHOLOGY: ================ TEST RESULT FLAG UNITS REF RANGE ST2 (serum)* 87.5 H ng/mL <30.0 TEST RESULT FLAG UNITS REF RANGE Reg3A (serum)* 54.6 ng/mL <74. RIEF HOSPITAL COURSE ================================= [MASKED] is a [MASKED] woman with a history of breast cancer s/p chemo/radiation and right mastectomy found to have high risk therapy related MDS, who was admitted for planned MUD Allo SCT with Flu/Mel reduced intensity conditioning ([MASKED]). Pre-transplant course complicated by acute sinusitis, treated with cefepime. Post transplant course complicated by cytopenias, opioid induced constipation, anorexia, & elevated LFTs. The transaminitis was initially thought to be due to posaconazole and was briefly switched to micafungin, however her liver enzymes continue to uptrend, and hepatology was consulted who thought this was a methotrexate effect. Prior to discharge her liver enzymes were normalizing and she was switched back to Posaconazole. She also had diarrhea and abdominal pain which was concerning for GVHD, was briefly on steroids. GI was consulted for colonoscopy however biopsies were normal and her steroids were discontinued. She did have a facial rash which improved with hydrocortisone cream. Ms. [MASKED] successfully engrafted [MASKED] D+14. She will be discharged on infection prophylaxis regimen of acyclovir, fluconazole (rather than Posaconazole), TMP/SMX, immune suppression regimen with tacrolimus 0.5 mg twice a day, and VOD/SOS prophylaxis with ursodiol. She was discharged on day +28. Her weight on discharge was 65.14 kg (143.61 LBS). Her ANC on discharge was 2330. Her hemoglobin hematocrit on discharge were 7.9 and 25.6 respectively. Her platelet count on discharge was 250. Creatinine discharge was 1.2. A single lumen chest power Port-a-cath was placed via L jugular vein access and was ready to use at the time of discharge. TRANSITIONAL ISSUES: ================================= Heme-Onc: [ ] Please follow pulmonary nodules with repeat chest CT in 6 months ([MASKED]). Has had a positive beta glucan on [MASKED], however all subsequent tests have been negative. [ ] A tacrolimus level was drawn on [MASKED], goal is [MASKED]. She is being discharged on 0.5 mg twice daily, which will need to continue to be titrated. [ ] Please repeat CMP and LFTs on discharge to ensure resolution. [ ] Please consider repeat CT abdomen/pelvis in [MASKED] weeks to ensure resolution of colonic thickening [ ] Please repeat an EKG in the week following discharge Gastroenterology: [] 3 polyps were found on your colonoscopy. Please follow-up with gastroenterology in [MASKED] year [MASKED] (Dr. [MASKED] [MASKED] [MASKED]: [] Please follow up for monocular diplopia in s/o presbyopia + refractive error # CODE: Full code # CONTACT: [MASKED] (HCP & SO)\| [MASKED] ACTIVE PROBLEMS: ====================== #high risk MDS [MASKED] in s/o pt's hx of chemo for breast cancer many years ago, thus characterized as therapy related MDS. [MASKED] here for MUD allo-SCT w/ Flu/Mel reduced intensity conditioning. ([MASKED]) s/p MTX course. Engraftment [MASKED] (D+14). Will be discharged on immunosuppressive regimen of: tacrolimus 0.5mg BID. Continuing ursodiol for VOD ppx. #Infection Prophylaxis Provided levofloxacin initially for neutropenia ppx, but developed achilles tendonitis, thus transitioned to cefpodoxime. Furthermore, initially on posaconazole rather than fluconazole d/t her initially positive beta glucan in s/o known pulmonary nodules. Due to elevated LFTs, transitioned to micafungin, but was later return to posaconazole as her transaminases normalized. After discussion with her primary oncologist, it was decided to ultimately discharge her on fluconazole. Will be discharged on: acyclovir 400mg TID and Fluconazole 400mg daily. Of note, pt is toxo+ therefore will require TMP-SMX indefinitely without transitioning to other agents. #Abdominal Pain #Concern for GVHD Patient had diffuse crampy abdominal pain along with loose stools, this is concerning for GVHD. A CT of the abdomen pelvis revealed diffuse colonic wall thickening. C. difficile/norovirus/stool culture all negative. She was empirically started on steroids. GI was called for colonoscopy which revealed normal mucosa and biopsies were negative for GVHD and subsequently her steroids were stopped. Of note 3 polyps were found on colonoscopy which were not removed this patient was on anticoagulation. ST2 was high, but REG3A was low. TI: Follow-up with GI in [MASKED] year for repeat colonoscopy. #Transaminitis More hepatocellular rather than cholestatic. Suspect d/t posaconazole & drug induced liver injury, but DDx also included DILI [MASKED] chemo vs. VOD/SOS. Regarding VOD/SOS, lack of ascites, hepatomegaly, and hyperbili argued against this dx. RUQUS unrevealing. Transitioned from posaconazole to micafungin, but later switched back to Posaconazole as above. Viral HBV/HCV/CMV/EBV/VZV/HSV were negative. Additionally on ursodiol for VOD/SOS. MRCP was performed which suggested chronic pancreatitis. #Access s/p tunneled line removal w/ insertion of LIJ [MASKED] d/t likely infiltration. Port-O-cath inserted on [MASKED]. #Atelectasis #Pulmonary Effusion Noted on CT imaging. Intermittently low O2 sats in AM. Incentive spirometry provided. Also responded well to furosemide for several days post-transplant. #Constipation Given good effect of methylnaltrexone previously, suspect opioid induced. Will be discharged on regimen of: senna and miralax as needed #Anorexia Many days of anorexia and poor PO post-transplant. Followed by nutrition & intiated on marinol. #Hypertension Likely side of tacrolimus, intitiated amlodipine 7.5mg PO daily. #Monocular Diplopia of Left Eye (refractive error + presbyopia) Opthalmology consult determined refractive error & presbyopia. Provided artificial tears. TI: follow-up with optometrist #Acute Sinusitis-RESOLVED CT e/o acute frontal sinusitis. Completed course of cefepime. CHRONIC/STABLE ISSUES: ======================= #Hx of Positive B-glucan Infectious workup on [MASKED] as part of pre-transplant screening notable for positive B-glucan, but reassured that repeat levels were negative. Remainder of fungal workup negative. Was on [MASKED] & micafungin per above. She was eventually switched to fluconazole upon discharge. #Insomnia Continued home trazodone 50mg PO QHS and used ambien as needed at night. #Mental Health Continued home citalopram 10mg PO Qday #Pulmonary Nodules Receives q6mo CT for monitoring. CT chest on [MASKED] new baseline. Recommend continue q6mo imaging for active surveillance given Ms. [MASKED] hx of former tobacco use & BCa s/p chemo/radiation. #Hx Hemorrhoids Stable. Bowel regimen per above. Used hydrocortisone cream with good effect. #Tremor-RESOLVED Very fine and only intermittent on exam. Suspect in s/o recent tacrolimus initiation. #Risky EtOH Use Appears pt on occasion drinks more than the recommended 14 drinks per week & no more than [MASKED] drinks per day for women. Does not appear to be causing negative harm in pts life. Recommend continued conversations with PCP. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Zolpidem Tartrate 2.5 mg PO QHS:PRN insomnia 2. TraZODone 50 mg PO QHS 3. Citalopram 10 mg PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q8H RX acyclovir 400 mg 1 capsule(s) by mouth every eight (8) hours Disp #90 Tablet Refills:0 2. amLODIPine 7.5 mg PO DAILY RX amlodipine 2.5 mg 3 tablet(s) by mouth once a day Disp #90 Tablet Refills:0 3. Dronabinol 2.5 mg PO BID:PRN poor appetite 4. Famotidine 40 mg PO DAILY RX famotidine 40 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 5. Fluconazole 400 mg PO DAILY RX fluconazole 200 mg 2 tablet(s) by mouth once a day Disp #60 Tablet Refills:3 6. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 7. Hydrocortisone (Rectal) 2.5% Cream AILY:PRN hemorrhoid pain 8. Hydrocortisone Cream 1% 1 Appl TP QID:PRN facial rash 9. Multivitamins 1 TAB PO DAILY RX multivitamin 1 capsule(s) by mouth once a day Disp #30 Tablet Refills:0 10. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH PAIN RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #10 Tablet Refills:0 11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line RX polyethylene glycol 3350 17 gram 1 dose by mouth once a day Disp #30 Packet Refills:0 12. Senna 8.6 mg PO BID:PRN Constipation - First Line RX sennosides 8.6 mg 1 tablet by mouth twice a day Disp #60 Tablet Refills:0 13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Do not start taking until D+21 on [MASKED] RX sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 14. Tacrolimus 0.5 mg PO Q12H Avoid grapefruit. Do not take AM dose on clinic days. Apply sunscreen daily. Monitor blood pressure RX tacrolimus [Prograf] 0.5 mg 1 capsule(s) by mouth twice a day Disp #120 Capsule Refills:1 15. Ursodiol 300 mg PO BID Please take with food RX ursodiol 300 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 16. Citalopram 10 mg PO DAILY RX citalopram 10 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 17. TraZODone 50 mg PO QHS RX trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime Disp #15 Tablet Refills:0 18. Zolpidem Tartrate 2.5 mg PO QHS:PRN insomnia RX zolpidem 5 mg 0.5 (One half) tablet(s) by mouth at bedtime Disp #15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: ================== Myelodysplastic Syndrome Status post matched unrelated donor CMV positive allo-SCT on [MASKED] Secondary diagnoses: =================== Acute Sinusitis Thrombocytopenia Neutropenia Anemia Opioid induced constipation Insomnia Pulmonary Nodules, positive beta glucan Concern for GVHD Hypertension related to tacrolimus Pleural Effusions Atelectasis Elevated LFTs Hemorrhoids 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 part in your care here at [MASKED]! Why was I admitted to the hospital? - You were admitted for a bone marrow transplant What was done for me while I was in the hospital? -We gave you chemotherapy prior to her bone marrow transplant -We gave you the bone marrow transplant -We gave you antibiotics, antivirals, and antifungals to prevent and treat any infections -We gave you immune suppressants to decrease your risk for graft versus host disease (GVHD) -We gave you blood products when your counts were low -We gave you medications to treat your pain & constipation -We did a colonoscopy because you were having diarrhea and we were concerned that it might have been some GVHD involvement, however biopsies were normal -We monitored your liver enzymes because they were elevated, however they became more normal before you are discharged -We had you work with the nutritionists & physical therapists -You had a port placed for ongoing blood draws and infusions before you left What should I do when I leave the hospital? -If you have any fevers, new rashes, chest pain, shortness of breath, abdominal pain, worsening diarrhea please call your doctor or go to the emergency department -Follow up with all of your physicians as directed -Take all of your medications as prescribed Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "Z87891", "Y92230", "G4700", "Y929" ]	[ "D46Z: Other myelodysplastic syndromes", "J9811: Atelectasis", "B370: Candidal stomatitis", "J90: Pleural effusion, not elsewhere classified", "T451X5S: Adverse effect of antineoplastic and immunosuppressive drugs, sequela", "Z006: Encounter for examination for normal comparison and control in clinical research program", "R109: Unspecified abdominal pain", "R197: Diarrhea, unspecified", "K635: Polyp of colon", "J0110: Acute frontal sinusitis, unspecified", "Z87891: Personal history of nicotine dependence", "R21: Rash and other nonspecific skin eruption", "K5903: Drug induced constipation", "T402X5A: Adverse effect of other opioids, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "R630: Anorexia", "Z6828: Body mass index [BMI] 28.0-28.9, adult", "G4700: Insomnia, unspecified", "R918: Other nonspecific abnormal finding of lung field", "I158: Other secondary hypertension", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "D701: Agranulocytosis secondary to cancer chemotherapy", "Y929: Unspecified place or not applicable", "D6959: Other secondary thrombocytopenia", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "Z853: Personal history of malignant neoplasm of breast", "R251: Tremor, unspecified", "F99: Mental disorder, not otherwise specified", "M7660: Achilles tendinitis, unspecified leg", "R5381: Other malaise", "H532: Diplopia", "K649: Unspecified hemorrhoids", "E876: Hypokalemia", "E8342: Hypomagnesemia" ]
10,092,879	28,272,715	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: INITIAL LABS ============ ___ 08:50AM BLOOD WBC-4.0 RBC-2.53* Hgb-8.1* Hct-25.1* MCV-99* MCH-32.0 MCHC-32.3 RDW-15.9* RDWSD-58.5* Plt ___ ___ 08:50AM BLOOD Neuts-65.3 ___ Monos-11.3 Eos-1.8 Baso-1.0 Im ___ AbsNeut-2.62 AbsLymp-0.81* AbsMono-0.45 AbsEos-0.07 AbsBaso-0.04 ___ 11:54AM BLOOD ___ PTT-30.5 ___ ___ 08:50AM BLOOD UreaN-23* Creat-1.6* Na-138 K-4.7 Cl-103 HCO3-22 AnGap-13 ___ 08:50AM BLOOD ALT-18 AST-19 LD(LDH)-180 AlkPhos-75 TotBili-0.2 ___ 08:50AM BLOOD TotProt-6.1* Albumin-4.1 Globuln-2.0 Calcium-9.8 Phos-4.5 Mg-2.1 ___ 08:50AM BLOOD tacroFK-8.3 ___ 12:03PM BLOOD Lactate-1.1 ___ 01:35PM URINE Color-Straw Appear-Clear Sp ___ ___ 01:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG MICROBIOLOGY ============ ___ 11:54 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___ 12:42 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___ 1:35 pm URINE *FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING ======= CXR (___): Left chest wall port is again noted. The lungs are clear. There is no consolidation, effusion, or edema. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. MRI BRAIN (___): There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are slightly prominent, likely reflecting age-related involutional changes. There is asymmetric brain parenchymal volume loss in the bilateral parietal lobes, more pronounced on the left, nonspecific, could be related to encephalomalacia versus age related phenomena. There are scattered foci of T2/FLAIR hyperintensity in the periventricular and subcortical white matter, nonspecific, and may represent chronic microangiopathy. There is no abnormal enhancement after contrast administration. The visualized vascular flow voids are patent. There is minimal mucosal thickening of the ethmoid air cells, otherwise the paranasal sinuses are clear. The mastoid air cells are clear. There is no abnormal marrow signal. IMPRESSION: 1. Unremarkable brain MRI. No evidence to suggest toxoplasmosis or PRES. 2. No evidence of an acute infarct, hemorrhage, or intracranial mass. OTHER RESULTS ============= ___ 09:43AM BLOOD tacroFK-6.9 DISCHARGE LABS ============== ___ 12:00AM BLOOD WBC-4.5 RBC-2.27 Hgb-7.2* Hct-22.9* MCV-101* MCH-31.7 MCHC-31.4* RDW-16.2* RDWSD-60.0* Plt ___ ___ 12:00AM BLOOD Neuts-65.0 Lymphs-18.6* Monos-12.8 Eos-2.5 Baso-0.7 Im ___ AbsNeut-2.91 AbsLymp-0.83* AbsMono-0.57 AbsEos-0.11 AbsBaso-0.03 ___ 12:00AM BLOOD Glucose-114* UreaN-20 Creat-1.5* Na-142 K-4.5 Cl-105 HCO3-21* AnGap-16 ___ 12:00AM BLOOD ALT-41* AST-41* LD(LDH)-201 AlkPhos-82 TotBili-<0.2 ___ 12:00AM BLOOD Calcium-9.5 Phos-4.8* Mg-1.___RIEF HOSPITAL COURSE ===================== Ms. ___ is a ___ year old female with history of breast cancer treated with mastectomy and chemoradiation (___) complicated by therapy-related high-risk myelodysplasia treated with allogeneic stem cell transplant (D0 = ___ who presented to ___ with transient loss of consciousness, and was found to have vasovagal syncope. ACTIVE ISSUES ============= # Vasovagal syncope Ms. ___ presented with two episodes of TLOC while eating breakfast. EKG demonstrated new reduced voltage and sinus bradycardia, while TTE and MRI were unremarkable. Telemetry for 48hrs was sinus rhythm in ___ without notable events. Orthostatic vitals were positive. She received 1L IVF with improvement. Ultimately, her TLOC was attributed to vasovagal syncope in the setting of poor oral intake. CHRONIC ISSUES ============== # t-AML s/p alloHSCT (D0 = ___ - She was continued on her home tacrolimus. # Vulvar lesions: Her valacyclovir was changed to prophylactic acyclovir after resolution of her vulvar lesions. # MDD - She was continued on her home citalopram. TRANSITIONAL ISSUES =================== [ ] ___-6: please follow-up results of ___-6 testing [ ] AMBULATORY MONITORING: please consider giving Ms. ___ Holter monitor if her symptoms recur Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 10 mg PO DAILY 2. TraZODone 50 mg PO QHS 3. Zolpidem Tartrate 2.5 mg PO QHS:PRN insomnia 4. Famotidine 40 mg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Tacrolimus 2 mg PO Q12H 10. Ursodiol 300 mg PO BID 11. Hydrocortisone Cream 1% 1 Appl TP QID:PRN facial rash 12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH PAIN 13. Fluconazole 400 mg PO DAILY 14. ValACYclovir 1000 mg PO Q12H Discharge Medications: 1. Acyclovir 400 mg PO TID RX acyclovir 400 mg 1 capsule(s) by mouth every eight (8) hours Disp #90 Tablet Refills:*0 2. Citalopram 10 mg PO DAILY 3. Famotidine 40 mg PO DAILY 4. Fluconazole 400 mg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Hydrocortisone Cream 1% 1 Appl TP QID:PRN facial rash 7. Mg-Plus-Protein (magnesium oxide-Mg AA chelate) 133 mg oral DAILY 8. Multivitamins 1 TAB PO DAILY 9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH PAIN 10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 12. Tacrolimus 2 mg PO Q12H 13. TraZODone 50 mg PO QHS 14. Ursodiol 300 mg PO BID 15. Zolpidem Tartrate 2.5 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ====================== - Vasovagal syncope SECONDARY DIAGNOSIS ====================== - Acute myelodysplasia - Allogeneic stem cell transplant - Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, WHY WERE YOU ADMITTED TO THE HOSPITAL? - You fainted twice while eating food WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? - You had several studies performed, including an echocardiogram and an MRI of your head, to figure out why you fainted - Ultimately, we believe you fainted because you weren't drinking/receiving enough water WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - Follow up with your doctors as listed below Please see below for more information on your hospitalization. It was a pleasure taking part in your care here at ___. We wish you all the best, - Your ___ Care Team Followup Instructions: ___	[ "R55", "D469", "A6004", "R21", "K219", "G4700", "Z9484", "Z853", "Z9011", "Z9221", "Z923", "Z87891" ]	Allergies: No Known Allergies / Adverse Drug Reactions Major Surgical or Invasive Procedure: None attach Pertinent Results: INITIAL LABS ============ [MASKED] 08:50AM BLOOD WBC-4.0 RBC-2.53* Hgb-8.1* Hct-25.1* MCV-99* MCH-32.0 MCHC-32.3 RDW-15.9* RDWSD-58.5* Plt [MASKED] [MASKED] 08:50AM BLOOD Neuts-65.3 [MASKED] Monos-11.3 Eos-1.8 Baso-1.0 Im [MASKED] AbsNeut-2.62 AbsLymp-0.81* AbsMono-0.45 AbsEos-0.07 AbsBaso-0.04 [MASKED] 11:54AM BLOOD [MASKED] PTT-30.5 [MASKED] [MASKED] 08:50AM BLOOD UreaN-23* Creat-1.6* Na-138 K-4.7 Cl-103 HCO3-22 AnGap-13 [MASKED] 08:50AM BLOOD ALT-18 AST-19 LD(LDH)-180 AlkPhos-75 TotBili-0.2 [MASKED] 08:50AM BLOOD TotProt-6.1* Albumin-4.1 Globuln-2.0 Calcium-9.8 Phos-4.5 Mg-2.1 [MASKED] 08:50AM BLOOD tacroFK-8.3 [MASKED] 12:03PM BLOOD Lactate-1.1 [MASKED] 01:35PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 01:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG MICROBIOLOGY ============ [MASKED] 11:54 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. [MASKED] 12:42 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. [MASKED] 1:35 pm URINE *FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING ======= CXR ([MASKED]): Left chest wall port is again noted. The lungs are clear. There is no consolidation, effusion, or edema. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. MRI BRAIN ([MASKED]): There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are slightly prominent, likely reflecting age-related involutional changes. There is asymmetric brain parenchymal volume loss in the bilateral parietal lobes, more pronounced on the left, nonspecific, could be related to encephalomalacia versus age related phenomena. There are scattered foci of T2/FLAIR hyperintensity in the periventricular and subcortical white matter, nonspecific, and may represent chronic microangiopathy. There is no abnormal enhancement after contrast administration. The visualized vascular flow voids are patent. There is minimal mucosal thickening of the ethmoid air cells, otherwise the paranasal sinuses are clear. The mastoid air cells are clear. There is no abnormal marrow signal. IMPRESSION: 1. Unremarkable brain MRI. No evidence to suggest toxoplasmosis or PRES. 2. No evidence of an acute infarct, hemorrhage, or intracranial mass. OTHER RESULTS ============= [MASKED] 09:43AM BLOOD tacroFK-6.9 DISCHARGE LABS ============== [MASKED] 12:00AM BLOOD WBC-4.5 RBC-2.27 Hgb-7.2* Hct-22.9* MCV-101* MCH-31.7 MCHC-31.4* RDW-16.2* RDWSD-60.0* Plt [MASKED] [MASKED] 12:00AM BLOOD Neuts-65.0 Lymphs-18.6* Monos-12.8 Eos-2.5 Baso-0.7 Im [MASKED] AbsNeut-2.91 AbsLymp-0.83* AbsMono-0.57 AbsEos-0.11 AbsBaso-0.03 [MASKED] 12:00AM BLOOD Glucose-114* UreaN-20 Creat-1.5* Na-142 K-4.5 Cl-105 HCO3-21* AnGap-16 [MASKED] 12:00AM BLOOD ALT-41* AST-41* LD(LDH)-201 AlkPhos-82 TotBili-<0.2 [MASKED] 12:00AM BLOOD Calcium-9.5 Phos-4.8* Mg-1. RIEF HOSPITAL COURSE ===================== Ms. [MASKED] is a [MASKED] year old female with history of breast cancer treated with mastectomy and chemoradiation ([MASKED]) complicated by therapy-related high-risk myelodysplasia treated with allogeneic stem cell transplant (D0 = [MASKED] who presented to [MASKED] with transient loss of consciousness, and was found to have vasovagal syncope. ACTIVE ISSUES ============= # Vasovagal syncope Ms. [MASKED] presented with two episodes of TLOC while eating breakfast. EKG demonstrated new reduced voltage and sinus bradycardia, while TTE and MRI were unremarkable. Telemetry for 48hrs was sinus rhythm in [MASKED] without notable events. Orthostatic vitals were positive. She received 1L IVF with improvement. Ultimately, her TLOC was attributed to vasovagal syncope in the setting of poor oral intake. CHRONIC ISSUES ============== # t-AML s/p alloHSCT (D0 = [MASKED] - She was continued on her home tacrolimus. # Vulvar lesions: Her valacyclovir was changed to prophylactic acyclovir after resolution of her vulvar lesions. # MDD - She was continued on her home citalopram. TRANSITIONAL ISSUES =================== [ ] [MASKED]-6: please follow-up results of [MASKED]-6 testing [ ] AMBULATORY MONITORING: please consider giving Ms. [MASKED] Holter monitor if her symptoms recur Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 10 mg PO DAILY 2. TraZODone 50 mg PO QHS 3. Zolpidem Tartrate 2.5 mg PO QHS:PRN insomnia 4. Famotidine 40 mg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Tacrolimus 2 mg PO Q12H 10. Ursodiol 300 mg PO BID 11. Hydrocortisone Cream 1% 1 Appl TP QID:PRN facial rash 12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH PAIN 13. Fluconazole 400 mg PO DAILY 14. ValACYclovir 1000 mg PO Q12H Discharge Medications: 1. Acyclovir 400 mg PO TID RX acyclovir 400 mg 1 capsule(s) by mouth every eight (8) hours Disp #90 Tablet Refills:*0 2. Citalopram 10 mg PO DAILY 3. Famotidine 40 mg PO DAILY 4. Fluconazole 400 mg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Hydrocortisone Cream 1% 1 Appl TP QID:PRN facial rash 7. Mg-Plus-Protein (magnesium oxide-Mg AA chelate) 133 mg oral DAILY 8. Multivitamins 1 TAB PO DAILY 9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH PAIN 10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 12. Tacrolimus 2 mg PO Q12H 13. TraZODone 50 mg PO QHS 14. Ursodiol 300 mg PO BID 15. Zolpidem Tartrate 2.5 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ====================== - Vasovagal syncope SECONDARY DIAGNOSIS ====================== - Acute myelodysplasia - Allogeneic stem cell transplant - Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], WHY WERE YOU ADMITTED TO THE HOSPITAL? - You fainted twice while eating food WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? - You had several studies performed, including an echocardiogram and an MRI of your head, to figure out why you fainted - Ultimately, we believe you fainted because you weren't drinking/receiving enough water WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - Follow up with your doctors as listed below Please see below for more information on your hospitalization. It was a pleasure taking part in your care here at [MASKED]. We wish you all the best, - Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "K219", "G4700", "Z87891" ]	[ "R55: Syncope and collapse", "D469: Myelodysplastic syndrome, unspecified", "A6004: Herpesviral vulvovaginitis", "R21: Rash and other nonspecific skin eruption", "K219: Gastro-esophageal reflux disease without esophagitis", "G4700: Insomnia, unspecified", "Z9484: Stem cells transplant status", "Z853: Personal history of malignant neoplasm of breast", "Z9011: Acquired absence of right breast and nipple", "Z9221: Personal history of antineoplastic chemotherapy", "Z923: Personal history of irradiation", "Z87891: Personal history of nicotine dependence" ]
10,092,911	21,137,683	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Type 4 Choledochal cyst Major Surgical or Invasive Procedure: ___: Robot-assisted excision of choledochal cyst, Open conversion for Roux-en-Y hepaticojejunostomy to extrahepatic common hepatic duct. . ___: PTBD replacement for drain migration . ___: Gravity cholangiogram History of Present Illness: ___ woman with recently diagnosed type 4A choledochal cyst treated with percutaneous decompression. She now presents for definitive excision. Of note, two co-surgeons were required due to the complex nature of this case. Past Medical History: No PMH or surgical history Social History: ___ Family History: No family history of GI cancers Physical Exam: Discharge Physical: Temp: 98.4 (Tm 99.2), BP: 109/65 (97-109/65-72), HR: 73 (63-78), RR: 18 (___), O2 sat: 100% (99-100), O2 delivery: RA, Wt: 99.8 lb/45.27 kg . GEN: NAD, AOx3, comfortable HEENT: AT/NC, PERRL, no scleral icterus CV: RRR R: On RA, no respiratory distress GI: Soft, appropriately tender, laparoscopic incisions with dermabond, JP drain with serosanguinous output; PTBD capped following cholangiogram. Both drains removed prior to discharge. EXT: warm and well perfused NEURO: Grossly intact sensory and motor function Pertinent Results: Labs post op: ___ WBC-9.5 RBC-2.75* Hgb-8.9* Hct-26.3* MCV-96 MCH-32.4* MCHC-33.8 RDW-12.5 RDWSD-44.0 Plt ___ PTT-28.6 ___ Glucose-143* UreaN-8 Creat-0.6 Na-142 K-4.3 Cl-104 HCO3-24 AnGap-14 ALT-112* AST-111* AlkPhos-185* TotBili-3.6* Calcium-8.8 Phos-4.9* Mg-1.9 . Labs at Discharge: ___ WBC-12.3* RBC-3.17* Hgb-9.9* Hct-29.7* MCV-94 MCH-31.2 MCHC-33.3 RDW-12.4 RDWSD-42.6 Plt ___ PTT-30.6 ___ Glucose-101* UreaN-5* Creat-0.5 Na-140 K-4.7 Cl-104 HCO3-24 AnGap-12 ALT-21 AST-19 AlkPhos-257* TotBili-1.0 Calcium-8.5 Phos-3.0 Mg-2.___ y/o female with history of Type 4 choledochal cyst with recent placement of PTBD in preparation for surgery who is now taken to the OR with Dr. ___ and Dr. ___, for Robot-assisted excision of choledochal cyst, Open conversion for Roux-en-Y hepaticojejunostomy to extrahepatic common hepatic duct. . The cyst was large but able to be removed. Please see the operative report for surgical detail. There were no complications reported and the patient was extubated and transferred to PACU in stable condition. . On POD 1, the pre-existing PTBD that had been left in place at time of surgery had moved with drainage around drain. A Cholangiogram showed side holes had migrated out, so the drain was replaced and left open to gravity. . Following NG removal, her diet was advanced slowly, and well tolerated by time of discharge. When catheter was removed, she voided without difficulty. . On POD 6 a gravity cholangiogram was performed which showed no leak. The PTBD was capped, and then removed the following day when the LFTs remained stable and all WNL except the alk phos. The JP drain was removed later the same day and she was discharged to home having completed a week of post op antibiotics. The incision was clean dry and intact, drain sites were dry after drain removal. . The only home medication is a multivitamin which she can resume at home. A follow up appointment has been scheduled and she should have labwork on that day. . Please note patient is not taking narcotic pain medication due to issues with nausea previously. Will use Tylenol for pain management and was given a script for tramadol if she wishes to have more than Tylenol for pain management successful gravity choleangiogram ___ febrile 102.7, fever workup, NGTD, no CXR. NGT out, regular diet ___ biliary leak, migrated drain. Choleangiogram. ___ OR. EBL 400cc IOP 3.5L. JP x1. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild maximum 6 of the 500 mg tablets daily 2. Docusate Sodium 100 mg PO BID may purchase over the counter. 3. TraMADol 50 mg PO Q6H:PRN Pain - Moderate RX tramadol 50 mg 1 tablet(s) by mouth Every 6 hours as needed Disp #20 Tablet Refills:*0 4. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Type 4a choledochal cyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr. ___ office at ___ for fever > 101, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, pain not controlled by your pain medication, swelling of the abdomen or ankles, worsening yellowing of the skin or eyes, itching, inability to tolerate food, fluids or medications, or any other concerning symptoms. . No lifting more than 10 pounds . No driving if taking narcotic pain medication . You may walk and climb stairs. No lifting more than 10 pounds for 6 weeks following surgery to avoid hernia formation. . You may shower, allow the water to run over the incision and pat dry. No lotions or powder to the incision until fully healed. No tub baths or swimming for a full 6 weeks following surgery to allow for full healing of the incision. . Do not expose the incision scar to direct sunlight as this can cause painful sunburn to tender new tissue and possibly make the scar not heal as well. Followup Instructions: ___	[ "Q444", "T85628A", "Z5331", "R5082", "D72829", "Y848" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Type 4 Choledochal cyst Major Surgical or Invasive Procedure: [MASKED]: Robot-assisted excision of choledochal cyst, Open conversion for Roux-en-Y hepaticojejunostomy to extrahepatic common hepatic duct. . [MASKED]: PTBD replacement for drain migration . [MASKED]: Gravity cholangiogram History of Present Illness: [MASKED] woman with recently diagnosed type 4A choledochal cyst treated with percutaneous decompression. She now presents for definitive excision. Of note, two co-surgeons were required due to the complex nature of this case. Past Medical History: No PMH or surgical history Social History: [MASKED] Family History: No family history of GI cancers Physical Exam: Discharge Physical: Temp: 98.4 (Tm 99.2), BP: 109/65 (97-109/65-72), HR: 73 (63-78), RR: 18 ([MASKED]), O2 sat: 100% (99-100), O2 delivery: RA, Wt: 99.8 lb/45.27 kg . GEN: NAD, AOx3, comfortable HEENT: AT/NC, PERRL, no scleral icterus CV: RRR R: On RA, no respiratory distress GI: Soft, appropriately tender, laparoscopic incisions with dermabond, JP drain with serosanguinous output; PTBD capped following cholangiogram. Both drains removed prior to discharge. EXT: warm and well perfused NEURO: Grossly intact sensory and motor function Pertinent Results: Labs post op: [MASKED] WBC-9.5 RBC-2.75* Hgb-8.9* Hct-26.3* MCV-96 MCH-32.4* MCHC-33.8 RDW-12.5 RDWSD-44.0 Plt [MASKED] PTT-28.6 [MASKED] Glucose-143* UreaN-8 Creat-0.6 Na-142 K-4.3 Cl-104 HCO3-24 AnGap-14 ALT-112* AST-111* AlkPhos-185* TotBili-3.6* Calcium-8.8 Phos-4.9* Mg-1.9 . Labs at Discharge: [MASKED] WBC-12.3* RBC-3.17* Hgb-9.9* Hct-29.7* MCV-94 MCH-31.2 MCHC-33.3 RDW-12.4 RDWSD-42.6 Plt [MASKED] PTT-30.6 [MASKED] Glucose-101* UreaN-5* Creat-0.5 Na-140 K-4.7 Cl-104 HCO3-24 AnGap-12 ALT-21 AST-19 AlkPhos-257* TotBili-1.0 Calcium-8.5 Phos-3.0 Mg-2.[MASKED] y/o female with history of Type 4 choledochal cyst with recent placement of PTBD in preparation for surgery who is now taken to the OR with Dr. [MASKED] and Dr. [MASKED], for Robot-assisted excision of choledochal cyst, Open conversion for Roux-en-Y hepaticojejunostomy to extrahepatic common hepatic duct. . The cyst was large but able to be removed. Please see the operative report for surgical detail. There were no complications reported and the patient was extubated and transferred to PACU in stable condition. . On POD 1, the pre-existing PTBD that had been left in place at time of surgery had moved with drainage around drain. A Cholangiogram showed side holes had migrated out, so the drain was replaced and left open to gravity. . Following NG removal, her diet was advanced slowly, and well tolerated by time of discharge. When catheter was removed, she voided without difficulty. . On POD 6 a gravity cholangiogram was performed which showed no leak. The PTBD was capped, and then removed the following day when the LFTs remained stable and all WNL except the alk phos. The JP drain was removed later the same day and she was discharged to home having completed a week of post op antibiotics. The incision was clean dry and intact, drain sites were dry after drain removal. . The only home medication is a multivitamin which she can resume at home. A follow up appointment has been scheduled and she should have labwork on that day. . Please note patient is not taking narcotic pain medication due to issues with nausea previously. Will use Tylenol for pain management and was given a script for tramadol if she wishes to have more than Tylenol for pain management successful gravity choleangiogram [MASKED] febrile 102.7, fever workup, NGTD, no CXR. NGT out, regular diet [MASKED] biliary leak, migrated drain. Choleangiogram. [MASKED] OR. EBL 400cc IOP 3.5L. JP x1. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild maximum 6 of the 500 mg tablets daily 2. Docusate Sodium 100 mg PO BID may purchase over the counter. 3. TraMADol 50 mg PO Q6H:PRN Pain - Moderate RX tramadol 50 mg 1 tablet(s) by mouth Every 6 hours as needed Disp #20 Tablet Refills:*0 4. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Type 4a choledochal cyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr. [MASKED] office at [MASKED] for fever > 101, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, pain not controlled by your pain medication, swelling of the abdomen or ankles, worsening yellowing of the skin or eyes, itching, inability to tolerate food, fluids or medications, or any other concerning symptoms. . No lifting more than 10 pounds . No driving if taking narcotic pain medication . You may walk and climb stairs. No lifting more than 10 pounds for 6 weeks following surgery to avoid hernia formation. . You may shower, allow the water to run over the incision and pat dry. No lotions or powder to the incision until fully healed. No tub baths or swimming for a full 6 weeks following surgery to allow for full healing of the incision. . Do not expose the incision scar to direct sunlight as this can cause painful sunburn to tender new tissue and possibly make the scar not heal as well. Followup Instructions: [MASKED]	[]	[]	[ "Q444: Choledochal cyst", "T85628A: Displacement of other specified internal prosthetic devices, implants and grafts, initial encounter", "Z5331: Laparoscopic surgical procedure converted to open procedure", "R5082: Postprocedural fever", "D72829: Elevated white blood cell count, unspecified", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure" ]
10,092,911	23,715,692	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ___ Major Surgical or Invasive Procedure: ERCP ___ History of Present Illness: HPI: Ms. ___ is a previously healthy ___ yo woman who presents with RUQ cyst and CBD dilation. The patient presented to her PCP ___ few weeks ago with abdominal pain. CT scan showed a massive distention of the intrahepatic biliary system and a large unilocular cystic mass in the right upper quadrant that measures 17 x 19 cm and is most likely a large cyst obstructing the common bile duct. The cystic mass may represent a choledochal cyst or a GI duplication cyst. The pancreatic duct did not appear to be dilated. The patient liver function tests where elevated with an ALT of 225, AST of 108, alkaline phosphatase of 147, and a total bilirubin of 8.4 with a direct bilirubin of 4.9. She has been having a "sensitive stomach" that has worsened over the last 3 weeks, described as bloating and discomfort with some constipation. The patient also added that she cannot eat a large amount. She has also been experiencing dark urine with lighter stool and was told by friends that she has yellowish eyes and face. Also in the last few weeks she experienced abdominal swelling and tenderness on palpation in the right upper quadrant. She underwent ERCP today, but the team was unable to reach the CBD or PD. Periprocedurally her SBPs were ~100. Upon arrival to the floor they were ~80. She was not tachycardic or febrile and had no symptoms with this other than feeling hungry and thirsty. She notes a history of low blood pressures and was once sent to the ED for SBPs in the ___. No pathology was found. On presentation to the floor her blood glucose was 66. She received an amp of d50 and a 1 L bolus of LR. ROS: A 10-point review of systems was obtained and was otherwise negative except as per HPI. Past Medical History: No PMH or surgical history Social History: ___ Family History: No family history of GI cancers Physical Exam: ADMISSION VITALS: SBPs in the ___ on the floor. At discharge 83/51-110/65 Afebrile GENERAL: Alert and in no apparent distress EYES: icteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. CV: Heart regular, no murmur, loud S2 RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-tender to palpation. Bowel sounds present MSK: Neck supple, moves all extremities SKIN: Jaundice NEURO: Alert, oriented, face symmetric PSYCH: pleasant, appropriate affect . Weight at discharge 47.0 kg Pertinent Results: ADMISSION Lab: ___ WBC-5.1 RBC-4.02 Hgb-12.9 Hct-39.4 MCV-98 MCH-32.1* MCHC-32.7 RDW-13.0 RDWSD-46.5* Plt ___ UreaN-7 Creat-0.7 Na-143 K-4.2 Cl-105 HCO3-29 AnGap-9* ALT-204* AST-89* AlkPhos-142* Amylase-121* TotBili-9.1* . Labs at Discharge: ___ WBC-6.8 RBC-3.70* Hgb-11.8 Hct-35.7 MCV-97 MCH-31.9 MCHC-33.1 RDW-12.9 RDWSD-45.9 Plt ___ PTT-32.0 ___ Glucose-83 UreaN-6 Creat-0.6 Na-140 K-4.2 Cl-103 HCO3-24 AnGap-13 ALT-77* AST-40 AlkPhos-119* TotBili-6.0* Calcium-8.3* Phos-3.3 Mg-2.0 Brief Hospital Course: This is a ___ year old female with 3 weeks of abdominal pressure and early satiety, found to have hyperbilirubinemia, biliary obstruction, and choledochal cyst, now status post failed ERCP, transferred to Transplant Surgery / ___ service # Biliary obstruction Patient present with progressive jaundice, and was found to have LFTs concerning for obstructive process. Outpatient imaging showed choledochocyst (as below), however obstruction from this process would be unusual. Advanced endoscopy attempted ERCP unsuccessfully. Patient was seen by ___ transplant surgery and service. Patient was transferred to ___ for PTBD and surgical planning. On ___ the patient underwent successful placement of the right ___ external biliary drain. At the time of the study, there was relatively normal appearing peripheral right duct accessed leading to large amount of intrahepatic biliary dilatation. There was extreme dilatation of the common bile duct. An External only catheter was placed within the common bile duct for decompression. At that time, over 1 L of bilious fluid was drained/decompressed from the biliary system. Given the extreme CBD dilatation, no attempt to internalized drain at the time of the original PTBD attempt. There was no contrast noted to pass into the bowel. Additionally a needle cholangiogram from the left biliary system demonstrated moderate to severe intrahepatic biliary dilatation with communication to the extremely dilated CBD. No separate drain placed given communication of the systems. Over the next two days, the drain was left to gravity drainage, and the bilirubin was decreasing each day. An ultrasound was done on ___, and after review by the interventional radiology team, they decided that there was no indication now to attempt internalization. ___ will be in contact with the patient to determine a time to attempt the internalization. As well the patient is scheduled in the outpatient clinic with Dr. ___ surgical planning. . Patient is tolerating a diet, and has been encouraged to drink extra fluids. The drain has been left open to gravity for now. She is ambulatory, and has declined narcotics for pain management. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY 2. Vitamin D 800 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 325 mg PO Q4H:PRN Pain - Mild Maximum 6 of the 325 mg tablets daily 2. Docusate Sodium 100 mg PO BID 3. Multivitamins 1 TAB PO DAILY 4. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Choledochal cyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr. ___ office at ___ for fever > 101, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, pain not controlled by your pain medication, swelling of the abdomen or ankles, yellowing of the skin or eyes, inability to tolerate food, fluids or medications,the drain site has redness, drainage or bleeding, or any other concerning symptoms. . No lifting more than 10 pounds . No driving if taking narcotic pain medication. . Empty and record the bile bag drain output as needed so that the drain is never more than ½ full. Call the office if the drain output increases by more than 200 cc from the previous day, turns becomes bloody or develops a foul odor. You may shower. Change the drain dressing once daily or after your shower. Do not allow the drain to hang freely at any time. Inspect the site for redness, drainage or bleeding. Make sure there is a stitch at the drain site. Followup Instructions: ___	[ "K831", "Q444", "I959" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: [MASKED] Major Surgical or Invasive Procedure: ERCP [MASKED] History of Present Illness: HPI: Ms. [MASKED] is a previously healthy [MASKED] yo woman who presents with RUQ cyst and CBD dilation. The patient presented to her PCP [MASKED] few weeks ago with abdominal pain. CT scan showed a massive distention of the intrahepatic biliary system and a large unilocular cystic mass in the right upper quadrant that measures 17 x 19 cm and is most likely a large cyst obstructing the common bile duct. The cystic mass may represent a choledochal cyst or a GI duplication cyst. The pancreatic duct did not appear to be dilated. The patient liver function tests where elevated with an ALT of 225, AST of 108, alkaline phosphatase of 147, and a total bilirubin of 8.4 with a direct bilirubin of 4.9. She has been having a "sensitive stomach" that has worsened over the last 3 weeks, described as bloating and discomfort with some constipation. The patient also added that she cannot eat a large amount. She has also been experiencing dark urine with lighter stool and was told by friends that she has yellowish eyes and face. Also in the last few weeks she experienced abdominal swelling and tenderness on palpation in the right upper quadrant. She underwent ERCP today, but the team was unable to reach the CBD or PD. Periprocedurally her SBPs were ~100. Upon arrival to the floor they were ~80. She was not tachycardic or febrile and had no symptoms with this other than feeling hungry and thirsty. She notes a history of low blood pressures and was once sent to the ED for SBPs in the [MASKED]. No pathology was found. On presentation to the floor her blood glucose was 66. She received an amp of d50 and a 1 L bolus of LR. ROS: A 10-point review of systems was obtained and was otherwise negative except as per HPI. Past Medical History: No PMH or surgical history Social History: [MASKED] Family History: No family history of GI cancers Physical Exam: ADMISSION VITALS: SBPs in the [MASKED] on the floor. At discharge 83/51-110/65 Afebrile GENERAL: Alert and in no apparent distress EYES: icteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. CV: Heart regular, no murmur, loud S2 RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-tender to palpation. Bowel sounds present MSK: Neck supple, moves all extremities SKIN: Jaundice NEURO: Alert, oriented, face symmetric PSYCH: pleasant, appropriate affect . Weight at discharge 47.0 kg Pertinent Results: ADMISSION Lab: [MASKED] WBC-5.1 RBC-4.02 Hgb-12.9 Hct-39.4 MCV-98 MCH-32.1* MCHC-32.7 RDW-13.0 RDWSD-46.5* Plt [MASKED] UreaN-7 Creat-0.7 Na-143 K-4.2 Cl-105 HCO3-29 AnGap-9* ALT-204* AST-89* AlkPhos-142* Amylase-121* TotBili-9.1* . Labs at Discharge: [MASKED] WBC-6.8 RBC-3.70* Hgb-11.8 Hct-35.7 MCV-97 MCH-31.9 MCHC-33.1 RDW-12.9 RDWSD-45.9 Plt [MASKED] PTT-32.0 [MASKED] Glucose-83 UreaN-6 Creat-0.6 Na-140 K-4.2 Cl-103 HCO3-24 AnGap-13 ALT-77* AST-40 AlkPhos-119* TotBili-6.0* Calcium-8.3* Phos-3.3 Mg-2.0 Brief Hospital Course: This is a [MASKED] year old female with 3 weeks of abdominal pressure and early satiety, found to have hyperbilirubinemia, biliary obstruction, and choledochal cyst, now status post failed ERCP, transferred to Transplant Surgery / [MASKED] service # Biliary obstruction Patient present with progressive jaundice, and was found to have LFTs concerning for obstructive process. Outpatient imaging showed choledochocyst (as below), however obstruction from this process would be unusual. Advanced endoscopy attempted ERCP unsuccessfully. Patient was seen by [MASKED] transplant surgery and service. Patient was transferred to [MASKED] for PTBD and surgical planning. On [MASKED] the patient underwent successful placement of the right [MASKED] external biliary drain. At the time of the study, there was relatively normal appearing peripheral right duct accessed leading to large amount of intrahepatic biliary dilatation. There was extreme dilatation of the common bile duct. An External only catheter was placed within the common bile duct for decompression. At that time, over 1 L of bilious fluid was drained/decompressed from the biliary system. Given the extreme CBD dilatation, no attempt to internalized drain at the time of the original PTBD attempt. There was no contrast noted to pass into the bowel. Additionally a needle cholangiogram from the left biliary system demonstrated moderate to severe intrahepatic biliary dilatation with communication to the extremely dilated CBD. No separate drain placed given communication of the systems. Over the next two days, the drain was left to gravity drainage, and the bilirubin was decreasing each day. An ultrasound was done on [MASKED], and after review by the interventional radiology team, they decided that there was no indication now to attempt internalization. [MASKED] will be in contact with the patient to determine a time to attempt the internalization. As well the patient is scheduled in the outpatient clinic with Dr. [MASKED] surgical planning. . Patient is tolerating a diet, and has been encouraged to drink extra fluids. The drain has been left open to gravity for now. She is ambulatory, and has declined narcotics for pain management. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY 2. Vitamin D 800 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 325 mg PO Q4H:PRN Pain - Mild Maximum 6 of the 325 mg tablets daily 2. Docusate Sodium 100 mg PO BID 3. Multivitamins 1 TAB PO DAILY 4. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Choledochal cyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr. [MASKED] office at [MASKED] for fever > 101, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, pain not controlled by your pain medication, swelling of the abdomen or ankles, yellowing of the skin or eyes, inability to tolerate food, fluids or medications,the drain site has redness, drainage or bleeding, or any other concerning symptoms. . No lifting more than 10 pounds . No driving if taking narcotic pain medication. . Empty and record the bile bag drain output as needed so that the drain is never more than ½ full. Call the office if the drain output increases by more than 200 cc from the previous day, turns becomes bloody or develops a foul odor. You may shower. Change the drain dressing once daily or after your shower. Do not allow the drain to hang freely at any time. Inspect the site for redness, drainage or bleeding. Make sure there is a stitch at the drain site. Followup Instructions: [MASKED]	[]	[]	[ "K831: Obstruction of bile duct", "Q444: Choledochal cyst", "I959: Hypotension, unspecified" ]
10,093,120	21,033,575	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: seasonal / candle fragrances and heavy perfumes / lidocaine Attending: ___. Chief Complaint: nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a pleasant ___ years old Female who presents to ___ ED for the further evaluation of nausea, vomiting, abdominal pain for the past two days associated with poor PO intake. Pt states she was in her usual state of health until 2 to 3 days ago when these symptoms started that have gradually been worsening. She endorses NBNB vomiting each time she attempts PO intake. Abdominal pain is described as crampy, although can be sharp at times, currently a ___ at time of exam, and improved by sitting upright. Last BM noted to be yesterday (___) morning. Denies passing any gas today. No recent fevers, chills, diarrhea, UTI sxs, recent prolonged traveling, or known exposure to sick contacts. She called her oncologist's office who advised her come to the ED for further evaluation. In the ED, initial vitals: 97.3 92 119/74 16 94% RA REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: Health Maintenance: - ___: BIRADS-2 benign ___ - Colonoscopy: none, FOBT negative this year - Pap smear: wnl ___ PMH: denies hypertension, diabetes, heart disease, or clotting disorder PSH: eye surgery, tonsillectomy OBHx: G0 GYNHx: - LMP ___ years ago, denies postmenopausal bleeding - h/o fibroid 5cm on ultrasound in ___ - not sexually active - denies history of abnormal Pap smears, last in ___ Social History: ___ Family History: Father: ___ Mom: osteoporosis Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: ___ 0004 Temp: 97.4 PO BP: 129/84 HR: 90 RR: 18 O2 sat: 97% O2 delivery: RA Gen: NAD, frail elderly woman, cachectic appearing w/ temporal wasting HEENT: PERRL, sclera anicteric, oropharynx with moist mucus membranes, no thrush RESP: CTAB CV: regular rate and rhythm, no murmurs Lungs: diminished breath sounds at bases ABD: soft, prior well healed surgical scar w/o induration; no bowel sounds; diffusely tender to deep palpation focal to LUQ without rigidity or guarding EXT: strength intact; no edema noted SKIN: intact NEURO: AOx3 ACCESS: R POC DISCHARGE PHYSICAL EXAM: ======================== Vitals: 24 HR Data (last updated ___ @ 2349) Temp: 98.0 (Tm 98.0), BP: 131/83 (114-131/79-83), HR: 82 (82-99), RR: 18, O2 sat: 95% (95-96), O2 delivery: Ra Gen: NAD, frail elderly woman, cachectic appearing w/ temporal wasting HEENT: PERRL, sclera anicteric, oropharynx with moist mucus membranes, no thrush RESP: CTAB CV: regular rate and rhythm, no murmurs Lungs: diminished breath sounds at bases ABD: soft, prior well healed surgical scar w/o induration; no bowel sounds; diffusely tender to deep palpation focal to LUQ without rigidity or guarding EXT: strength intact; no edema noted NEURO: AOx3 ACCESS: R Port Pertinent Results: ADMISSION LABS ============== ___ 01:02PM BLOOD WBC-10.2* RBC-4.70 Hgb-12.8 Hct-41.1 MCV-87 MCH-27.2 MCHC-31.1* RDW-16.7* RDWSD-52.7* Plt ___ ___ 01:02PM BLOOD Glucose-101* UreaN-13 Creat-0.4 Na-141 K-4.1 Cl-97 HCO3-23 AnGap-21* ___ 01:02PM BLOOD ALT-<5 AST-14 AlkPhos-90 TotBili-0.3 ___ 01:02PM BLOOD Albumin-3.9 Calcium-9.7 Phos-3.7 Mg-1.9 ___ 01:07PM BLOOD Lactate-1.8 DISCHARGE LABS =============== ___ 05:51AM BLOOD WBC-4.3 RBC-3.80* Hgb-10.1* Hct-32.9* MCV-87 MCH-26.6 MCHC-30.7* RDW-16.5* RDWSD-51.8* Plt ___ ___ 10:55AM BLOOD ___ ___ 05:56AM BLOOD Glucose-94 UreaN-2* Creat-0.3* Na-142 K-3.9 Cl-105 HCO3-27 AnGap-10 ___ 05:56AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.6 IMAGING ======= ___ CT ABD PELVIS W CONTRAST 1. Small-bowel obstruction with likely transition point in the lower pelvis. No definite mass or specific etiology identified. 2. Interval increase in small to moderate volume ascites. Peripheral thickening/rim enhancement of the ascites, slightly increased in conspicuity, may be related to the ___ malignancy although infectious peritonitis cannot be excluded. 3. Thickening of few small loops of small bowel. Unclear if this is related to infection or ___ underlying malignancy. Ischemia cannot be excluded. 4. Partially occlusive thrombus extending from the right common iliac vein to the visualize right femoral vein, increased in conspicuity compared to prior. 5. Interval increase in small to moderate nonhemorrhagic left pleural effusion which is likely loculated. 6. Interval decrease in small nonhemorrhagic right pleural effusion. MICROBIOLOGY ============= ___ 1:45 pm URINE CLEAN CATCH. *FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Brief Hospital Course: TRANSITION ISSUES: ================== [ ___ DVT was treated with heparin drip. She was transitioned to lovenox 50mg BID, which she will continue upon discharge. She will pick up a 12-day supply on discharge due to cost. She will need a new prescription during her next follow-up appointment. [ ___ pleurex drainage schedule changed to 2x per week (___) from 3x per week, after discussion with Dr. ___. [ ___ Mg was 1.6 on the morning of discharge and was repleted. Please recheck a chem10 at next follow-up appointment. [ ]Ensure patient continues standing bowel regimen at home SUMMARY: ======== ___ PMH of stage IIIB (pT3bN0) ovarian carcinoma (low grade serous & endometrioid; ER-) and stage II (pT2N0) endometrioid endometrial adenocarcinoma, grade 1 (Genetics: CHEK2, VUS BRCA2 on 47 Gene) who presents for eval of nausea, vomiting, abd pain x2days a/w poor PO intake, found to have SBO and DVT on imaging. ACTIVE/ACUTE ISSUES: ==================== # SBO Patient was aferile and stable on admission. She has a history of SBO, most recently in ___ and was managed conservatively at that time. SBO likely ___ known metastatic disease and CT AP found SBO with likely transition point in lower pelvis, no definite mass. She was made NPO and received fluids; she did not require NGT placement. She received Ativan and Reglan for nausea. She was able to pass gas and advance her diet to solids without pain or nausea. She had not yet had a bowel movement on day of discharge, but opted to leave the hospital with plan to continue taking standing bowel regimen at home. # DVT CT A/P had incidental finding of partial occlusive thrombus extending from R common iliac to R femoral. She was started on a heparin drip and was transitioned to lovenox 50mg BID, which she will continue upon discharge. Due to insurance issues, she was discharged with 12d supply and e-mail was sent to outpatient oncologist Dr. ___ to ensure she continues to receive lovenox. # Ovarian cancer, platinum refractory The patient has stage IIIb ovarian carcinoma and stage II endometrioid endometrial adenocarcinoma s/p 6 cycles of adjuvant chemotherapy with ___ (c/b neuropathy) with refractory disease and a malignant pleural effusion s/p 5 cycles of ___. Recently, she is s/p C2D1 Topotecan on ___. Dr ___ primary oncologist, was updated by email. CHRONIC/STABLE ISSUES: ====================== # Malignant Pleural Effusion Patient has a pleurex catheter. Initially, it was drained per her home schedule, 3x per week (MWF). After discussion with Dr. ___ Interventional ___, her schedule was changed to 2x weekly (___) given low volume output (70-80cc) during drainage. # GERD - Continued home Famotidine PO qAM and pantoprazole 20mg PO qHS # Neuropathy - Continued home B12 supplementation monthly injections Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cyanocobalamin 1000 mcg IM/SC EVERY 4 WEEKS (FR) 2. LORazepam 0.5 mg PO Q8H:PRN nausea and vomiting 3. Pantoprazole 20 mg PO QHS 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 5. Calcium Carbonate 500 mg PO DAILY 6. Famotidine 20 mg PO DAILY 7. Loratadine 10 mg PO DAILY:PRN allergy 8. ___ ___ mg oral DAILY Discharge Medications: 1. Enoxaparin Sodium 50 mg SC Q12H RX enoxaparin 60 mg/0.6 mL 50 mg SC twice a day Disp #24 Syringe Refills:0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 3. Calcium Carbonate 500 mg PO DAILY 4. Cyanocobalamin 1000 mcg IM/SC EVERY 4 WEEKS (FR) 5. Famotidine 20 mg PO DAILY 6. Loratadine 10 mg PO DAILY:PRN allergy 7. LORazepam 0.5 mg PO Q8H:PRN nausea and vomiting 8. Pantoprazole 20 mg PO QHS 9. ___ ___ mg oral DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnoses: small bowel obstruction, deep vein thrombosis, ovarian carcinoma, endometrioid endometrial adenocarcinoma Secondary diagnoses: osteoarthritis, gastroesophageal reflux, peripheral neuropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You came to the hospital because you had nausea and vomiting, and were unable to keep any food or liquids down. - The CT scan showed that you had a small bowel obstruction. - The CT scan also showed that you had a blood clot in your leg. WHAT HAPPENED IN THE HOSPITAL? ============================== - You received fluids to keep you hydrated and medications to help with your nausea. - Your diet was slowly advanced until you were able to eat regularly. - You received medications to treat your blood clot. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Please continue to take all of your medications as directed. It is extremely important that you continue taking your blood thinner (lovenox) twice daily EVERY DAY. This medication will prevent you from forming additional blood clots. If you stop taking this medication, you could develop more blood clots, which could travel to your lungs and cause you to have SERIOUS problems with your breathing. If you have any difficulty filling your lovenox prescription, you should call your doctor immediately! - Please follow up with all the appointments scheduled with your doctor. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___	[ "C786", "E43", "C784", "J910", "I82421", "C561", "C562", "Z681", "C541", "K219", "I10", "M1610", "E538", "Z171", "G620", "T451X5S", "Z23" ]	Allergies: seasonal / candle fragrances and heavy perfumes / lidocaine Chief Complaint: nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] is a pleasant [MASKED] years old Female who presents to [MASKED] ED for the further evaluation of nausea, vomiting, abdominal pain for the past two days associated with poor PO intake. Pt states she was in her usual state of health until 2 to 3 days ago when these symptoms started that have gradually been worsening. She endorses NBNB vomiting each time she attempts PO intake. Abdominal pain is described as crampy, although can be sharp at times, currently a [MASKED] at time of exam, and improved by sitting upright. Last BM noted to be yesterday ([MASKED]) morning. Denies passing any gas today. No recent fevers, chills, diarrhea, UTI sxs, recent prolonged traveling, or known exposure to sick contacts. She called her oncologist's office who advised her come to the ED for further evaluation. In the ED, initial vitals: 97.3 92 119/74 16 94% RA REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: Health Maintenance: - [MASKED]: BIRADS-2 benign [MASKED] - Colonoscopy: none, FOBT negative this year - Pap smear: wnl [MASKED] PMH: denies hypertension, diabetes, heart disease, or clotting disorder PSH: eye surgery, tonsillectomy OBHx: G0 GYNHx: - LMP [MASKED] years ago, denies postmenopausal bleeding - h/o fibroid 5cm on ultrasound in [MASKED] - not sexually active - denies history of abnormal Pap smears, last in [MASKED] Social History: [MASKED] Family History: Father: [MASKED] Mom: osteoporosis Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: [MASKED] 0004 Temp: 97.4 PO BP: 129/84 HR: 90 RR: 18 O2 sat: 97% O2 delivery: RA Gen: NAD, frail elderly woman, cachectic appearing w/ temporal wasting HEENT: PERRL, sclera anicteric, oropharynx with moist mucus membranes, no thrush RESP: CTAB CV: regular rate and rhythm, no murmurs Lungs: diminished breath sounds at bases ABD: soft, prior well healed surgical scar w/o induration; no bowel sounds; diffusely tender to deep palpation focal to LUQ without rigidity or guarding EXT: strength intact; no edema noted SKIN: intact NEURO: AOx3 ACCESS: R POC DISCHARGE PHYSICAL EXAM: ======================== Vitals: 24 HR Data (last updated [MASKED] @ 2349) Temp: 98.0 (Tm 98.0), BP: 131/83 (114-131/79-83), HR: 82 (82-99), RR: 18, O2 sat: 95% (95-96), O2 delivery: Ra Gen: NAD, frail elderly woman, cachectic appearing w/ temporal wasting HEENT: PERRL, sclera anicteric, oropharynx with moist mucus membranes, no thrush RESP: CTAB CV: regular rate and rhythm, no murmurs Lungs: diminished breath sounds at bases ABD: soft, prior well healed surgical scar w/o induration; no bowel sounds; diffusely tender to deep palpation focal to LUQ without rigidity or guarding EXT: strength intact; no edema noted NEURO: AOx3 ACCESS: R Port Pertinent Results: ADMISSION LABS ============== [MASKED] 01:02PM BLOOD WBC-10.2* RBC-4.70 Hgb-12.8 Hct-41.1 MCV-87 MCH-27.2 MCHC-31.1* RDW-16.7* RDWSD-52.7* Plt [MASKED] [MASKED] 01:02PM BLOOD Glucose-101* UreaN-13 Creat-0.4 Na-141 K-4.1 Cl-97 HCO3-23 AnGap-21* [MASKED] 01:02PM BLOOD ALT-<5 AST-14 AlkPhos-90 TotBili-0.3 [MASKED] 01:02PM BLOOD Albumin-3.9 Calcium-9.7 Phos-3.7 Mg-1.9 [MASKED] 01:07PM BLOOD Lactate-1.8 DISCHARGE LABS =============== [MASKED] 05:51AM BLOOD WBC-4.3 RBC-3.80* Hgb-10.1* Hct-32.9* MCV-87 MCH-26.6 MCHC-30.7* RDW-16.5* RDWSD-51.8* Plt [MASKED] [MASKED] 10:55AM BLOOD [MASKED] [MASKED] 05:56AM BLOOD Glucose-94 UreaN-2* Creat-0.3* Na-142 K-3.9 Cl-105 HCO3-27 AnGap-10 [MASKED] 05:56AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.6 IMAGING ======= [MASKED] CT ABD PELVIS W CONTRAST 1. Small-bowel obstruction with likely transition point in the lower pelvis. No definite mass or specific etiology identified. 2. Interval increase in small to moderate volume ascites. Peripheral thickening/rim enhancement of the ascites, slightly increased in conspicuity, may be related to the [MASKED] malignancy although infectious peritonitis cannot be excluded. 3. Thickening of few small loops of small bowel. Unclear if this is related to infection or [MASKED] underlying malignancy. Ischemia cannot be excluded. 4. Partially occlusive thrombus extending from the right common iliac vein to the visualize right femoral vein, increased in conspicuity compared to prior. 5. Interval increase in small to moderate nonhemorrhagic left pleural effusion which is likely loculated. 6. Interval decrease in small nonhemorrhagic right pleural effusion. MICROBIOLOGY ============= [MASKED] 1:45 pm URINE CLEAN CATCH. *FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Brief Hospital Course: TRANSITION ISSUES: ================== [ [MASKED] DVT was treated with heparin drip. She was transitioned to lovenox 50mg BID, which she will continue upon discharge. She will pick up a 12-day supply on discharge due to cost. She will need a new prescription during her next follow-up appointment. [ [MASKED] pleurex drainage schedule changed to 2x per week ([MASKED]) from 3x per week, after discussion with Dr. [MASKED]. [ [MASKED] Mg was 1.6 on the morning of discharge and was repleted. Please recheck a chem10 at next follow-up appointment. [ ]Ensure patient continues standing bowel regimen at home SUMMARY: ======== [MASKED] PMH of stage IIIB (pT3bN0) ovarian carcinoma (low grade serous & endometrioid; ER-) and stage II (pT2N0) endometrioid endometrial adenocarcinoma, grade 1 (Genetics: CHEK2, VUS BRCA2 on 47 Gene) who presents for eval of nausea, vomiting, abd pain x2days a/w poor PO intake, found to have SBO and DVT on imaging. ACTIVE/ACUTE ISSUES: ==================== # SBO Patient was aferile and stable on admission. She has a history of SBO, most recently in [MASKED] and was managed conservatively at that time. SBO likely [MASKED] known metastatic disease and CT AP found SBO with likely transition point in lower pelvis, no definite mass. She was made NPO and received fluids; she did not require NGT placement. She received Ativan and Reglan for nausea. She was able to pass gas and advance her diet to solids without pain or nausea. She had not yet had a bowel movement on day of discharge, but opted to leave the hospital with plan to continue taking standing bowel regimen at home. # DVT CT A/P had incidental finding of partial occlusive thrombus extending from R common iliac to R femoral. She was started on a heparin drip and was transitioned to lovenox 50mg BID, which she will continue upon discharge. Due to insurance issues, she was discharged with 12d supply and e-mail was sent to outpatient oncologist Dr. [MASKED] to ensure she continues to receive lovenox. # Ovarian cancer, platinum refractory The patient has stage IIIb ovarian carcinoma and stage II endometrioid endometrial adenocarcinoma s/p 6 cycles of adjuvant chemotherapy with [MASKED] (c/b neuropathy) with refractory disease and a malignant pleural effusion s/p 5 cycles of [MASKED]. Recently, she is s/p C2D1 Topotecan on [MASKED]. Dr [MASKED] primary oncologist, was updated by email. CHRONIC/STABLE ISSUES: ====================== # Malignant Pleural Effusion Patient has a pleurex catheter. Initially, it was drained per her home schedule, 3x per week (MWF). After discussion with Dr. [MASKED] Interventional [MASKED], her schedule was changed to 2x weekly ([MASKED]) given low volume output (70-80cc) during drainage. # GERD - Continued home Famotidine PO qAM and pantoprazole 20mg PO qHS # Neuropathy - Continued home B12 supplementation monthly injections Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cyanocobalamin 1000 mcg IM/SC EVERY 4 WEEKS (FR) 2. LORazepam 0.5 mg PO Q8H:PRN nausea and vomiting 3. Pantoprazole 20 mg PO QHS 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 5. Calcium Carbonate 500 mg PO DAILY 6. Famotidine 20 mg PO DAILY 7. Loratadine 10 mg PO DAILY:PRN allergy 8. [MASKED] [MASKED] mg oral DAILY Discharge Medications: 1. Enoxaparin Sodium 50 mg SC Q12H RX enoxaparin 60 mg/0.6 mL 50 mg SC twice a day Disp #24 Syringe Refills:0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 3. Calcium Carbonate 500 mg PO DAILY 4. Cyanocobalamin 1000 mcg IM/SC EVERY 4 WEEKS (FR) 5. Famotidine 20 mg PO DAILY 6. Loratadine 10 mg PO DAILY:PRN allergy 7. LORazepam 0.5 mg PO Q8H:PRN nausea and vomiting 8. Pantoprazole 20 mg PO QHS 9. [MASKED] [MASKED] mg oral DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary diagnoses: small bowel obstruction, deep vein thrombosis, ovarian carcinoma, endometrioid endometrial adenocarcinoma Secondary diagnoses: osteoarthritis, gastroesophageal reflux, peripheral neuropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]! WHY WAS I IN THE HOSPITAL? ========================== - You came to the hospital because you had nausea and vomiting, and were unable to keep any food or liquids down. - The CT scan showed that you had a small bowel obstruction. - The CT scan also showed that you had a blood clot in your leg. WHAT HAPPENED IN THE HOSPITAL? ============================== - You received fluids to keep you hydrated and medications to help with your nausea. - Your diet was slowly advanced until you were able to eat regularly. - You received medications to treat your blood clot. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Please continue to take all of your medications as directed. It is extremely important that you continue taking your blood thinner (lovenox) twice daily EVERY DAY. This medication will prevent you from forming additional blood clots. If you stop taking this medication, you could develop more blood clots, which could travel to your lungs and cause you to have SERIOUS problems with your breathing. If you have any difficulty filling your lovenox prescription, you should call your doctor immediately! - Please follow up with all the appointments scheduled with your doctor. Thank you for allowing us to be involved in your care, we wish you all the best! Your [MASKED] Healthcare Team Followup Instructions: [MASKED]	[]	[ "K219", "I10" ]	[ "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "E43: Unspecified severe protein-calorie malnutrition", "C784: Secondary malignant neoplasm of small intestine", "J910: Malignant pleural effusion", "I82421: Acute embolism and thrombosis of right iliac vein", "C561: Malignant neoplasm of right ovary", "C562: Malignant neoplasm of left ovary", "Z681: Body mass index [BMI] 19.9 or less, adult", "C541: Malignant neoplasm of endometrium", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "M1610: Unilateral primary osteoarthritis, unspecified hip", "E538: Deficiency of other specified B group vitamins", "Z171: Estrogen receptor negative status [ER-]", "G620: Drug-induced polyneuropathy", "T451X5S: Adverse effect of antineoplastic and immunosuppressive drugs, sequela", "Z23: Encounter for immunization" ]
10,093,120	22,404,925	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: seasonal / frangrance / lidocaine Attending: ___. Chief Complaint: nausea and vomiting Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ year old gravida 0 with history of stage IIIB platinum refractory low grade serous and endometrioid ovarian carcinoma and stage II grade I endometrioid endometrial adenocarcinoma status post diagnostic laparoscopy converted to exploratory laparotomy, modified radical abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy, omentectomy, and tumor debulking (___), status post 6 cycles of adjuvant ___ (complicated by neuropathy) and malignant pleural effusion with right pleurex (___), 5 cycles of doxil/bevacizumab, and currently undergoing gemcitabine/bevacizumab (C7D1 ___ who presents as transfer from ___ emergency department with nausea and vomiting. She reports being in her usual state of health until yesterday morning. She reports waking up in morning and having one episode of non-bloody non-bilious emesis. She then ate some toast and had an additional episode of non-bloody non-bilious emesis. She then presented to clinic for chemotherapy. Given the two episodes of emesis, Dr. ___ deferring chemotherapy at the time and getting imaging to rule out small bowel obstruction. At ___ emergency department, she underwent an abdominal xray on ___ which was concerning for dilated loops of small bowel. She then underwent a CT abdomen and pelvis with intravenous contrast which was notable for "Moderate to high-grade partial small bowel obstruction with transition in right lower pelvis possibly due to tethering from an apparent enhancing soft tissue mass, likely metastatic, measuring 2.2 cm in the right lower pelvis. Moderate perihepatic ascites, slightly increased. Trace free fluid in the pelvis, slightly less on prior exam. New pneumonia or aspiration right lung base. Moderate size right pleural effusion is slightly larger. A small left effusion is much smaller." She was then transferred to ___. Here she is doing well. She denies any further emesis after her second episode yesterday at 1100. Denies abdominal pain. Last bowel movement was ___. She has periods of alternating diarrhea and constipation. She will usually have daily bowel movements for the first few days after chemo. She has been passing flatus per usual and last passed flatus at 0800 this morning in the emergency department. She also reports feeling hungry. She notes that she had a right chest pleurex placed by interventional radiology on ___ and her shortness of breath has improved. She reports she is supposed to have the catheter drained every 2 days at home by ___ and is due to have it drained today. She denies any coughs, chest pain, sputum production, shortness of breath, or fevers. Does not remember any recent episodes of aspiration. Past Medical History: Health Maintenance: - ___: BIRADS-2 benign ___ - Colonoscopy: none, FOBT negative this year - Pap smear: wnl ___ PMH: denies hypertension, diabetes, heart disease, or clotting disorder PSH: eye surgery, tonsillectomy OBHx: G0 GYNHx: - LMP ___ years ago, denies postmenopausal bleeding - h/o fibroid 5cm on ultrasound in ___ - not sexually active - denies history of abnormal Pap smears, last in ___ Social History: ___ Family History: Father: ___ Mom: osteoporosis Physical Exam: On day of discharge: General: no apparent distress, comfortable in bed CV: regular rate and rhythm Lungs: Right sided pleural friction rub on lower lung field, left side clear, no crackles, clear to auscultation bilaterally, pleurex catheter in place Abdomen: soft, non-distended, non-tender, normoactive bowel sounds, tympanic in upper abdomen Skin: port and pleurex dressing clean, dry, and intact Extremities: no edema, non-tender, pboots in place Pertinent Results: ___ 11:45PM URINE HOURS-RANDOM ___ 11:45PM URINE UHOLD-HOLD ___ 11:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-80* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 11:45PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 11:45PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE EPI-1 ___ 11:27PM LACTATE-1.1 ___ 11:16PM GLUCOSE-85 UREA N-13 CREAT-0.5 SODIUM-136 POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-23 ANION GAP-13 ___ 11:16PM estGFR-Using this ___ 11:16PM ALT(SGPT)-<5 AST(SGOT)-14 ALK PHOS-83 TOT BILI-0.2 ___ 11:16PM LIPASE-19 ___ 11:16PM ALBUMIN-3.3* CALCIUM-9.4 PHOSPHATE-3.5 MAGNESIUM-2.2 ___ 11:16PM WBC-6.1 RBC-3.89* HGB-11.0* HCT-35.6 MCV-92 MCH-28.3 MCHC-30.9* RDW-14.4 RDWSD-47.1* ___ 11:16PM NEUTS-76.1* LYMPHS-15.5* MONOS-7.4 EOS-0.2* BASOS-0.3 IM ___ AbsNeut-4.60 AbsLymp-0.94* AbsMono-0.45 AbsEos-0.01* AbsBaso-0.02 ___ 11:16PM PLT COUNT-293 ___ 11:16PM ___ PTT-45.2* ___ ___ 10:26AM UREA N-13 CREAT-0.5 SODIUM-136 POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-23 ANION GAP-17 ___ 10:26AM estGFR-Using this ___ 10:26AM ALT(SGPT)-7 AST(SGOT)-17 ALK PHOS-91 TOT BILI-0.3 ___ 10:26AM CALCIUM-10.1 PHOSPHATE-3.3 MAGNESIUM-2.1 ___ 10:26AM CA125-186* ___ 10:26AM WBC-8.6 RBC-4.61 HGB-13.1 HCT-41.4 MCV-90 MCH-28.4 MCHC-31.6* RDW-14.4 RDWSD-45.5 ___ 10:26AM NEUTS-74.5* LYMPHS-12.8* MONOS-9.5 EOS-1.9 BASOS-0.8 IM ___ AbsNeut-6.43* AbsLymp-1.10* AbsMono-0.82* AbsEos-0.16 AbsBaso-0.07 ___ 10:26AM PLT COUNT-388 Brief Hospital Course: Ms. ___ was admitted to the gyn/onc service with a small bowel obstruction. CT abdomen/pelvis from ___ demonstrated moderate to high-grade partial small bowel obstruction with transition likely in the right lower pelvis possibly due to tethering from an apparent enhancing soft tissue mass, likely metastatic, measuring 2.2 cm in the right lower pelvis. She was managed conservatively, made NPO and started on maintenance IV fluids. Her abdominal exam showed no peritoneal signs during her stay and she remained afebrile with a normal white blood cell count. On hospital day 2, she passed gas and her diet was advanced to clears. On hospital day 3 she was advanced to a regular diet. On hospital day #5, she was tolerating a regular diet, she continued to pass flatus and bowel movements and had a normal abdominal exam. Prior to her admission, IP guided right pleurex catheter was placed on ___ for known malignant pleural effusion. Her pleurex was drained on each ___, and ___ of her hospital stay. Her CT abdomen/pelvis demonstrated airspace opacification at right lung base and could not rule out pneumonia vs aspiration, atelectasis. Given that she was afebrile, no leukocytosis, or signs or symptoms of infection, treatment was deferred. She remained afebrile with appropriate oxygen saturation on room air and with a benign respiratory exam. Because she remained stable and was tolerating a regular diet without nausea and vomiting, she was discharged home with follow-up on hospital day 5. Medications on Admission: 1. Acetaminophen Extra Strength 500 mg tablet1-2 tablet(s) by mouth every eight (8) hours as needed for pain [Not Taking as Prescribed] 2. Calcium with Vitamin D 600 mg (1,500 mg)-400 unit tablet(dose uncertain) 3. Claritin 10 mg tablet1 tablet(s) by mouth once a day as needed for allergy symptoms 4. docusate sodium 100 mg capsule1 capsule(s) by mouth once to twice daily as needed for to prevent constipation hold for loose stools 5. famotidine 20 mg tablet1 tablet(s) by mouth twice a day 6. lorazepam 0.5 mg tablet1 tablet(s) by mouth every eight (8) hours as needed for nausea/anxiety/insomnia do not drink or drive if taking 7. polyethylene glycol 3350 17 gram/dose oral powder1 powder(s) by mouth daily as needed for constipation Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild Do not exceed 4000 mg per day. RX acetaminophen 500 mg 1 to 2 tablet(s) by mouth every six (6) hours Disp #50 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: partial small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology oncology service for a small bowel obstruction. You were conservatively managed. You were made n.p.o. Your nausea was treated with antiemetics. Labs were done which showed no signs of systemic infection. You were afebrile with stable vital signs and monitored closely for resolution of symptoms. When signs of return of bowel function were present your diet was advanced without incident and you are discharged home on a low residual diet. Your home medications were continued. You have recovered well and the team now feels it is safe for you to be discharged home. Please follow these instructions: Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen, and use the narcotic as needed for breakthrough pain. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * Please continue on your low residual diet until xxxxxx Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms Followup Instructions: ___	[ "K56600", "J910", "C782", "C569", "Z9221", "K219", "R7989", "C541" ]	Allergies: seasonal / frangrance / lidocaine Chief Complaint: nausea and vomiting Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [MASKED] is a [MASKED] year old gravida 0 with history of stage IIIB platinum refractory low grade serous and endometrioid ovarian carcinoma and stage II grade I endometrioid endometrial adenocarcinoma status post diagnostic laparoscopy converted to exploratory laparotomy, modified radical abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy, omentectomy, and tumor debulking ([MASKED]), status post 6 cycles of adjuvant [MASKED] (complicated by neuropathy) and malignant pleural effusion with right pleurex ([MASKED]), 5 cycles of doxil/bevacizumab, and currently undergoing gemcitabine/bevacizumab (C7D1 [MASKED] who presents as transfer from [MASKED] emergency department with nausea and vomiting. She reports being in her usual state of health until yesterday morning. She reports waking up in morning and having one episode of non-bloody non-bilious emesis. She then ate some toast and had an additional episode of non-bloody non-bilious emesis. She then presented to clinic for chemotherapy. Given the two episodes of emesis, Dr. [MASKED] deferring chemotherapy at the time and getting imaging to rule out small bowel obstruction. At [MASKED] emergency department, she underwent an abdominal xray on [MASKED] which was concerning for dilated loops of small bowel. She then underwent a CT abdomen and pelvis with intravenous contrast which was notable for "Moderate to high-grade partial small bowel obstruction with transition in right lower pelvis possibly due to tethering from an apparent enhancing soft tissue mass, likely metastatic, measuring 2.2 cm in the right lower pelvis. Moderate perihepatic ascites, slightly increased. Trace free fluid in the pelvis, slightly less on prior exam. New pneumonia or aspiration right lung base. Moderate size right pleural effusion is slightly larger. A small left effusion is much smaller." She was then transferred to [MASKED]. Here she is doing well. She denies any further emesis after her second episode yesterday at 1100. Denies abdominal pain. Last bowel movement was [MASKED]. She has periods of alternating diarrhea and constipation. She will usually have daily bowel movements for the first few days after chemo. She has been passing flatus per usual and last passed flatus at 0800 this morning in the emergency department. She also reports feeling hungry. She notes that she had a right chest pleurex placed by interventional radiology on [MASKED] and her shortness of breath has improved. She reports she is supposed to have the catheter drained every 2 days at home by [MASKED] and is due to have it drained today. She denies any coughs, chest pain, sputum production, shortness of breath, or fevers. Does not remember any recent episodes of aspiration. Past Medical History: Health Maintenance: - [MASKED]: BIRADS-2 benign [MASKED] - Colonoscopy: none, FOBT negative this year - Pap smear: wnl [MASKED] PMH: denies hypertension, diabetes, heart disease, or clotting disorder PSH: eye surgery, tonsillectomy OBHx: G0 GYNHx: - LMP [MASKED] years ago, denies postmenopausal bleeding - h/o fibroid 5cm on ultrasound in [MASKED] - not sexually active - denies history of abnormal Pap smears, last in [MASKED] Social History: [MASKED] Family History: Father: [MASKED] Mom: osteoporosis Physical Exam: On day of discharge: General: no apparent distress, comfortable in bed CV: regular rate and rhythm Lungs: Right sided pleural friction rub on lower lung field, left side clear, no crackles, clear to auscultation bilaterally, pleurex catheter in place Abdomen: soft, non-distended, non-tender, normoactive bowel sounds, tympanic in upper abdomen Skin: port and pleurex dressing clean, dry, and intact Extremities: no edema, non-tender, pboots in place Pertinent Results: [MASKED] 11:45PM URINE HOURS-RANDOM [MASKED] 11:45PM URINE UHOLD-HOLD [MASKED] 11:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-80* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [MASKED] 11:45PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 11:45PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE EPI-1 [MASKED] 11:27PM LACTATE-1.1 [MASKED] 11:16PM GLUCOSE-85 UREA N-13 CREAT-0.5 SODIUM-136 POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-23 ANION GAP-13 [MASKED] 11:16PM estGFR-Using this [MASKED] 11:16PM ALT(SGPT)-<5 AST(SGOT)-14 ALK PHOS-83 TOT BILI-0.2 [MASKED] 11:16PM LIPASE-19 [MASKED] 11:16PM ALBUMIN-3.3* CALCIUM-9.4 PHOSPHATE-3.5 MAGNESIUM-2.2 [MASKED] 11:16PM WBC-6.1 RBC-3.89* HGB-11.0* HCT-35.6 MCV-92 MCH-28.3 MCHC-30.9* RDW-14.4 RDWSD-47.1* [MASKED] 11:16PM NEUTS-76.1* LYMPHS-15.5* MONOS-7.4 EOS-0.2* BASOS-0.3 IM [MASKED] AbsNeut-4.60 AbsLymp-0.94* AbsMono-0.45 AbsEos-0.01* AbsBaso-0.02 [MASKED] 11:16PM PLT COUNT-293 [MASKED] 11:16PM [MASKED] PTT-45.2* [MASKED] [MASKED] 10:26AM UREA N-13 CREAT-0.5 SODIUM-136 POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-23 ANION GAP-17 [MASKED] 10:26AM estGFR-Using this [MASKED] 10:26AM ALT(SGPT)-7 AST(SGOT)-17 ALK PHOS-91 TOT BILI-0.3 [MASKED] 10:26AM CALCIUM-10.1 PHOSPHATE-3.3 MAGNESIUM-2.1 [MASKED] 10:26AM CA125-186* [MASKED] 10:26AM WBC-8.6 RBC-4.61 HGB-13.1 HCT-41.4 MCV-90 MCH-28.4 MCHC-31.6* RDW-14.4 RDWSD-45.5 [MASKED] 10:26AM NEUTS-74.5* LYMPHS-12.8* MONOS-9.5 EOS-1.9 BASOS-0.8 IM [MASKED] AbsNeut-6.43* AbsLymp-1.10* AbsMono-0.82* AbsEos-0.16 AbsBaso-0.07 [MASKED] 10:26AM PLT COUNT-388 Brief Hospital Course: Ms. [MASKED] was admitted to the gyn/onc service with a small bowel obstruction. CT abdomen/pelvis from [MASKED] demonstrated moderate to high-grade partial small bowel obstruction with transition likely in the right lower pelvis possibly due to tethering from an apparent enhancing soft tissue mass, likely metastatic, measuring 2.2 cm in the right lower pelvis. She was managed conservatively, made NPO and started on maintenance IV fluids. Her abdominal exam showed no peritoneal signs during her stay and she remained afebrile with a normal white blood cell count. On hospital day 2, she passed gas and her diet was advanced to clears. On hospital day 3 she was advanced to a regular diet. On hospital day #5, she was tolerating a regular diet, she continued to pass flatus and bowel movements and had a normal abdominal exam. Prior to her admission, IP guided right pleurex catheter was placed on [MASKED] for known malignant pleural effusion. Her pleurex was drained on each [MASKED], and [MASKED] of her hospital stay. Her CT abdomen/pelvis demonstrated airspace opacification at right lung base and could not rule out pneumonia vs aspiration, atelectasis. Given that she was afebrile, no leukocytosis, or signs or symptoms of infection, treatment was deferred. She remained afebrile with appropriate oxygen saturation on room air and with a benign respiratory exam. Because she remained stable and was tolerating a regular diet without nausea and vomiting, she was discharged home with follow-up on hospital day 5. Medications on Admission: 1. Acetaminophen Extra Strength 500 mg tablet1-2 tablet(s) by mouth every eight (8) hours as needed for pain [Not Taking as Prescribed] 2. Calcium with Vitamin D 600 mg (1,500 mg)-400 unit tablet(dose uncertain) 3. Claritin 10 mg tablet1 tablet(s) by mouth once a day as needed for allergy symptoms 4. docusate sodium 100 mg capsule1 capsule(s) by mouth once to twice daily as needed for to prevent constipation hold for loose stools 5. famotidine 20 mg tablet1 tablet(s) by mouth twice a day 6. lorazepam 0.5 mg tablet1 tablet(s) by mouth every eight (8) hours as needed for nausea/anxiety/insomnia do not drink or drive if taking 7. polyethylene glycol 3350 17 gram/dose oral powder1 powder(s) by mouth daily as needed for constipation Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild Do not exceed 4000 mg per day. RX acetaminophen 500 mg 1 to 2 tablet(s) by mouth every six (6) hours Disp #50 Tablet Refills:0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: partial small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the gynecology oncology service for a small bowel obstruction. You were conservatively managed. You were made n.p.o. Your nausea was treated with antiemetics. Labs were done which showed no signs of systemic infection. You were afebrile with stable vital signs and monitored closely for resolution of symptoms. When signs of return of bowel function were present your diet was advanced without incident and you are discharged home on a low residual diet. Your home medications were continued. You have recovered well and the team now feels it is safe for you to be discharged home. Please follow these instructions: Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen, and use the narcotic as needed for breakthrough pain. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * Please continue on your low residual diet until xxxxxx Call your doctor at [MASKED] for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms Followup Instructions: [MASKED]	[]	[ "K219" ]	[ "K56600: Partial intestinal obstruction, unspecified as to cause", "J910: Malignant pleural effusion", "C782: Secondary malignant neoplasm of pleura", "C569: Malignant neoplasm of unspecified ovary", "Z9221: Personal history of antineoplastic chemotherapy", "K219: Gastro-esophageal reflux disease without esophagitis", "R7989: Other specified abnormal findings of blood chemistry", "C541: Malignant neoplasm of endometrium" ]
10,093,120	28,669,551	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal distention Major Surgical or Invasive Procedure: paracentesis diagnostic laparoscopy, explorative laparotomy, total abdominal hysterectomy, bilateral salpingo-ophorectomy, omentectomy, appendectomy, left pelvic lymphadenectomy, pelvic peritonectomy, oversew of bowel serosa and cystoscopy History of Present Illness: Ms. ___ is a lovely ___ G0 transferred from ___ to ___ ED on ___ for partial small bowel obstruction, pelvic masses, and carcinomatosis on CT scan. She was admitted to the medicine service from the ED, where she has been managed. She initially presented to ___ with abdominal distention and nausea that developed over the past week. She reports decreased appetite and nausea with dry heaving, no vomiting because she feels her stomach has been empty from minimal PO intake. She also reported abdominal pain throughout her abdomen. At ___, she had CT A/P that was read as follows: 1. 8 x 12 cm cystic and solid pelvic soft tissue mass likely representing ovarian malignancy. Malignant ascites and peritoneal enhancement suggesting peritoneal carcinomatosis. 2. Partial SBO likely secondary to small bowel into by pelvic tumor. She was then transferred to ___ for further evaluation and management. In the ED here, she was initially mildly tachycardic but afebrile. Her HR normalized with hydration. Her vitals have remained normal in the floor. Her SBO has been managed conservatively NPO/IVFs. She has not required an NG tube. She states today that her nausea has completely improved and she has not had vomiting or dry heaving since being in the hospital. She has continued to pass gas throughout the past week, including today, and feels like she is going to have a BM soon. Her last BM was on ___. She did undergo a paracentesis for 2L of clear, straw-colored fluid on ___, and states she felt much better after paracentesis but is already feeling fluid re-accumulate. Peritoneal fluid was sent for cytology which is pending. ___ was consulted by medicine to consider ___ biopsy of omental nodules, but felt that the nodules were too small to successfully and safely biopsy with ___ so this was deferred. On ROS, patient states she had a 15lb weight-loss over the past year but has been trying to lose weight. She denies CP, SOB, fever, chills, changes in bowel movements or urination, vaginal bleeding, or abnormal discharge. ROS: full review of systems was negative except as above Past Medical History: Health Maintenance: - ___: BIRADS-2 benign ___ - Colonoscopy: none, FOBT negative this year - Pap smear: wnl ___ PMH: denies hypertension, diabetes, heart disease, or clotting disorder PSH: eye surgery, tonsillectomy OBHx: G0 GYNHx: - LMP ___ years ago, denies postmenopausal bleeding - h/o fibroid 5cm on ultrasound in ___ - not sexually active - denies history of abnormal Pap smears, last in ___ Social History: ___ Family History: Father: ___ Mom: osteoporosis Physical Exam: Physical Exam on Admission ___: T 98.0 HR 108 BP 130/82 RR 18 O2Sat 98% RA Gen: A&O, NAD CV: RRR Resp: CTAB Abd: somewhat hypoactive BS, softly distended, nontender, no rebound or guarding Ext: calves nontender bilaterally SSE: Normal vaginal mucosa with pink tinge, no lesions, Cervix unable to be visualized due to patient discomfort even with small size speculum BME: Small smooth cervix, exam limited due to ascites, large pelvic mass palpated, nontender Rectovaginal exam: no nodularity, again large pelvic mass palpated Physical Exam on Day of Discharge: ___ 0731 Temp: 98.5 PO BP: 127/79 HR: 88 RR: 18 O2 sat: 95% O2 delivery: Ra ___ 0506 Temp: 98.1 PO BP: 145/75 HR: 94 RR: 18 O2 sat: 98% O2 delivery: RA ___ Total Intake: 60ml PO Amt: 60ml ___ Total Intake: 300ml PO Amt: 300ml ___ Total Output: 1100ml Urine Amt: 1100ml ___ Total Output: 3370ml Urine Amt: 3350ml Emesis: 20ml General: NAD, comfortable appearing. Neuro: AxO x 3, affect appropriate. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Cardiovascular: RRR, no rubs/murmurs/gallops. Pulmonary: normal rate and work of breathing, Lungs CTAB Abdomen: + bowel sounds. Soft, nontender to palpation, minimally distended. No rebound/guarding. Vertical midline incision closed with staples and c/d/I without surrounding erythema, induration, or exudate. GU: No blood on pad. MSK: Lower extremities with 2+ edema to knee bilaterally; no erythema or TTP, compression stocking on Pertinent Results: ___ 02:00AM BLOOD WBC-8.8 RBC-4.92 Hgb-12.9 Hct-39.9 MCV-81* MCH-26.2 MCHC-32.3 RDW-12.8 RDWSD-37.3 Plt ___ ___ 06:10AM BLOOD WBC-7.4 RBC-4.36 Hgb-11.6 Hct-36.4 MCV-84 MCH-26.6 MCHC-31.9* RDW-12.8 RDWSD-38.8 Plt ___ ___ 02:00AM BLOOD Neuts-62.2 ___ Monos-13.0 Eos-0.8* Baso-0.7 Im ___ AbsNeut-5.47 AbsLymp-1.98 AbsMono-1.14* AbsEos-0.07 AbsBaso-0.06 ___ 06:10AM BLOOD ___ ___ 02:00AM BLOOD Glucose-105* UreaN-9 Creat-0.5 Na-139 K-4.3 Cl-96 HCO3-23 AnGap-20* ___ 02:00AM BLOOD ALT-<5 AST-9 AlkPhos-66 TotBili-0.4 ___ 06:10AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9 ___ 02:00AM BLOOD Albumin-3.1* ___ 02:00AM BLOOD CEA-0.6 ___* - CT chest (___): anterior supradiaphragmatic lymph nodes are 0.9cm, concerning for possible metastatic involvement, for further follow-up. - CT A/P: 12cm cystic and solid pelvic soft tissue mass likely representing ovarian malignancy, malignant ascites, and peritoneal carcinomatosis Brief Hospital Course: Ms. ___ is a ___ year old woman without significant past medical history presenting with partial small bowel obstruction, pelvic masses, carcinomatosis, who was initially admitted to medicine for further workup and was transferred to gynecologic oncology service on hospital day #2 given concern for ovarian malignancy. In regards to her partial small bowel obstruction, patient had a CT abdomen/pelvis which demonstrated a dilated small bowel with transition point in pelvis. Per radiology, the small bowel was likely entrapped and dilated by tumor. Patient did not endorse any nausea and continued to pass flatus. Acute care surgery was consulted and patient was made NPO with IV fluids, anti-emetics, and narcotics as needed. Patient tolerated sips on hospital day #2, Ensure clear/toast/crackers on hospital day #3, and a regular diet on hospital day #4. In regards to the concern for ovarian malignancy, she had a CT which demonstrated a 12cm cystic and solid pelvic soft tissue mass, ascites, and peritoneal carcinomatosis. A CT chest revealed 0.9cm supradiaphragmatic lymph nodes, which could possibly represent metastases. ___ was Tumor markers revealed elevated CA-125 of 522 and CEA level of 0.6. She had a paracentesis performed in the emergency room for 2 liters of ascites, and cytology was sent for analysis. Interventional radiology was consulted, however her omental lesions were too small to biopsy. On hospital day #6, patient underwent a TAH/BSO, appendectomy, omenectomy. Afterwards she was admitted to ___ for mild hypotension post-op requiring neo. She was treated with unasyn for purulent fluid from one ovary as well as imaging concerning for pneumonia, and her blood pressure improved. She had an NGT placed intra-operatively which was removed without issue on post-operative day 3. Her post-operative course was complicated by an elevated INR, for which she received vitamin K with resolution. Her pain was initially managed with an epidural and was then transitioned to oral medications. Her diet was advanced slowly due to post-operative ileus. Her foley catheter was removed on post-operative day 3 and she voided spontaneously. By post-operative day 10 she was voiding, tolerating a regular diet, ambulating independently with good pain control. She was then discharged home with ___ services to continue lovenox for prophylactic anticoagulation. Medications on Admission: Loratadine 10 mg PO DAILY Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity do not exceed 4000mg in 24 hrs RX acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours as needed Disp #50 Tablet Refills:1 2. Docusate Sodium 100 mg PO BID hold for loose stools RX docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #60 Capsule Refills:1 3. Enoxaparin Sodium 40 mg SC DAILY RX enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #19 Syringe Refills:0 4. Ondansetron ODT 4 mg PO Q8H:PRN nausea may be constipating, call MD if needing to use frequently RX ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp #10 Tablet Refills:0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate do not drive or drink alcohol, may cause sedation RX oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #20 Tablet Refills:0 6. Loratadine 10 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: partial small bowel obstruction pelvic mass and carcinomatosis left tuboovarian abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology oncology service for a partial small bowel obstruction and were found to have a pelvic mass. You then underwent the procedure listed below. You have recovered well after your procedure, and the team feels that you are safe to be discharged home. Please follow these instructions: Abdominal instructions: Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor at ___ for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms Lovenox injections: * Patients having surgery for cancer have risk of developing blood clots after surgery. This risk is highest in the first four weeks after surgery. You will be discharged with a daily Lovenox (blood thinning) medication. This is a preventive dose of medication to decrease your risk of a forming a blood clot. A visiting nurse ___ assist you in administering these injections. Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. Followup Instructions: ___	[ "C562", "J189", "R180", "A419", "C784", "E440", "E872", "E8809", "C786", "C785", "D688", "K567", "D62", "J9811", "C561", "N7093", "Z6822", "Z23", "E861", "R0902", "Z781", "Z7901" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: abdominal distention Major Surgical or Invasive Procedure: paracentesis diagnostic laparoscopy, explorative laparotomy, total abdominal hysterectomy, bilateral salpingo-ophorectomy, omentectomy, appendectomy, left pelvic lymphadenectomy, pelvic peritonectomy, oversew of bowel serosa and cystoscopy History of Present Illness: Ms. [MASKED] is a lovely [MASKED] G0 transferred from [MASKED] to [MASKED] ED on [MASKED] for partial small bowel obstruction, pelvic masses, and carcinomatosis on CT scan. She was admitted to the medicine service from the ED, where she has been managed. She initially presented to [MASKED] with abdominal distention and nausea that developed over the past week. She reports decreased appetite and nausea with dry heaving, no vomiting because she feels her stomach has been empty from minimal PO intake. She also reported abdominal pain throughout her abdomen. At [MASKED], she had CT A/P that was read as follows: 1. 8 x 12 cm cystic and solid pelvic soft tissue mass likely representing ovarian malignancy. Malignant ascites and peritoneal enhancement suggesting peritoneal carcinomatosis. 2. Partial SBO likely secondary to small bowel into by pelvic tumor. She was then transferred to [MASKED] for further evaluation and management. In the ED here, she was initially mildly tachycardic but afebrile. Her HR normalized with hydration. Her vitals have remained normal in the floor. Her SBO has been managed conservatively NPO/IVFs. She has not required an NG tube. She states today that her nausea has completely improved and she has not had vomiting or dry heaving since being in the hospital. She has continued to pass gas throughout the past week, including today, and feels like she is going to have a BM soon. Her last BM was on [MASKED]. She did undergo a paracentesis for 2L of clear, straw-colored fluid on [MASKED], and states she felt much better after paracentesis but is already feeling fluid re-accumulate. Peritoneal fluid was sent for cytology which is pending. [MASKED] was consulted by medicine to consider [MASKED] biopsy of omental nodules, but felt that the nodules were too small to successfully and safely biopsy with [MASKED] so this was deferred. On ROS, patient states she had a 15lb weight-loss over the past year but has been trying to lose weight. She denies CP, SOB, fever, chills, changes in bowel movements or urination, vaginal bleeding, or abnormal discharge. ROS: full review of systems was negative except as above Past Medical History: Health Maintenance: - [MASKED]: BIRADS-2 benign [MASKED] - Colonoscopy: none, FOBT negative this year - Pap smear: wnl [MASKED] PMH: denies hypertension, diabetes, heart disease, or clotting disorder PSH: eye surgery, tonsillectomy OBHx: G0 GYNHx: - LMP [MASKED] years ago, denies postmenopausal bleeding - h/o fibroid 5cm on ultrasound in [MASKED] - not sexually active - denies history of abnormal Pap smears, last in [MASKED] Social History: [MASKED] Family History: Father: [MASKED] Mom: osteoporosis Physical Exam: Physical Exam on Admission [MASKED]: T 98.0 HR 108 BP 130/82 RR 18 O2Sat 98% RA Gen: A&O, NAD CV: RRR Resp: CTAB Abd: somewhat hypoactive BS, softly distended, nontender, no rebound or guarding Ext: calves nontender bilaterally SSE: Normal vaginal mucosa with pink tinge, no lesions, Cervix unable to be visualized due to patient discomfort even with small size speculum BME: Small smooth cervix, exam limited due to ascites, large pelvic mass palpated, nontender Rectovaginal exam: no nodularity, again large pelvic mass palpated Physical Exam on Day of Discharge: [MASKED] 0731 Temp: 98.5 PO BP: 127/79 HR: 88 RR: 18 O2 sat: 95% O2 delivery: Ra [MASKED] 0506 Temp: 98.1 PO BP: 145/75 HR: 94 RR: 18 O2 sat: 98% O2 delivery: RA [MASKED] Total Intake: 60ml PO Amt: 60ml [MASKED] Total Intake: 300ml PO Amt: 300ml [MASKED] Total Output: 1100ml Urine Amt: 1100ml [MASKED] Total Output: 3370ml Urine Amt: 3350ml Emesis: 20ml General: NAD, comfortable appearing. Neuro: AxO x 3, affect appropriate. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Cardiovascular: RRR, no rubs/murmurs/gallops. Pulmonary: normal rate and work of breathing, Lungs CTAB Abdomen: + bowel sounds. Soft, nontender to palpation, minimally distended. No rebound/guarding. Vertical midline incision closed with staples and c/d/I without surrounding erythema, induration, or exudate. GU: No blood on pad. MSK: Lower extremities with 2+ edema to knee bilaterally; no erythema or TTP, compression stocking on Pertinent Results: [MASKED] 02:00AM BLOOD WBC-8.8 RBC-4.92 Hgb-12.9 Hct-39.9 MCV-81* MCH-26.2 MCHC-32.3 RDW-12.8 RDWSD-37.3 Plt [MASKED] [MASKED] 06:10AM BLOOD WBC-7.4 RBC-4.36 Hgb-11.6 Hct-36.4 MCV-84 MCH-26.6 MCHC-31.9* RDW-12.8 RDWSD-38.8 Plt [MASKED] [MASKED] 02:00AM BLOOD Neuts-62.2 [MASKED] Monos-13.0 Eos-0.8* Baso-0.7 Im [MASKED] AbsNeut-5.47 AbsLymp-1.98 AbsMono-1.14* AbsEos-0.07 AbsBaso-0.06 [MASKED] 06:10AM BLOOD [MASKED] [MASKED] 02:00AM BLOOD Glucose-105* UreaN-9 Creat-0.5 Na-139 K-4.3 Cl-96 HCO3-23 AnGap-20* [MASKED] 02:00AM BLOOD ALT-<5 AST-9 AlkPhos-66 TotBili-0.4 [MASKED] 06:10AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9 [MASKED] 02:00AM BLOOD Albumin-3.1* [MASKED] 02:00AM BLOOD CEA-0.6 [MASKED]* - CT chest ([MASKED]): anterior supradiaphragmatic lymph nodes are 0.9cm, concerning for possible metastatic involvement, for further follow-up. - CT A/P: 12cm cystic and solid pelvic soft tissue mass likely representing ovarian malignancy, malignant ascites, and peritoneal carcinomatosis Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old woman without significant past medical history presenting with partial small bowel obstruction, pelvic masses, carcinomatosis, who was initially admitted to medicine for further workup and was transferred to gynecologic oncology service on hospital day #2 given concern for ovarian malignancy. In regards to her partial small bowel obstruction, patient had a CT abdomen/pelvis which demonstrated a dilated small bowel with transition point in pelvis. Per radiology, the small bowel was likely entrapped and dilated by tumor. Patient did not endorse any nausea and continued to pass flatus. Acute care surgery was consulted and patient was made NPO with IV fluids, anti-emetics, and narcotics as needed. Patient tolerated sips on hospital day #2, Ensure clear/toast/crackers on hospital day #3, and a regular diet on hospital day #4. In regards to the concern for ovarian malignancy, she had a CT which demonstrated a 12cm cystic and solid pelvic soft tissue mass, ascites, and peritoneal carcinomatosis. A CT chest revealed 0.9cm supradiaphragmatic lymph nodes, which could possibly represent metastases. [MASKED] was Tumor markers revealed elevated CA-125 of 522 and CEA level of 0.6. She had a paracentesis performed in the emergency room for 2 liters of ascites, and cytology was sent for analysis. Interventional radiology was consulted, however her omental lesions were too small to biopsy. On hospital day #6, patient underwent a TAH/BSO, appendectomy, omenectomy. Afterwards she was admitted to [MASKED] for mild hypotension post-op requiring neo. She was treated with unasyn for purulent fluid from one ovary as well as imaging concerning for pneumonia, and her blood pressure improved. She had an NGT placed intra-operatively which was removed without issue on post-operative day 3. Her post-operative course was complicated by an elevated INR, for which she received vitamin K with resolution. Her pain was initially managed with an epidural and was then transitioned to oral medications. Her diet was advanced slowly due to post-operative ileus. Her foley catheter was removed on post-operative day 3 and she voided spontaneously. By post-operative day 10 she was voiding, tolerating a regular diet, ambulating independently with good pain control. She was then discharged home with [MASKED] services to continue lovenox for prophylactic anticoagulation. Medications on Admission: Loratadine 10 mg PO DAILY Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity do not exceed 4000mg in 24 hrs RX acetaminophen 500 mg [MASKED] tablet(s) by mouth every 6 hours as needed Disp #50 Tablet Refills:1 2. Docusate Sodium 100 mg PO BID hold for loose stools RX docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #60 Capsule Refills:1 3. Enoxaparin Sodium 40 mg SC DAILY RX enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #19 Syringe Refills:0 4. Ondansetron ODT 4 mg PO Q8H:PRN nausea may be constipating, call MD if needing to use frequently RX ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp #10 Tablet Refills:0 5. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate do not drive or drink alcohol, may cause sedation RX oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #20 Tablet Refills:0 6. Loratadine 10 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: partial small bowel obstruction pelvic mass and carcinomatosis left tuboovarian abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the gynecology oncology service for a partial small bowel obstruction and were found to have a pelvic mass. You then underwent the procedure listed below. You have recovered well after your procedure, and the team feels that you are safe to be discharged home. Please follow these instructions: Abdominal instructions: Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call [MASKED]. Call your doctor at [MASKED] for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms Lovenox injections: * Patients having surgery for cancer have risk of developing blood clots after surgery. This risk is highest in the first four weeks after surgery. You will be discharged with a daily Lovenox (blood thinning) medication. This is a preventive dose of medication to decrease your risk of a forming a blood clot. A visiting nurse [MASKED] assist you in administering these injections. Constipation: * Drink [MASKED] liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener [MASKED] times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. Followup Instructions: [MASKED]	[]	[ "E872", "D62", "Z7901" ]	[ "C562: Malignant neoplasm of left ovary", "J189: Pneumonia, unspecified organism", "R180: Malignant ascites", "A419: Sepsis, unspecified organism", "C784: Secondary malignant neoplasm of small intestine", "E440: Moderate protein-calorie malnutrition", "E872: Acidosis", "E8809: Other disorders of plasma-protein metabolism, not elsewhere classified", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "C785: Secondary malignant neoplasm of large intestine and rectum", "D688: Other specified coagulation defects", "K567: Ileus, unspecified", "D62: Acute posthemorrhagic anemia", "J9811: Atelectasis", "C561: Malignant neoplasm of right ovary", "N7093: Salpingitis and oophoritis, unspecified", "Z6822: Body mass index [BMI] 22.0-22.9, adult", "Z23: Encounter for immunization", "E861: Hypovolemia", "R0902: Hypoxemia", "Z781: Physical restraint status", "Z7901: Long term (current) use of anticoagulants" ]
10,093,609	29,765,478	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Demerol / Cocaine / Compazine / Augmentin / Ergotamine / Bactrim / Shellfish / Penicillins / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: Ms ___ is a ___ w/hx of hypothyroidism, HLD, and ?vasculitis who initially p/w DOE, transferred from ___ after being found to have b/l L>R pleural effusions and pericardial effusion Pt states has felt generally unwell for the past 1wk, markedly fatigued. +Night sweats and chills. No overt SOB, though patient says her breathing has felt "different, there is something happening in my chest." +Non productive cough. She also notes intermittent R chest and back discomfort, no association with movement/exertion. She has been sleeping upright for comfort. The pt was feeling particularly unwell today, presented to urgent care. She was noted to be tachycardic. Labs were notable for neg trop/BNP and D-dimer 5722. Flu swab was Neg. Pt was HDS and in NAD. She was noted to desat to 88% when ambulating but is NAD at rest. Initial CXR w/evidence of a left pleural effusion. Pt expressed Rt sided pleuritic CP, investigated further with EKG demonstrating TWI aVL/I as well as V2 and TWF laterally with low voltage in the inferior leads, no obvious alternans and no STEMI criteria. CTA was obtained, w/pericardial effusion w/evidence of R heart strain & ?tamponade, L>R pleural effusions, no PE. Pt was given IVF, transferred from ___ to ___ for further eval. No recent travel, Pt w/o hx of breast cancer. Up to date on mammograms. No recent travel. Sigmodioscopy neg in ___. Neg thyroid scan. In the ED, initial vitals were: T98.6 105 153/75 18 98% RA - Exam notable for: Slightly anxious, circumferential in speech. Decreased bibasilar lung sounds. Tachycardic, regular rhythm, soft systolic ejection murmur best heard at ___, no rubs. No elevated JVP. Abd benign. Pretibial edema L>R. WWP. - Labs notable for: WBC 7.9, Hb 13.3, Plt 252, BNP 121, Na 135, Cr 0.7, Trop neg, D-dimer 5722, Flu rapid Ag neg - Imaging was notable for: CXR w/Lt pleural effusion, CT-A w/Small to moderate amount of pericardial the fusion with evidence of right heart strain. Tamponade physiology is difficult to evaluate on current modality. Further evaluation with echocardiogram and or consultation with interventional cardiology is recommended for pericardiocentesis. -No evidence of pulmonary embolism. - Patient was given: Klonopin 1mg, Montelukast 10mg Upon arrival to the floor, patient reports that Sx started 1.5 wks prior, developed chest soreness, achiness. didn't feel like the flu but muscle aches. diff breathing and pain w/breathing. felt more uncomfortable lying flat. DOE but no SOB at rest. pt's Sx had been steadily improving over the week after last weekend, but then this weekend Sx had worsened again. +C/NS, didn't check for fevers. Dec appetite/PO intake. No sick contacts. +flu vaccine this yr. No abd pain, no n/v/d/c. no rashes. no dysuria/urinary changes. weak, rare dry cough. Had migraine HA in ED, better with midron. No recent med changes, except for ___ med & mild change in thyroid meds. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: PAST MEDICAL HISTORY: ASTHMA CERVICAL SPONDYLOSIS HYPERTRIGLYCERIDEMIA MANIERE'S DISEASE MIGRAINE HEADACHES OLECRANON BURSITIS,LEFT OSTEOPENIA,SPINE SINUSITIS ? VASCULITIS FASTING HYPERGLYCEMIA OSTEOPENIA THYROID NODULE HYPOTHYROIDISM H/O TAH/BSO PAST SURGICAL HISTORY: s/p L oophorectomy for cysts s/p total hysterectomy ___ GYN HISTORY: no h/o abnl paps s/p L oophorectomy for cysts s/p total hysterectomy ___ ___ due in ___. h/o fibroadenomas Social History: ___ Family History: father: CAD, htn, sarcoma, testicular ca, aneurysms mother: lung cancer (smoker) one brother died of ___ Physical Exam: ADMISSION PHYSICAL EXAM: Vital Signs: 97.9, 147/89, 98, 18, 96 RA, 89.9kg General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, NCAT Neck: Supple. No JVD. CV: RRR. Normal S1+S2, no murmurs, rubs, gallops. Pulsus <5. Lungs: Decreased bibasilar breath sounds Abdomen: Soft, non-tender, non-distended, bowel sounds present, 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 Skin: no rashes observed. Discharge exam: VS: 99 105/68 93 16 92-94% RA resting and ambulating GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, JVP 12cm HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, decreased breath sounds bilaterally ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: Admission: ___ 04:15PM NEUTS-74.4* LYMPHS-12.0* MONOS-10.8 EOS-1.9 BASOS-0.5 IM ___ AbsNeut-5.85# AbsLymp-0.94* AbsMono-0.85* AbsEos-0.15 AbsBaso-0.04 ___ 04:15PM WBC-7.9 RBC-4.50 HGB-13.3 HCT-39.7 MCV-88 MCH-29.6 MCHC-33.5 RDW-14.0 RDWSD-45.0 ___ 04:15PM CRP-109.6* ___ 04:15PM FREE T4-1.1 ___ 04:15PM TSH-1.9 ___ 04:15PM D-DIMER-5722* ___ 04:15PM ALBUMIN-4.3 CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-2.4 ___ 04:15PM CK-MB-<1 proBNP-121 ___ 04:15PM cTropnT-<0.01 ___ 04:15PM ALT(SGPT)-13 AST(SGOT)-17 LD(LDH)-335* CK(CPK)-64 ALK PHOS-59 TOT BILI-0.7 ___ 04:15PM GLUCOSE-131* UREA N-16 CREAT-0.7 SODIUM-135 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-23 ANION GAP-18 IMAGING & STUDIES: - CXR ___ --Small left pleural effusion with overlying atelectasis; underlying left base consolidation is not excluded. - CT-A Chest ___ --Moderate pericardial effusion with straightening of the interventricular septum raising concern for underlying right heart strain which could be further assessed for on echocardiogram. Tamponade physiology is difficult to evaluate on current modality. Further evaluation with echocardiogram and or consultation with interventional cardiology is recommended for pericardiocentesis. --Small bilateral pleural effusions, left greater than right. Subtle perihilar ground-glass opacities could relate to respiratory motion versus mild pulmonary edema. --No evidence of pulmonary embolism. - ECG ___ --HR 104, SR, NA, TWI aVL/V1-V2, diffuse TW flattening, lower end voltage, no priors to compare TTE ___ The left atrium is normal in size. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is high (>4.0L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is a small circumferential pericardial effusion, most promient (1cm) inferolateral to the left ventricle and anterior to the right ventricular free wall and right atrium. No right atrial or right ventricular diastolic collapse is seen. IMPRESSION: Small circumferential pericardial effusion without echocardiographic evidence for tampmonade physiology. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. No valvular pathology or pathologic flow identified. ___ CXR IMPRESSION: Compared to chest radiographs since ___ most recently ___. Moderate left pleural effusion and moderately severe left lower lobe atelectasis have worsened since ___. Pneumonia left lower lobe would be difficult to exclude under the circumstances. No change in diameter of the top-normal cardiac silhouette or distension of mediastinal veins to suggest either cardiac tamponade or substantial increase in pericardial effusion. Right lung and left upper lung are clear. No appreciable right pleural effusion. No pulmonary vascular abnormality. Discharge labs: ___ 07:00AM BLOOD WBC-6.3 RBC-4.29 Hgb-12.5 Hct-38.3 MCV-89 MCH-29.1 MCHC-32.6 RDW-14.4 RDWSD-46.4* Plt ___ ___ 07:00AM BLOOD Glucose-123* UreaN-13 Creat-0.7 Na-141 K-3.8 Cl-104 HCO3-23 AnGap-18 ___ 07:00AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.3 ___ 03:09AM BLOOD HIV Ab-Negative ___ 04:15PM BLOOD ___ * Titer-1:40 CRP-109.6* Brief Hospital Course: Ms ___ is a ___ w/hx of hypothyroidism, HLD, and possible prior ANCA vasculitis who initially presented with dyspnea with exertion, transferred from urgent care after being found to have bilateral L>R pleural effusions and pericardial effusion. # Pericardial Effusion # DOE/Pleural Effusion Presented with dyspnea associated with non-positional chest aching during respiration. Also with night sweat/chills, fatigue over the last week, although no URI symptoms. Labs with elevated CRP, D-dimer, and CT-A w/moderate pericardial effusion. Mildly low voltage on EKG, though w/o electrical alternans. Hemodynamically stable with no clinical signs of tamponade. TTE shows small pericaridial effusion without tamponade physiology. No history of malignancy, no lesions seen on CT-A. Viral pericarditis is the most likely etiology. Given possible vasculitis history, she was seen by the rheumatology team, who agreed that a viral process is most likely given that she has no symptoms consistent with an active vasculitis or connective tissue disease. No active urine sediment and normal urine protein: creatinine. ___ borderline high (1:40), which can also be elevated during a viral infection. Hypothyroidism unlikely to be contributing with normal TSH, FT4. Trops neg x2. Flu, HIV neg. During the hospitalization she required some supplemental oxygen of ___ L at night for mild hypoxemia likely due to pleural effusions and atelectasis. This improved with incentive spirometry and likely improvement in the pleural effusions. On discharge, her resting and ambulatory O2 saturations were 92-94% on room air. Patient felt significantly better at time of discharge without significant intervention. # Fever Fever to 101.1 on ___ with increasing O2 requirement. CXR with worsening pleural effusion with hard to exclude PNA. No further fevers since. Repeat UA bland. Urine and blood cultures with no growth. Likely due to viral process. No antibiotics were given. CHRONIC ISSUES ============== # Hypothyroidism: c/w home levothyroxine # Psych: c/w home Klonopin # HLD: c/w home statin # Asthma: c/w home singulair, cetirizine # MEDREC: c/w home VitD, MVI ==================== Transitional issues: ==================== - Please repeat oxygen saturation at upcoming visits. - Recommend repeat urinalysis with protein to creatinine ratio if symptoms persist - Recommend CT chest to evaluate for resolution of pleural effusion and pericardial effusion. If persistent or worsening, consider a diagnostic and therapeutic paracentesis. - Updated cancer screening and malignancy workup is deferred to the primary outpatient providers. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob 2. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID:PRN 3. ClonazePAM 0.5 mg PO DAILY 4. Simvastatin 20 mg PO QPM 5. Montelukast 10 mg PO DAILY 6. Tirosint (levothyroxine) 39 mcg oral 6X/WEEK 7. Tirosint (levothyroxine) 26 mcg oral 1X/WEEK 8. Cetirizine 10 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Ciprofloxacin HCl 250 mg PO BID:PRN PRN 11. GuaiFENesin ER 600 mg PO Q12H 12. Multivitamins W/minerals 1 TAB PO DAILY 13. Fish Oil (Omega 3) 1000 mg PO DAILY 14. isometh-dichloral-acetaminophn 65-100-325 mg oral Q6H:PRN 15. ClonazePAM 1 mg PO DAILY Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob 2. Cetirizine 10 mg PO DAILY 3. Ciprofloxacin HCl 250 mg PO BID:PRN PRN 4. ClonazePAM 0.5 mg PO DAILY 5. ClonazePAM 1 mg PO DAILY 6. Fish Oil (Omega 3) 1000 mg PO DAILY 7. GuaiFENesin ER 600 mg PO Q12H 8. isometh-dichloral-acetaminophn 65-100-325 mg oral Q6H:PRN 9. Montelukast 10 mg PO DAILY 10. Multivitamins W/minerals 1 TAB PO DAILY 11. Simvastatin 20 mg PO QPM 12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID:PRN wheeze 13. Tirosint (levothyroxine) 26 mcg oral 1X/WEEK (MO) 14. Tirosint (levothyroxine) 39 mcg oral 6X/WEEK 15. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Pleural effusion Pericardial effusion Discharge Condition: Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at ___. You were admitted because you had fluid around your heart and around your lungs. This was probably a result of "serositis" which is an inflammation of the lining around the heart and lungs. As we discussed, the most likely cause of this is a viral infection and it will probably improve with time. You were also evaluated by the rheumatology team while you were here, and they agree that this is most likely due to a viral infection. If your breathing and other symptoms do not improve over the next few weeks, it is a good idea to return to your primary care provider for more diagnostic workup. Please follow up with your PCP as scheduled. Your ___ team Followup Instructions: ___	[ "I313", "J90", "J9811", "B9789", "E039", "E781", "R0902", "J45909" ]	Allergies: Demerol / Cocaine / Compazine / Augmentin / Ergotamine / Bactrim / Shellfish / Penicillins / Sulfa (Sulfonamide Antibiotics) Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: Ms [MASKED] is a [MASKED] w/hx of hypothyroidism, HLD, and ?vasculitis who initially p/w DOE, transferred from [MASKED] after being found to have b/l L>R pleural effusions and pericardial effusion Pt states has felt generally unwell for the past 1wk, markedly fatigued. +Night sweats and chills. No overt SOB, though patient says her breathing has felt "different, there is something happening in my chest." +Non productive cough. She also notes intermittent R chest and back discomfort, no association with movement/exertion. She has been sleeping upright for comfort. The pt was feeling particularly unwell today, presented to urgent care. She was noted to be tachycardic. Labs were notable for neg trop/BNP and D-dimer 5722. Flu swab was Neg. Pt was HDS and in NAD. She was noted to desat to 88% when ambulating but is NAD at rest. Initial CXR w/evidence of a left pleural effusion. Pt expressed Rt sided pleuritic CP, investigated further with EKG demonstrating TWI aVL/I as well as V2 and TWF laterally with low voltage in the inferior leads, no obvious alternans and no STEMI criteria. CTA was obtained, w/pericardial effusion w/evidence of R heart strain & ?tamponade, L>R pleural effusions, no PE. Pt was given IVF, transferred from [MASKED] to [MASKED] for further eval. No recent travel, Pt w/o hx of breast cancer. Up to date on mammograms. No recent travel. Sigmodioscopy neg in [MASKED]. Neg thyroid scan. In the ED, initial vitals were: T98.6 105 153/75 18 98% RA - Exam notable for: Slightly anxious, circumferential in speech. Decreased bibasilar lung sounds. Tachycardic, regular rhythm, soft systolic ejection murmur best heard at [MASKED], no rubs. No elevated JVP. Abd benign. Pretibial edema L>R. WWP. - Labs notable for: WBC 7.9, Hb 13.3, Plt 252, BNP 121, Na 135, Cr 0.7, Trop neg, D-dimer 5722, Flu rapid Ag neg - Imaging was notable for: CXR w/Lt pleural effusion, CT-A w/Small to moderate amount of pericardial the fusion with evidence of right heart strain. Tamponade physiology is difficult to evaluate on current modality. Further evaluation with echocardiogram and or consultation with interventional cardiology is recommended for pericardiocentesis. -No evidence of pulmonary embolism. - Patient was given: Klonopin 1mg, Montelukast 10mg Upon arrival to the floor, patient reports that Sx started 1.5 wks prior, developed chest soreness, achiness. didn't feel like the flu but muscle aches. diff breathing and pain w/breathing. felt more uncomfortable lying flat. DOE but no SOB at rest. pt's Sx had been steadily improving over the week after last weekend, but then this weekend Sx had worsened again. +C/NS, didn't check for fevers. Dec appetite/PO intake. No sick contacts. +flu vaccine this yr. No abd pain, no n/v/d/c. no rashes. no dysuria/urinary changes. weak, rare dry cough. Had migraine HA in ED, better with midron. No recent med changes, except for [MASKED] med & mild change in thyroid meds. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: PAST MEDICAL HISTORY: ASTHMA CERVICAL SPONDYLOSIS HYPERTRIGLYCERIDEMIA MANIERE'S DISEASE MIGRAINE HEADACHES OLECRANON BURSITIS,LEFT OSTEOPENIA,SPINE SINUSITIS ? VASCULITIS FASTING HYPERGLYCEMIA OSTEOPENIA THYROID NODULE HYPOTHYROIDISM H/O TAH/BSO PAST SURGICAL HISTORY: s/p L oophorectomy for cysts s/p total hysterectomy [MASKED] GYN HISTORY: no h/o abnl paps s/p L oophorectomy for cysts s/p total hysterectomy [MASKED] [MASKED] due in [MASKED]. h/o fibroadenomas Social History: [MASKED] Family History: father: CAD, htn, sarcoma, testicular ca, aneurysms mother: lung cancer (smoker) one brother died of [MASKED] Physical Exam: ADMISSION PHYSICAL EXAM: Vital Signs: 97.9, 147/89, 98, 18, 96 RA, 89.9kg General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, NCAT Neck: Supple. No JVD. CV: RRR. Normal S1+S2, no murmurs, rubs, gallops. Pulsus <5. Lungs: Decreased bibasilar breath sounds Abdomen: Soft, non-tender, non-distended, bowel sounds present, 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 Skin: no rashes observed. Discharge exam: VS: 99 105/68 93 16 92-94% RA resting and ambulating GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, JVP 12cm HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, decreased breath sounds bilaterally ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: Admission: [MASKED] 04:15PM NEUTS-74.4* LYMPHS-12.0* MONOS-10.8 EOS-1.9 BASOS-0.5 IM [MASKED] AbsNeut-5.85# AbsLymp-0.94* AbsMono-0.85* AbsEos-0.15 AbsBaso-0.04 [MASKED] 04:15PM WBC-7.9 RBC-4.50 HGB-13.3 HCT-39.7 MCV-88 MCH-29.6 MCHC-33.5 RDW-14.0 RDWSD-45.0 [MASKED] 04:15PM CRP-109.6* [MASKED] 04:15PM FREE T4-1.1 [MASKED] 04:15PM TSH-1.9 [MASKED] 04:15PM D-DIMER-5722* [MASKED] 04:15PM ALBUMIN-4.3 CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-2.4 [MASKED] 04:15PM CK-MB-<1 proBNP-121 [MASKED] 04:15PM cTropnT-<0.01 [MASKED] 04:15PM ALT(SGPT)-13 AST(SGOT)-17 LD(LDH)-335* CK(CPK)-64 ALK PHOS-59 TOT BILI-0.7 [MASKED] 04:15PM GLUCOSE-131* UREA N-16 CREAT-0.7 SODIUM-135 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-23 ANION GAP-18 IMAGING & STUDIES: - CXR [MASKED] --Small left pleural effusion with overlying atelectasis; underlying left base consolidation is not excluded. - CT-A Chest [MASKED] --Moderate pericardial effusion with straightening of the interventricular septum raising concern for underlying right heart strain which could be further assessed for on echocardiogram. Tamponade physiology is difficult to evaluate on current modality. Further evaluation with echocardiogram and or consultation with interventional cardiology is recommended for pericardiocentesis. --Small bilateral pleural effusions, left greater than right. Subtle perihilar ground-glass opacities could relate to respiratory motion versus mild pulmonary edema. --No evidence of pulmonary embolism. - ECG [MASKED] --HR 104, SR, NA, TWI aVL/V1-V2, diffuse TW flattening, lower end voltage, no priors to compare TTE [MASKED] The left atrium is normal in size. The estimated right atrial pressure is [MASKED] mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is high (>4.0L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is a small circumferential pericardial effusion, most promient (1cm) inferolateral to the left ventricle and anterior to the right ventricular free wall and right atrium. No right atrial or right ventricular diastolic collapse is seen. IMPRESSION: Small circumferential pericardial effusion without echocardiographic evidence for tampmonade physiology. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. No valvular pathology or pathologic flow identified. [MASKED] CXR IMPRESSION: Compared to chest radiographs since [MASKED] most recently [MASKED]. Moderate left pleural effusion and moderately severe left lower lobe atelectasis have worsened since [MASKED]. Pneumonia left lower lobe would be difficult to exclude under the circumstances. No change in diameter of the top-normal cardiac silhouette or distension of mediastinal veins to suggest either cardiac tamponade or substantial increase in pericardial effusion. Right lung and left upper lung are clear. No appreciable right pleural effusion. No pulmonary vascular abnormality. Discharge labs: [MASKED] 07:00AM BLOOD WBC-6.3 RBC-4.29 Hgb-12.5 Hct-38.3 MCV-89 MCH-29.1 MCHC-32.6 RDW-14.4 RDWSD-46.4* Plt [MASKED] [MASKED] 07:00AM BLOOD Glucose-123* UreaN-13 Creat-0.7 Na-141 K-3.8 Cl-104 HCO3-23 AnGap-18 [MASKED] 07:00AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.3 [MASKED] 03:09AM BLOOD HIV Ab-Negative [MASKED] 04:15PM BLOOD [MASKED] * Titer-1:40 CRP-109.6* Brief Hospital Course: Ms [MASKED] is a [MASKED] w/hx of hypothyroidism, HLD, and possible prior ANCA vasculitis who initially presented with dyspnea with exertion, transferred from urgent care after being found to have bilateral L>R pleural effusions and pericardial effusion. # Pericardial Effusion # DOE/Pleural Effusion Presented with dyspnea associated with non-positional chest aching during respiration. Also with night sweat/chills, fatigue over the last week, although no URI symptoms. Labs with elevated CRP, D-dimer, and CT-A w/moderate pericardial effusion. Mildly low voltage on EKG, though w/o electrical alternans. Hemodynamically stable with no clinical signs of tamponade. TTE shows small pericaridial effusion without tamponade physiology. No history of malignancy, no lesions seen on CT-A. Viral pericarditis is the most likely etiology. Given possible vasculitis history, she was seen by the rheumatology team, who agreed that a viral process is most likely given that she has no symptoms consistent with an active vasculitis or connective tissue disease. No active urine sediment and normal urine protein: creatinine. [MASKED] borderline high (1:40), which can also be elevated during a viral infection. Hypothyroidism unlikely to be contributing with normal TSH, FT4. Trops neg x2. Flu, HIV neg. During the hospitalization she required some supplemental oxygen of [MASKED] L at night for mild hypoxemia likely due to pleural effusions and atelectasis. This improved with incentive spirometry and likely improvement in the pleural effusions. On discharge, her resting and ambulatory O2 saturations were 92-94% on room air. Patient felt significantly better at time of discharge without significant intervention. # Fever Fever to 101.1 on [MASKED] with increasing O2 requirement. CXR with worsening pleural effusion with hard to exclude PNA. No further fevers since. Repeat UA bland. Urine and blood cultures with no growth. Likely due to viral process. No antibiotics were given. CHRONIC ISSUES ============== # Hypothyroidism: c/w home levothyroxine # Psych: c/w home Klonopin # HLD: c/w home statin # Asthma: c/w home singulair, cetirizine # MEDREC: c/w home VitD, MVI ==================== Transitional issues: ==================== - Please repeat oxygen saturation at upcoming visits. - Recommend repeat urinalysis with protein to creatinine ratio if symptoms persist - Recommend CT chest to evaluate for resolution of pleural effusion and pericardial effusion. If persistent or worsening, consider a diagnostic and therapeutic paracentesis. - Updated cancer screening and malignancy workup is deferred to the primary outpatient providers. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN sob 2. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID:PRN 3. ClonazePAM 0.5 mg PO DAILY 4. Simvastatin 20 mg PO QPM 5. Montelukast 10 mg PO DAILY 6. Tirosint (levothyroxine) 39 mcg oral 6X/WEEK 7. Tirosint (levothyroxine) 26 mcg oral 1X/WEEK 8. Cetirizine 10 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Ciprofloxacin HCl 250 mg PO BID:PRN PRN 11. GuaiFENesin ER 600 mg PO Q12H 12. Multivitamins W/minerals 1 TAB PO DAILY 13. Fish Oil (Omega 3) 1000 mg PO DAILY 14. isometh-dichloral-acetaminophn 65-100-325 mg oral Q6H:PRN 15. ClonazePAM 1 mg PO DAILY Discharge Medications: 1. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN sob 2. Cetirizine 10 mg PO DAILY 3. Ciprofloxacin HCl 250 mg PO BID:PRN PRN 4. ClonazePAM 0.5 mg PO DAILY 5. ClonazePAM 1 mg PO DAILY 6. Fish Oil (Omega 3) 1000 mg PO DAILY 7. GuaiFENesin ER 600 mg PO Q12H 8. isometh-dichloral-acetaminophn 65-100-325 mg oral Q6H:PRN 9. Montelukast 10 mg PO DAILY 10. Multivitamins W/minerals 1 TAB PO DAILY 11. Simvastatin 20 mg PO QPM 12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID:PRN wheeze 13. Tirosint (levothyroxine) 26 mcg oral 1X/WEEK (MO) 14. Tirosint (levothyroxine) 39 mcg oral 6X/WEEK 15. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Pleural effusion Pericardial effusion Discharge Condition: Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure caring for you at [MASKED]. You were admitted because you had fluid around your heart and around your lungs. This was probably a result of "serositis" which is an inflammation of the lining around the heart and lungs. As we discussed, the most likely cause of this is a viral infection and it will probably improve with time. You were also evaluated by the rheumatology team while you were here, and they agree that this is most likely due to a viral infection. If your breathing and other symptoms do not improve over the next few weeks, it is a good idea to return to your primary care provider for more diagnostic workup. Please follow up with your PCP as scheduled. Your [MASKED] team Followup Instructions: [MASKED]	[]	[ "E039", "J45909" ]	[ "I313: Pericardial effusion (noninflammatory)", "J90: Pleural effusion, not elsewhere classified", "J9811: Atelectasis", "B9789: Other viral agents as the cause of diseases classified elsewhere", "E039: Hypothyroidism, unspecified", "E781: Pure hyperglyceridemia", "R0902: Hypoxemia", "J45909: Unspecified asthma, uncomplicated" ]
10,093,625	25,027,802	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PSYCHIATRY Allergies: mushroom Attending: ___. Chief Complaint: "Just some drama" Major Surgical or Invasive Procedure: None History of Present Illness: Briefly, Mr. ___ is a ___ year old male with reported history of schizoaffective disorder presenting via EMS aftre what he says was an intentional overdose on 7 tablets of Haldol of unknown strength. . Per Dr. ___ ___ ED Initial Psychiatry Consult note: On interview, patient is quite sedated and has difficult time remaining awake and attentive to interview. Patient reports that he was arguing with his baby's mother earlier today. He took 7 tabs of Haldol following in attempt to end his life. Patient does not know strength of tablet (first saying 700mg, then 50 or 100mg tablets) but does report taking it twice a day. He obtains his medications from ___ and does not have current outpatient treaters. Patient reports feeling depressed but denies recent psychotic sx for the last few months. He is currently denying suicidal or homicidal ideation. . Per Dr. ___ ___ Initial Attending ED Psychiatry Consult note: "The presentation is very confusing and inconsistent. The patient has had over 20 psychiatric admissions, was recently discharged from ___ where he had been admitted for assault and battery. He has currently 3 pending charges for assault. When discharged from ___ he was on aripiprazole, clonidine, Depakote and haloperidol. There is however no documentation that the patient has filled any prescriptions. He states that he gets treatment at ___ for the Homeless, ___, but there is no record of him filling his medications. He has carried the diagnosis of depression, has a history of cutting, states that he started cutting at age ___. Reports that he was adopted at age ___, has trauma history from foster care. When I spoke to him he had difficulties waking up but was able to participate. He denied any psychotic symptoms, stated that he wanted an admission 'to stop wanting to kill myself'. He appears quite dependent on the mental health care inpatient system, got irritable when I wanted to discuss his treatment." . In the ED, patient was noted to sedated and on review of vitals by author it appears he was bradycardic at presentation to ___ to ___ with subsequent improvement. Serial ECGs appeared to be normal except for aforementioned sinus bradycardia. He had a prostate exam with tenderness and due to this and bacteriuria was diagnosed with prostatitis and given a single dose of azithromycin and started on doxycycline 100mg BID. He was medically cleared. . On admission interview, patient explained that he was on the phone with his girlfriend when the two were arguing about the name of their unborn child; patient became upset when girlfriend said that she was going to name the child after someone else (e.g. "I got pissed off when she said that she wasn't going to name him ___. Prior to this conversation, patient denied having thoughts of suicide or urges to engage in self-harm, but he recalled becoming acutely overwhelmed with anger and distress so he impulsively ingested Haldol (prescribed from recent admission to ___). Mid-ingestion patient stated that he went to the bathroom and vomited up most of the medication. Unclear if he remained on the phone with his girlfriend during this incident, but girlfriend called EMS after patient informed her of his actions. Regarding the incident, patient reflected, "It was stupid. I shouldn't have done it. I didn't want to die. I don't want to be doing that kind of stuff when I have a kid. My girlfriend was mad at me for doing stuff like that to prove a point." When asked about previous suicide attempts, recalls a prior overdose several years ago from which he did not require medical attention. More recently, patient stated that he tried to "jump in front of traffic" after he was discharged from ___ ED following an emergency psych evaluation (e.g. "I told them that I was suicidal, but they wouldn't send me inpatient. I told them that I'd jump in front of traffic to prove to them that I was suicidal"). . As noted in ED, patient is unable to provide linear or detailed narrative of his psychiatric history; however, recalls being hospitalized first at age ___ for anger outbursts (e.g. "I stabbed a teacher with a pen"..."I kicked my dog when I got upset"). He also stated, "I also have problems with manipulating people." Stated that he was diagnosed with schizoaffective disorder, but denied ever experiencing perceptual disturbances; qualified, "they thought I was psychotic because I would talk to myself when I was younger, but I wasn't hearing any voices." . Reported multiple medication trials, including antipsychotics and mood stabilizers, but patient has been non-adherent following discharge because "they make me sleepy." Identified current providers through ___. . Reports history of legal involvement beginning in adolescence; discloses history of both violent and non-violent offenses, including several charges for assault on corrections officers, EMS staff, and "people in uniform;" currently has open case for A&B on a corrections officer (hearing scheduled for ___ also on probation through ___ of ___. Requested that treatment team contact PO regarding current admission. . Patient currently consumes ___ of marijuana daily; when asked how he finances his habit, he says, "I buy in bulk." Currently receives SSI. Living with family. States that he wants to find work but is having a hard time finding employment. Moved to ___ in ___. Grew up in ___ had IEP in school for learning disability. . COLLATERAL: Per collateral obtained in ED, as per Dr. ___ ___ ED Initial Psychiatry Consult note: "Patient provided contact number for ___, ___. She was happy to receive phone call as she was unsure where he was. Confirms incident of argument earlier today. Reports patient was sending her text messages including "I'm going to hurt myself... I have no reason to live anymore...Tell my son I'm a coward." Relays that patient has not seemed like himself lately with disorganized thought process. She will attempt to confirm dose of Haldol and will call back when able." . REVIEW OF SYSTEMS: As per HPI; also denies current suicidal ideation, violent or homicidal ideation, auditory or visual hallucinations. 10-point ROS completed and negative except for weight loss. . Past Medical History: PAST PSYCHIATRIC HISTORY: per ED consult note by Dr. ___ ___, reviewed and updated with patient as appropriate: -Sx/Dx: Schizoaffective disorder, bipolar disorder, PTSD, ADHD -Hospitalizations: over 20 lifetime, most recently 3 months ago at ___ after assault and battery, ___ at age ___ after stabbing a teacher with a pen -Current treaters and treatment: therapist ___ at ___, no psychiatrist (has been assigned previously but never saw) -Medication trials: endorses multiple medication trials saying only "they made me sleepy." patient reports most recently being on Haldol, Abilify, and Depakote which he says he has not taken since he was last hospitalized. -Self-injury/Suicide attempts: multiple prior suicide attempts including prior overdose in ___ and jumping in front of a car -Harm to others: Denies -Access to weapons: Knives . PAST MEDICAL HISTORY: -PCP: does not know name of PCP but has primary care at ___ -Denies medical problems. . Social History: SUBSTANCE USE HISTORY: He endorses smoking at least ___ of marijuana every day. Asked how he afford it says, "I buy in bulk." Endorses occasional alcohol use. Denies other substance use including cocaine, meth, opiates, or tobacco. . FORENSIC HISTORY: ___ SOCIAL HISTORY: ___ Family History: FAMILY PSYCHIATRIC HISTORY: Not reviewed at this time, but prior documentation indicates depression in patient's mother. . Physical Exam: VITAL SIGNS: ___ 1736 Temp: 97.6 PO BP: 114/76 R Sitting HR: 62 RR: 16 O2 sat: 98% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ . EXAM: General: -HEENT: Normocephalic, atraumatic. Moist mucous membranes, oropharynx clear, supple neck. No scleral icterus. -Cardiovascular: Regular rate and rhythm, S1/S2 heard, no murmurs/rubs/gallops. -Pulmonary: No increased work of breathing. Lungs clear to auscultation bilaterally. No wheezes/rhonchi/rales. -Abdominal: Not assessed. -Extremities: Warm and well-perfused. No edema of the limbs. Pain in left upper extremity on strength testing "I injured it playing basketball" -Skin: A few well-healed linear scars noted on forearm. No rashes. . Neurological: -Cranial Nerves: ---I: Olfaction not tested. ---II: PERRL 3 to 2mm, both directly and consentually; brisk bilaterally. VFF to confrontation. ---III, IV, VI: EOMI without nystagmus ---V: Facial sensation intact to light touch in all distributions ---VII: No facial droop, facial musculature symmetric and ___ strength in upper and lower distributions, bilaterally ---VIII: Hearing intact to finger rub bilaterally ---IX, X: Palate elevates symmetrically ---XI: ___ strength in trapezii and SCM bilaterally ---XII: Tongue protrudes in midline -Motor: Normal bulk and tone bilaterally. No abnormal movements, no tremor. Strength ___ throughout. -Sensory: No deficits to fine touch throughout -DTRs: Not tested. -Coordination: Normal on finger to nose test, no intention tremor noted -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. . Cognition: -Wakefulness/alertness: Awake and alert -Attention: DOWb with 0 errors -Orientation: Oriented to person, time, place, situation -Executive function (go-no go, Luria, trails, FAS): Not tested -Memory: ___ registration, ___ recall after 5 ___ grossly intact -Fund of knowledge: Consistent with education; intact to last 3 presidents -Calculations: 7 quarters = "$1.75" -Abstraction: Interprets book/cover as "don't judge something by how it looks" -Visuospatial: Not assessed -Language: Native ___ speaker, no paraphasic errors, appropriate to conversation . Mental Status: -Appearance: man appearing older than stated age, wearing hospital gown, in no apparent distress -Behavior/Attitude: appears disinterested, attending to his phone at start of interview, superficially engaged, mild psychomotor retardation -Mood: "okay" -Affect: euthymic, restricted range, not irritable or agitated -Speech: normal rate, volume, and tone -Thought process: linear, coherent, no loose associations -Thought Content: ---Safety: Denies current SI/HI ---Delusions: No evidence of paranoia, etc. ---Obsessions/Compulsions: No evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli -Insight: Poor -Judgment: Poor . LABS, IMAGING, AND OTHER STUDIES (___) -CBC/diff with Hgb 11.8, otherwise wnl -BMP wnl -UA with trace protein, 2 urobiln, small amt leuks, 19 WBC, few bacteria, 2 hyaline casts, moderate mucous -UCx pending -Serum and urine tox screens neg . Pertinent Results: CBC (___): WBC-7.4 RBC-4.49* HGB-11.8* HCT-38.5* MCV-86 MCH-26.3 MCHC-30.6* RDW-13.1 RDWSD-40.7 PLT COUNT-245 . BMP (___): GLUCOSE-84 UREA N-11 CREAT-1.0 SODIUM-141 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13 . Urine tox screens (___): bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG . Serum tox screen (___): ASA-NEG ETHANOL-NEG ACETMNPHN-NEG tricyclic-NEG . Urinalysis with microscopy (___): COLOR-Yellow APPEAR-Clear SP ___ BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.0 LEUK-SM* RBC-1 WBC-19* BACTERIA-FEW* YEAST-NONE EPI-0 HYALINE-2* MUCOUS-MOD* . Brief Hospital Course: 1. LEGAL & SAFETY: On admission, the patient declined to sign a conditional voluntary agreement and was admitted on a ___. He was discharged before the ___ expired. He was also placed on 15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. . 2. PSYCHIATRIC: #) Intentional overdose; r/o antisocial personality disorder Patient presented after intentional overdose on unknown quantity of haloperidol. History and collateral supported the narrative that this was an impulsive act of self harm in the setting of an argument with the mother of his baby. It was unclear whether his intention in that moment was to end his life or "prove a point," but he regretted the action during or immediately afterwards and induced vomiting. He reported a history of harming himself and others when overwhelmed beginning at age ___ (as per HPI); patient also acknowledged a history of "manipulating other people," but he declined to elaborate further. It was difficult to determine whether any illicit substance use played contributed to his impulsive ingestion, but he denied being intoxicated prior to and during said ingestion; additionally, toxicology screens obtained in the ED were negative for illicit substances. Regardless, although the patient reportedly carried the diagnoses of bipolar disorder or schizoaffective disorder, there was no evidence to suggest that the patient's impulsive ingestion was the result of a decompensated affective or psychotic disorder. Rather, his presentation was most consistent with cluster B personality disorder (e.g. antisocial personality disorder, borderline personality disorder), in addition to a possible neurodevelopmental disorder or impulse control disorder. . Psychotropics (mood stabilizer, antipsychotic) were re-started for aggression, impulsivity, and behavioral dysregulation. Patient was given Depakote ER 750mg QHS and Abilify 10mg QHS (medications he had previously been prescribed), which patient tolerated without side effects. Haloperidol was not restarted due to patient's reported subjective side effect of oversedation. No further psychotropic medication changes were made. Attempts were made to engage patient in individual therapy and psychoeducation, but patient repeatedly declined to participate. . Given that acute mood and psychotic symptoms remained absent throughout the admission, it was determined that a short hospitalization would be most appropriate for acute stabilization and aftercare planning, but that a longer hospitalization would be unlikely to provide any benefit to patient, and negatively impact his ability to function in the community by reinforcing maladaptive behaviors (e.g. impulsive self-harm) for the purpose of manipulating others or instrumental suicidal ideation (e.g. escalating threats of self-harm in order to be admitted to ___ facility, as per HPI). Therefore, patient was discharged shortly after admission following confirmation that patient has community based support through ___ (see below). Throughout his brief hospital course, he was superficially engaged, became irritable when challenged to change his beliefs or behaviors, and demonstrated poor insight and judgment. However, he did not exhibit any unsafe behaviors, he remained medication complaint, and he demonstrated adequate self care, euthymic affect (except when challenged), and linear thought process. He consistently denied suicidal ideation and violent/homicidal ideation. . On the day of discharge, he expressed his intent to followup with his probation officer. He also stated that he would follow up with his outpatient providers and would continue taking his medications. Outpatient providers should assess for adherence and tolerability of medications and symptom improvement. Given that patient has a history of medication non-adherence, would strongly recommend transitioning to long-acting injectable form of antipsychotic medication (Abilify Maintenna, administered monthly); additionally, would also recommend monitoring of Depakote blood level as a measure of patient adherence to treatment. . 3. SUBSTANCE USE DISORDERS: #) Cannabis use disorder Patient reports smoking ___ of marijuana daily. He denied adverse consequences. He was precontemplative regarding cutting down or quitting, and he resisted attempts at psychoeducation. Outpatient providers should continue to counsel patient about cannabis use. . 4. MEDICAL #) Prostatitis Patient had abnormal urinalysis and prostate tenderness on digital rectal exam in the emergency department. He was given a single dose of azithromycin and started on a 14 day course of doxycycline 100mg BID, which was prescribed at the time of discharge. He did not complain of symptoms. Patient's PCP should consider offering STI screening, which was not performed during the hospitalization. . #) Bradycardia Patient intermittently had heart rate to ___ throughout his time in the ED and hospital but he denied symptoms, had normal cardiovascular exam, maintained normal blood pressure, and ECG showed normal sinus rhythm. Therefore this was felt to be physiologic with no need for further workup. . 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The patient attended a group about stress management where he made relevant contributions. He was otherwise largely isolative and infrequently seen in milieu. . #) COLLATERAL CONTACTS & FAMILY INVOLVEMENT Contacted patient's baby's mother ___ ___ for collateral information, as documented in history of present illness. . Spoke with patient's probation officer, ___ Division, ___, ___ ___ Phone: ___ Fax: ___) who confirmed that the patient is involved with the Bridges to Justice program at ___ (i.e. mental health session at ___. He has been working with his attorney and social worker, ___ (___), at ___'s jail diversion program to provide additional support in the community (e.g. Father's ___ program which mentors young fathers). Ms. ___ indicated that the patient has been inconsistent in his willingness to participate in community based programming as terms of his probation, but confirmed that the court/probation has been actively working to engage him further. Ms. ___ confirmed that the patient could check in with her at ___ immediately following discharge. . Contacted ___ ___, ___ Phone: ___ confirmed that patient has a primary care physician ___) who he last saw on ___. Last saw therapist, ___, on ___. Was scheduled to see her on ___ but no showed to appointment. Patient was to attend at least three therapy appointments before seeing a prescriber. . #) INTERVENTIONS - Medications: started Depakote ER 750mg QHS, started Abilify 10mg QHS, gave 1 dose of azithromycin, started doxycycline 100mg x14 days - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: arranged followup with probation officer (same office also provides support through Bridge program for prevention of re-offense), psychotherapy (and psychiatrist after attending therapy appointments), and primary care - Behavioral Interventions: encouraged stress management and coping skills - Guardianships: n/a . INFORMED CONSENT: Depakote, Abilify, Doxycycline The team discussed the indications for, intended benefits of, and possible side effects and risks of starting this medication, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team. The patient appeared able to understand and consented to begin the medication. . RISK ASSESSMENT & PROGNOSIS On presentation, the patient was evaluated and felt to be at an increased risk of harm to himself based on intentional overdose. Their static factors noted at that time include history of suicide attempts, history of abuse/trauma, history of substance abuse, recent discharge from an inpatient psychiatric unit, male gender, age, single relationship status, and presence of a concurrent personality disorder. The modifiable risk factors included poor medication compliance, narcissistic vulnerability, active substance abuse, lack of engagement with outpatient treatment, and poor coping skills. These were addressed through psychopharmacologic management, individual therapy/psychoeducation, group therapy, and milieu, with possible improvement (patient reported willingness to take medications and attend outpatient appointments). Patient is being discharged with many protective risk factors, including social supports from family and significant other, and extensive array of outpatient providers (although patient does not consistently engage). Overall, based on totality of evidence patient was determined to no longer be at acutely elevated risk of harm to self or others, however based on static risk factors will continue to be at chronically elevated risk to self and others. . MODIFIABLE RISK FACTORS - medication noncompliance - inconsistent engagement with outpatient treatment - limited coping skills - active substance abuse - impulsivity - polarized thinking - poor problem-solving skills - poor tolerance for rejection . PROTECTIVE RISK FACTORS - future-oriented viewpoint - sense of responsibility to child - lack of current suicidal ideation - extensive support from outpatient providers - presence of social supports . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ARIPiprazole Dose is Unknown PO DAILY 2. Haloperidol Dose is Unknown PO QHS 3. Divalproex (DELayed Release) 500 mg PO QHS Discharge Medications: 1. Doxycycline Hyclate 100 mg PO Q12H Take 1 pill twice per day for 12 more days (24 more doses) even if you feel better. RX doxycycline hyclate 100 mg 1 tablet(s) by mouth twice daily Disp #24 Tablet Refills:0 2. ARIPiprazole 10 mg PO QHS RX aripiprazole 10 mg 1 tablet(s) by mouth at bedtime Disp #14 Tablet Refills:0 3. Divalproex (EXTended Release) 750 mg PO QHS RX divalproex ___ mg 3 tablet(s) by mouth at bedtime Disp #42 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: - Conduct disorder, Unspecified onset - Unspecified disruptive, impulse-control, and conduct disorder - Other specified neurodevelopmental disorder - Cannabis use disorder, Severe . Discharge Condition: Vital signs: Temp 98.2, BP 105/66, HR 48, RR 18, O2 sat 99% RA . Mental Status: -Appearance: man appearing somewhat older than stated age, wearing hospital gown, in no apparent distress -Behavior/Attitude: superficially engaged, remains in bed during interview and complains about early interview time at 9:30AM -Mood: 'fine' -Affect: euthymic, restricted range, irritable when challenged -Speech: normal rate, volume, and tone -Thought process: linear, coherent, no loose associations -Thought Content: ---Safety: Denies current SI/HI ---Delusions: No evidence of paranoia, etc. ---Obsessions/Compulsions: No evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli -Insight: Poor -Judgment: Poor . Level of Consciousness: Alert and interactive. 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: ___	[ "F919", "F259", "Z9114", "F1220", "F639", "F88", "T434X2A", "Y929", "F4310", "F909", "N419", "R001", "Z915", "Z653" ]	Allergies: mushroom Chief Complaint: "Just some drama" Major Surgical or Invasive Procedure: None History of Present Illness: Briefly, Mr. [MASKED] is a [MASKED] year old male with reported history of schizoaffective disorder presenting via EMS aftre what he says was an intentional overdose on 7 tablets of Haldol of unknown strength. . Per Dr. [MASKED] [MASKED] ED Initial Psychiatry Consult note: On interview, patient is quite sedated and has difficult time remaining awake and attentive to interview. Patient reports that he was arguing with his baby's mother earlier today. He took 7 tabs of Haldol following in attempt to end his life. Patient does not know strength of tablet (first saying 700mg, then 50 or 100mg tablets) but does report taking it twice a day. He obtains his medications from [MASKED] and does not have current outpatient treaters. Patient reports feeling depressed but denies recent psychotic sx for the last few months. He is currently denying suicidal or homicidal ideation. . Per Dr. [MASKED] [MASKED] Initial Attending ED Psychiatry Consult note: "The presentation is very confusing and inconsistent. The patient has had over 20 psychiatric admissions, was recently discharged from [MASKED] where he had been admitted for assault and battery. He has currently 3 pending charges for assault. When discharged from [MASKED] he was on aripiprazole, clonidine, Depakote and haloperidol. There is however no documentation that the patient has filled any prescriptions. He states that he gets treatment at [MASKED] for the Homeless, [MASKED], but there is no record of him filling his medications. He has carried the diagnosis of depression, has a history of cutting, states that he started cutting at age [MASKED]. Reports that he was adopted at age [MASKED], has trauma history from foster care. When I spoke to him he had difficulties waking up but was able to participate. He denied any psychotic symptoms, stated that he wanted an admission 'to stop wanting to kill myself'. He appears quite dependent on the mental health care inpatient system, got irritable when I wanted to discuss his treatment." . In the ED, patient was noted to sedated and on review of vitals by author it appears he was bradycardic at presentation to [MASKED] to [MASKED] with subsequent improvement. Serial ECGs appeared to be normal except for aforementioned sinus bradycardia. He had a prostate exam with tenderness and due to this and bacteriuria was diagnosed with prostatitis and given a single dose of azithromycin and started on doxycycline 100mg BID. He was medically cleared. . On admission interview, patient explained that he was on the phone with his girlfriend when the two were arguing about the name of their unborn child; patient became upset when girlfriend said that she was going to name the child after someone else (e.g. "I got pissed off when she said that she wasn't going to name him [MASKED]. Prior to this conversation, patient denied having thoughts of suicide or urges to engage in self-harm, but he recalled becoming acutely overwhelmed with anger and distress so he impulsively ingested Haldol (prescribed from recent admission to [MASKED]). Mid-ingestion patient stated that he went to the bathroom and vomited up most of the medication. Unclear if he remained on the phone with his girlfriend during this incident, but girlfriend called EMS after patient informed her of his actions. Regarding the incident, patient reflected, "It was stupid. I shouldn't have done it. I didn't want to die. I don't want to be doing that kind of stuff when I have a kid. My girlfriend was mad at me for doing stuff like that to prove a point." When asked about previous suicide attempts, recalls a prior overdose several years ago from which he did not require medical attention. More recently, patient stated that he tried to "jump in front of traffic" after he was discharged from [MASKED] ED following an emergency psych evaluation (e.g. "I told them that I was suicidal, but they wouldn't send me inpatient. I told them that I'd jump in front of traffic to prove to them that I was suicidal"). . As noted in ED, patient is unable to provide linear or detailed narrative of his psychiatric history; however, recalls being hospitalized first at age [MASKED] for anger outbursts (e.g. "I stabbed a teacher with a pen"..."I kicked my dog when I got upset"). He also stated, "I also have problems with manipulating people." Stated that he was diagnosed with schizoaffective disorder, but denied ever experiencing perceptual disturbances; qualified, "they thought I was psychotic because I would talk to myself when I was younger, but I wasn't hearing any voices." . Reported multiple medication trials, including antipsychotics and mood stabilizers, but patient has been non-adherent following discharge because "they make me sleepy." Identified current providers through [MASKED]. . Reports history of legal involvement beginning in adolescence; discloses history of both violent and non-violent offenses, including several charges for assault on corrections officers, EMS staff, and "people in uniform;" currently has open case for A&B on a corrections officer (hearing scheduled for [MASKED] also on probation through [MASKED] of [MASKED]. Requested that treatment team contact PO regarding current admission. . Patient currently consumes [MASKED] of marijuana daily; when asked how he finances his habit, he says, "I buy in bulk." Currently receives SSI. Living with family. States that he wants to find work but is having a hard time finding employment. Moved to [MASKED] in [MASKED]. Grew up in [MASKED] had IEP in school for learning disability. . COLLATERAL: Per collateral obtained in ED, as per Dr. [MASKED] [MASKED] ED Initial Psychiatry Consult note: "Patient provided contact number for [MASKED], [MASKED]. She was happy to receive phone call as she was unsure where he was. Confirms incident of argument earlier today. Reports patient was sending her text messages including "I'm going to hurt myself... I have no reason to live anymore...Tell my son I'm a coward." Relays that patient has not seemed like himself lately with disorganized thought process. She will attempt to confirm dose of Haldol and will call back when able." . REVIEW OF SYSTEMS: As per HPI; also denies current suicidal ideation, violent or homicidal ideation, auditory or visual hallucinations. 10-point ROS completed and negative except for weight loss. . Past Medical History: PAST PSYCHIATRIC HISTORY: per ED consult note by Dr. [MASKED] [MASKED], reviewed and updated with patient as appropriate: -Sx/Dx: Schizoaffective disorder, bipolar disorder, PTSD, ADHD -Hospitalizations: over 20 lifetime, most recently 3 months ago at [MASKED] after assault and battery, [MASKED] at age [MASKED] after stabbing a teacher with a pen -Current treaters and treatment: therapist [MASKED] at [MASKED], no psychiatrist (has been assigned previously but never saw) -Medication trials: endorses multiple medication trials saying only "they made me sleepy." patient reports most recently being on Haldol, Abilify, and Depakote which he says he has not taken since he was last hospitalized. -Self-injury/Suicide attempts: multiple prior suicide attempts including prior overdose in [MASKED] and jumping in front of a car -Harm to others: Denies -Access to weapons: Knives . PAST MEDICAL HISTORY: -PCP: does not know name of PCP but has primary care at [MASKED] -Denies medical problems. . Social History: SUBSTANCE USE HISTORY: He endorses smoking at least [MASKED] of marijuana every day. Asked how he afford it says, "I buy in bulk." Endorses occasional alcohol use. Denies other substance use including cocaine, meth, opiates, or tobacco. . FORENSIC HISTORY: [MASKED] SOCIAL HISTORY: [MASKED] Family History: FAMILY PSYCHIATRIC HISTORY: Not reviewed at this time, but prior documentation indicates depression in patient's mother. . Physical Exam: VITAL SIGNS: [MASKED] 1736 Temp: 97.6 PO BP: 114/76 R Sitting HR: 62 RR: 16 O2 sat: 98% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: [MASKED] . EXAM: General: -HEENT: Normocephalic, atraumatic. Moist mucous membranes, oropharynx clear, supple neck. No scleral icterus. -Cardiovascular: Regular rate and rhythm, S1/S2 heard, no murmurs/rubs/gallops. -Pulmonary: No increased work of breathing. Lungs clear to auscultation bilaterally. No wheezes/rhonchi/rales. -Abdominal: Not assessed. -Extremities: Warm and well-perfused. No edema of the limbs. Pain in left upper extremity on strength testing "I injured it playing basketball" -Skin: A few well-healed linear scars noted on forearm. No rashes. . Neurological: -Cranial Nerves: ---I: Olfaction not tested. ---II: PERRL 3 to 2mm, both directly and consentually; brisk bilaterally. VFF to confrontation. ---III, IV, VI: EOMI without nystagmus ---V: Facial sensation intact to light touch in all distributions ---VII: No facial droop, facial musculature symmetric and [MASKED] strength in upper and lower distributions, bilaterally ---VIII: Hearing intact to finger rub bilaterally ---IX, X: Palate elevates symmetrically ---XI: [MASKED] strength in trapezii and SCM bilaterally ---XII: Tongue protrudes in midline -Motor: Normal bulk and tone bilaterally. No abnormal movements, no tremor. Strength [MASKED] throughout. -Sensory: No deficits to fine touch throughout -DTRs: Not tested. -Coordination: Normal on finger to nose test, no intention tremor noted -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. . Cognition: -Wakefulness/alertness: Awake and alert -Attention: DOWb with 0 errors -Orientation: Oriented to person, time, place, situation -Executive function (go-no go, Luria, trails, FAS): Not tested -Memory: [MASKED] registration, [MASKED] recall after 5 [MASKED] grossly intact -Fund of knowledge: Consistent with education; intact to last 3 presidents -Calculations: 7 quarters = "$1.75" -Abstraction: Interprets book/cover as "don't judge something by how it looks" -Visuospatial: Not assessed -Language: Native [MASKED] speaker, no paraphasic errors, appropriate to conversation . Mental Status: -Appearance: man appearing older than stated age, wearing hospital gown, in no apparent distress -Behavior/Attitude: appears disinterested, attending to his phone at start of interview, superficially engaged, mild psychomotor retardation -Mood: "okay" -Affect: euthymic, restricted range, not irritable or agitated -Speech: normal rate, volume, and tone -Thought process: linear, coherent, no loose associations -Thought Content: ---Safety: Denies current SI/HI ---Delusions: No evidence of paranoia, etc. ---Obsessions/Compulsions: No evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli -Insight: Poor -Judgment: Poor . LABS, IMAGING, AND OTHER STUDIES ([MASKED]) -CBC/diff with Hgb 11.8, otherwise wnl -BMP wnl -UA with trace protein, 2 urobiln, small amt leuks, 19 WBC, few bacteria, 2 hyaline casts, moderate mucous -UCx pending -Serum and urine tox screens neg . Pertinent Results: CBC ([MASKED]): WBC-7.4 RBC-4.49* HGB-11.8* HCT-38.5* MCV-86 MCH-26.3 MCHC-30.6* RDW-13.1 RDWSD-40.7 PLT COUNT-245 . BMP ([MASKED]): GLUCOSE-84 UREA N-11 CREAT-1.0 SODIUM-141 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13 . Urine tox screens ([MASKED]): bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG . Serum tox screen ([MASKED]): ASA-NEG ETHANOL-NEG ACETMNPHN-NEG tricyclic-NEG . Urinalysis with microscopy ([MASKED]): COLOR-Yellow APPEAR-Clear SP [MASKED] BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.0 LEUK-SM* RBC-1 WBC-19* BACTERIA-FEW* YEAST-NONE EPI-0 HYALINE-2* MUCOUS-MOD* . Brief Hospital Course: 1. LEGAL & SAFETY: On admission, the patient declined to sign a conditional voluntary agreement and was admitted on a [MASKED]. He was discharged before the [MASKED] expired. He was also placed on 15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. . 2. PSYCHIATRIC: #) Intentional overdose; r/o antisocial personality disorder Patient presented after intentional overdose on unknown quantity of haloperidol. History and collateral supported the narrative that this was an impulsive act of self harm in the setting of an argument with the mother of his baby. It was unclear whether his intention in that moment was to end his life or "prove a point," but he regretted the action during or immediately afterwards and induced vomiting. He reported a history of harming himself and others when overwhelmed beginning at age [MASKED] (as per HPI); patient also acknowledged a history of "manipulating other people," but he declined to elaborate further. It was difficult to determine whether any illicit substance use played contributed to his impulsive ingestion, but he denied being intoxicated prior to and during said ingestion; additionally, toxicology screens obtained in the ED were negative for illicit substances. Regardless, although the patient reportedly carried the diagnoses of bipolar disorder or schizoaffective disorder, there was no evidence to suggest that the patient's impulsive ingestion was the result of a decompensated affective or psychotic disorder. Rather, his presentation was most consistent with cluster B personality disorder (e.g. antisocial personality disorder, borderline personality disorder), in addition to a possible neurodevelopmental disorder or impulse control disorder. . Psychotropics (mood stabilizer, antipsychotic) were re-started for aggression, impulsivity, and behavioral dysregulation. Patient was given Depakote ER 750mg QHS and Abilify 10mg QHS (medications he had previously been prescribed), which patient tolerated without side effects. Haloperidol was not restarted due to patient's reported subjective side effect of oversedation. No further psychotropic medication changes were made. Attempts were made to engage patient in individual therapy and psychoeducation, but patient repeatedly declined to participate. . Given that acute mood and psychotic symptoms remained absent throughout the admission, it was determined that a short hospitalization would be most appropriate for acute stabilization and aftercare planning, but that a longer hospitalization would be unlikely to provide any benefit to patient, and negatively impact his ability to function in the community by reinforcing maladaptive behaviors (e.g. impulsive self-harm) for the purpose of manipulating others or instrumental suicidal ideation (e.g. escalating threats of self-harm in order to be admitted to [MASKED] facility, as per HPI). Therefore, patient was discharged shortly after admission following confirmation that patient has community based support through [MASKED] (see below). Throughout his brief hospital course, he was superficially engaged, became irritable when challenged to change his beliefs or behaviors, and demonstrated poor insight and judgment. However, he did not exhibit any unsafe behaviors, he remained medication complaint, and he demonstrated adequate self care, euthymic affect (except when challenged), and linear thought process. He consistently denied suicidal ideation and violent/homicidal ideation. . On the day of discharge, he expressed his intent to followup with his probation officer. He also stated that he would follow up with his outpatient providers and would continue taking his medications. Outpatient providers should assess for adherence and tolerability of medications and symptom improvement. Given that patient has a history of medication non-adherence, would strongly recommend transitioning to long-acting injectable form of antipsychotic medication (Abilify Maintenna, administered monthly); additionally, would also recommend monitoring of Depakote blood level as a measure of patient adherence to treatment. . 3. SUBSTANCE USE DISORDERS: #) Cannabis use disorder Patient reports smoking [MASKED] of marijuana daily. He denied adverse consequences. He was precontemplative regarding cutting down or quitting, and he resisted attempts at psychoeducation. Outpatient providers should continue to counsel patient about cannabis use. . 4. MEDICAL #) Prostatitis Patient had abnormal urinalysis and prostate tenderness on digital rectal exam in the emergency department. He was given a single dose of azithromycin and started on a 14 day course of doxycycline 100mg BID, which was prescribed at the time of discharge. He did not complain of symptoms. Patient's PCP should consider offering STI screening, which was not performed during the hospitalization. . #) Bradycardia Patient intermittently had heart rate to [MASKED] throughout his time in the ED and hospital but he denied symptoms, had normal cardiovascular exam, maintained normal blood pressure, and ECG showed normal sinus rhythm. Therefore this was felt to be physiologic with no need for further workup. . 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The patient attended a group about stress management where he made relevant contributions. He was otherwise largely isolative and infrequently seen in milieu. . #) COLLATERAL CONTACTS & FAMILY INVOLVEMENT Contacted patient's baby's mother [MASKED] [MASKED] for collateral information, as documented in history of present illness. . Spoke with patient's probation officer, [MASKED] Division, [MASKED], [MASKED] [MASKED] Phone: [MASKED] Fax: [MASKED]) who confirmed that the patient is involved with the Bridges to Justice program at [MASKED] (i.e. mental health session at [MASKED]. He has been working with his attorney and social worker, [MASKED] ([MASKED]), at [MASKED]'s jail diversion program to provide additional support in the community (e.g. Father's [MASKED] program which mentors young fathers). Ms. [MASKED] indicated that the patient has been inconsistent in his willingness to participate in community based programming as terms of his probation, but confirmed that the court/probation has been actively working to engage him further. Ms. [MASKED] confirmed that the patient could check in with her at [MASKED] immediately following discharge. . Contacted [MASKED] [MASKED], [MASKED] Phone: [MASKED] confirmed that patient has a primary care physician [MASKED]) who he last saw on [MASKED]. Last saw therapist, [MASKED], on [MASKED]. Was scheduled to see her on [MASKED] but no showed to appointment. Patient was to attend at least three therapy appointments before seeing a prescriber. . #) INTERVENTIONS - Medications: started Depakote ER 750mg QHS, started Abilify 10mg QHS, gave 1 dose of azithromycin, started doxycycline 100mg x14 days - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: arranged followup with probation officer (same office also provides support through Bridge program for prevention of re-offense), psychotherapy (and psychiatrist after attending therapy appointments), and primary care - Behavioral Interventions: encouraged stress management and coping skills - Guardianships: n/a . INFORMED CONSENT: Depakote, Abilify, Doxycycline The team discussed the indications for, intended benefits of, and possible side effects and risks of starting this medication, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team. The patient appeared able to understand and consented to begin the medication. . RISK ASSESSMENT & PROGNOSIS On presentation, the patient was evaluated and felt to be at an increased risk of harm to himself based on intentional overdose. Their static factors noted at that time include history of suicide attempts, history of abuse/trauma, history of substance abuse, recent discharge from an inpatient psychiatric unit, male gender, age, single relationship status, and presence of a concurrent personality disorder. The modifiable risk factors included poor medication compliance, narcissistic vulnerability, active substance abuse, lack of engagement with outpatient treatment, and poor coping skills. These were addressed through psychopharmacologic management, individual therapy/psychoeducation, group therapy, and milieu, with possible improvement (patient reported willingness to take medications and attend outpatient appointments). Patient is being discharged with many protective risk factors, including social supports from family and significant other, and extensive array of outpatient providers (although patient does not consistently engage). Overall, based on totality of evidence patient was determined to no longer be at acutely elevated risk of harm to self or others, however based on static risk factors will continue to be at chronically elevated risk to self and others. . MODIFIABLE RISK FACTORS - medication noncompliance - inconsistent engagement with outpatient treatment - limited coping skills - active substance abuse - impulsivity - polarized thinking - poor problem-solving skills - poor tolerance for rejection . PROTECTIVE RISK FACTORS - future-oriented viewpoint - sense of responsibility to child - lack of current suicidal ideation - extensive support from outpatient providers - presence of social supports . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ARIPiprazole Dose is Unknown PO DAILY 2. Haloperidol Dose is Unknown PO QHS 3. Divalproex (DELayed Release) 500 mg PO QHS Discharge Medications: 1. Doxycycline Hyclate 100 mg PO Q12H Take 1 pill twice per day for 12 more days (24 more doses) even if you feel better. RX doxycycline hyclate 100 mg 1 tablet(s) by mouth twice daily Disp #24 Tablet Refills:0 2. ARIPiprazole 10 mg PO QHS RX aripiprazole 10 mg 1 tablet(s) by mouth at bedtime Disp #14 Tablet Refills:0 3. Divalproex (EXTended Release) 750 mg PO QHS RX divalproex [MASKED] mg 3 tablet(s) by mouth at bedtime Disp #42 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: - Conduct disorder, Unspecified onset - Unspecified disruptive, impulse-control, and conduct disorder - Other specified neurodevelopmental disorder - Cannabis use disorder, Severe . Discharge Condition: Vital signs: Temp 98.2, BP 105/66, HR 48, RR 18, O2 sat 99% RA . Mental Status: -Appearance: man appearing somewhat older than stated age, wearing hospital gown, in no apparent distress -Behavior/Attitude: superficially engaged, remains in bed during interview and complains about early interview time at 9:30AM -Mood: 'fine' -Affect: euthymic, restricted range, irritable when challenged -Speech: normal rate, volume, and tone -Thought process: linear, coherent, no loose associations -Thought Content: ---Safety: Denies current SI/HI ---Delusions: No evidence of paranoia, etc. ---Obsessions/Compulsions: No evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli -Insight: Poor -Judgment: Poor . Level of Consciousness: Alert and interactive. 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]	[]	[ "Y929" ]	[ "F919: Conduct disorder, unspecified", "F259: Schizoaffective disorder, unspecified", "Z9114: Patient's other noncompliance with medication regimen", "F1220: Cannabis dependence, uncomplicated", "F639: Impulse disorder, unspecified", "F88: Other disorders of psychological development", "T434X2A: Poisoning by butyrophenone and thiothixene neuroleptics, intentional self-harm, initial encounter", "Y929: Unspecified place or not applicable", "F4310: Post-traumatic stress disorder, unspecified", "F909: Attention-deficit hyperactivity disorder, unspecified type", "N419: Inflammatory disease of prostate, unspecified", "R001: Bradycardia, unspecified", "Z915: Personal history of self-harm", "Z653: Problems related to other legal circumstances" ]
10,093,718	21,035,395	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: benzo withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ gentleman with complex psychiatric hx and benzo abuse including withdrawal seizures who presented with jitteriness, mild tremors, tachycardia (up to 150s in the ED) in the setting of not using benzos in ___ prior to arrival; admitted for benzo withdrawal. In the ED, was given 10mg IV valium and transitioned to PO valium. initial vitals in the ED were HR 150 153/91, R 20 100% on RA. His tachycardia improved after the valium to 94. He asked me to take him to another room for the interview because he was embarrassed to talk with his roommate there. Mr. ___ admitted to taking crystal meth earlier in the week. states that he became homeless in ___ after he moved out of the house o his childs mother and is "sick of the lifestyle." he came to the ED because he had had seizures when he has tried to self detox in the past and felt like he wanted to do it in a monitored setting. notes passive SI like, "if something were to happen to me I wouldn't be that worried" but notes that he was worried about having seizures which prompted him to come to the ED. Denies ever having had a low sodium in the past. Every day recently he has been taking EITHER about ___ Xanax per day OR about ___ of klonopin; whichever he is able to buy off the street. His last dose of Xanax was ___ on ___. ROS: (+)palpitations (-)seizures, LOC, nausea, vomiting, chest pain, SOB Remainder of comprehensive 10 point ROS it otherwise negative. Past Medical History: HCV, congenital kyphosis with disc, asthmaherniation, shattered L zygomatic bone s/p surgical repair. PSYCHIATRIC HISTORY: Pt reported major depression, generalized anxiety disorder,panic disorder and obsessive-compulsive disorder. He has been hospitalized for psychiatric reasons several times, first around age ___ after a "bad trip" on LSD. He reports ___ prior suicide attempts. All but one have been overdoses on pills, first with Soma at age ~___. His most recent suicide attempt was ___ ago when he was hospitalized in ___ for detox and tried to asfixiate himself with a plastic bag. He does not identify specific stressors or triggers for his suicide attempts, but states that he has always been using or recovering from using drugs. He has reports a history of violent behavior although he denies having ever seriously injured anyone. Mr. ___ reports that he has tried a number of antidepressants which have been somewhat helpful. He thinks the fluoxetine started in ___ hospitalization was the most helpful; he took it for 3 weeks. He c/o sexual side effects from several other antidepressants. He finds his current gabapentin to be very helpful for his mood, his anxiety and his back pain. He has also tried ECT in the past and found it to be somewhat helpful. Social History: ___ Family History: Denies any family history of mental illness, substance abuse or addiction, suicide or suicide attempts. Per past OMR notes, father has bipolar disorder and is recovering from chemical dependency Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.4 120/76 ___ R18 99% on RA GEN: Alert but anxious and interactive. HEENT: MMM, anicteric sclera, no conjunctival pallor NECK: Supple without LAD PULM: Clear, no wheeze, rales, or rhonchi COR: tachy, reg rhythm, normal S1/S2, no murmurs ABD: Soft, NT ND, normal BS EXTREM: Warm, no edema SKIN: no stigmata of chronic liver disease, scaly red patches all over - non appear infected NEURO: CN II-XII grossly intact, motor function grossly normal, very fine tremor on outstretched hands, no asterixis Discharge Exam not performed because patient eloped Pertinent Results: ___ 04:43AM URINE HOURS-RANDOM ___ 04:43AM URINE HOURS-RANDOM ___ 04:43AM URINE HOURS-RANDOM ___ 04:43AM URINE UHOLD-HOLD ___ 04:43AM URINE GR HOLD-HOLD ___ 04:43AM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG amphetmn-POS oxycodn-NEG mthdone-NEG ___ 12:25AM K+-4.8 ___ 12:20AM GLUCOSE-100 UREA N-12 CREAT-1.1 SODIUM-131* POTASSIUM-GREATERTHA CHLORIDE-98 TOTAL CO2-23 ___ 12:20AM estGFR-Using this ___ 12:20AM WBC-12.3* RBC-5.01 HGB-14.1 HCT-42.2 MCV-84 MCH-28.1 MCHC-33.4 RDW-13.0 RDWSD-39.1 ___ 12:20AM NEUTS-62.0 ___ MONOS-9.8 EOS-1.4 BASOS-0.4 IM ___ AbsNeut-7.60* AbsLymp-3.22 AbsMono-1.20* AbsEos-0.17 AbsBaso-0.05 ___ 12:20AM PLT COUNT-257 Brief Hospital Course: Mr. ___ is a ___ gentleman with complex psychiatric hx, asthma, polysubstance abuse including benzo abuse including withdrawal seizures who presented with jitteriness, mild tremors, tachycardia (up to 150s in the ED) in the setting of not using benzos in ___ prior to arrival and admitted to taking crystal meth earlier in the week; admitted for benzo withdrawal. Also found to have asymptomatic hyponatremia on admission which resolved without specific intervention. Tachycardia was much improved with standing benzodiazepines. He noted a few occasional 'hallucinations' consisting of seeing some patterns in his vision but otherwise his withdrawal symptoms were fairly uncomplicated. His tremors improved although he did experience some anxiety and requested restarting his adderral which was granted. Unfortunately, on the afternoon of ___, he eloped. No one actually saw him leave but we suspect he escaped from the side exit on the 8 ___ unit. His backpack and other belongings were gone as well. He had threatened to leave earlier in the day and I conceded in restarting half of his home dose of Adderall (due to tachycardia) and he agreed to stay in the hospital. At that time, I discussed the risks of leaving the hospital including seizures and death which he expressed good understanding of. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H PRN 2. Amphetamine-Dextroamphetamine 30 mg PO BID Discharge Disposition: Home Facility: ___ Discharge Diagnosis: the patient left against medical advice Discharge Condition: the patient left against medical advice Discharge Instructions: the patient left against medical advice Followup Instructions: ___	[ "F19939", "E871", "R000", "F909", "J45909", "Z590" ]	Allergies: Sulfa (Sulfonamide Antibiotics) Chief Complaint: benzo withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [MASKED] is a [MASKED] gentleman with complex psychiatric hx and benzo abuse including withdrawal seizures who presented with jitteriness, mild tremors, tachycardia (up to 150s in the ED) in the setting of not using benzos in [MASKED] prior to arrival; admitted for benzo withdrawal. In the ED, was given 10mg IV valium and transitioned to PO valium. initial vitals in the ED were HR 150 153/91, R 20 100% on RA. His tachycardia improved after the valium to 94. He asked me to take him to another room for the interview because he was embarrassed to talk with his roommate there. Mr. [MASKED] admitted to taking crystal meth earlier in the week. states that he became homeless in [MASKED] after he moved out of the house o his childs mother and is "sick of the lifestyle." he came to the ED because he had had seizures when he has tried to self detox in the past and felt like he wanted to do it in a monitored setting. notes passive SI like, "if something were to happen to me I wouldn't be that worried" but notes that he was worried about having seizures which prompted him to come to the ED. Denies ever having had a low sodium in the past. Every day recently he has been taking EITHER about [MASKED] Xanax per day OR about [MASKED] of klonopin; whichever he is able to buy off the street. His last dose of Xanax was [MASKED] on [MASKED]. ROS: (+)palpitations (-)seizures, LOC, nausea, vomiting, chest pain, SOB Remainder of comprehensive 10 point ROS it otherwise negative. Past Medical History: HCV, congenital kyphosis with disc, asthmaherniation, shattered L zygomatic bone s/p surgical repair. PSYCHIATRIC HISTORY: Pt reported major depression, generalized anxiety disorder,panic disorder and obsessive-compulsive disorder. He has been hospitalized for psychiatric reasons several times, first around age [MASKED] after a "bad trip" on LSD. He reports [MASKED] prior suicide attempts. All but one have been overdoses on pills, first with Soma at age ~[MASKED]. His most recent suicide attempt was [MASKED] ago when he was hospitalized in [MASKED] for detox and tried to asfixiate himself with a plastic bag. He does not identify specific stressors or triggers for his suicide attempts, but states that he has always been using or recovering from using drugs. He has reports a history of violent behavior although he denies having ever seriously injured anyone. Mr. [MASKED] reports that he has tried a number of antidepressants which have been somewhat helpful. He thinks the fluoxetine started in [MASKED] hospitalization was the most helpful; he took it for 3 weeks. He c/o sexual side effects from several other antidepressants. He finds his current gabapentin to be very helpful for his mood, his anxiety and his back pain. He has also tried ECT in the past and found it to be somewhat helpful. Social History: [MASKED] Family History: Denies any family history of mental illness, substance abuse or addiction, suicide or suicide attempts. Per past OMR notes, father has bipolar disorder and is recovering from chemical dependency Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.4 120/76 [MASKED] R18 99% on RA GEN: Alert but anxious and interactive. HEENT: MMM, anicteric sclera, no conjunctival pallor NECK: Supple without LAD PULM: Clear, no wheeze, rales, or rhonchi COR: tachy, reg rhythm, normal S1/S2, no murmurs ABD: Soft, NT ND, normal BS EXTREM: Warm, no edema SKIN: no stigmata of chronic liver disease, scaly red patches all over - non appear infected NEURO: CN II-XII grossly intact, motor function grossly normal, very fine tremor on outstretched hands, no asterixis Discharge Exam not performed because patient eloped Pertinent Results: [MASKED] 04:43AM URINE HOURS-RANDOM [MASKED] 04:43AM URINE HOURS-RANDOM [MASKED] 04:43AM URINE HOURS-RANDOM [MASKED] 04:43AM URINE UHOLD-HOLD [MASKED] 04:43AM URINE GR HOLD-HOLD [MASKED] 04:43AM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG amphetmn-POS oxycodn-NEG mthdone-NEG [MASKED] 12:25AM K+-4.8 [MASKED] 12:20AM GLUCOSE-100 UREA N-12 CREAT-1.1 SODIUM-131* POTASSIUM-GREATERTHA CHLORIDE-98 TOTAL CO2-23 [MASKED] 12:20AM estGFR-Using this [MASKED] 12:20AM WBC-12.3* RBC-5.01 HGB-14.1 HCT-42.2 MCV-84 MCH-28.1 MCHC-33.4 RDW-13.0 RDWSD-39.1 [MASKED] 12:20AM NEUTS-62.0 [MASKED] MONOS-9.8 EOS-1.4 BASOS-0.4 IM [MASKED] AbsNeut-7.60* AbsLymp-3.22 AbsMono-1.20* AbsEos-0.17 AbsBaso-0.05 [MASKED] 12:20AM PLT COUNT-257 Brief Hospital Course: Mr. [MASKED] is a [MASKED] gentleman with complex psychiatric hx, asthma, polysubstance abuse including benzo abuse including withdrawal seizures who presented with jitteriness, mild tremors, tachycardia (up to 150s in the ED) in the setting of not using benzos in [MASKED] prior to arrival and admitted to taking crystal meth earlier in the week; admitted for benzo withdrawal. Also found to have asymptomatic hyponatremia on admission which resolved without specific intervention. Tachycardia was much improved with standing benzodiazepines. He noted a few occasional 'hallucinations' consisting of seeing some patterns in his vision but otherwise his withdrawal symptoms were fairly uncomplicated. His tremors improved although he did experience some anxiety and requested restarting his adderral which was granted. Unfortunately, on the afternoon of [MASKED], he eloped. No one actually saw him leave but we suspect he escaped from the side exit on the 8 [MASKED] unit. His backpack and other belongings were gone as well. He had threatened to leave earlier in the day and I conceded in restarting half of his home dose of Adderall (due to tachycardia) and he agreed to stay in the hospital. At that time, I discussed the risks of leaving the hospital including seizures and death which he expressed good understanding of. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H PRN 2. Amphetamine-Dextroamphetamine 30 mg PO BID Discharge Disposition: Home Facility: [MASKED] Discharge Diagnosis: the patient left against medical advice Discharge Condition: the patient left against medical advice Discharge Instructions: the patient left against medical advice Followup Instructions: [MASKED]	[]	[ "E871", "J45909" ]	[ "F19939: Other psychoactive substance use, unspecified with withdrawal, unspecified", "E871: Hypo-osmolality and hyponatremia", "R000: Tachycardia, unspecified", "F909: Attention-deficit hyperactivity disorder, unspecified type", "J45909: Unspecified asthma, uncomplicated", "Z590: Homelessness" ]
10,093,718	21,604,509	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: AMS/overdose/SI Major Surgical or Invasive Procedure: ___ Tracheal Intubation ___ - Right IJ placement ___ - Right radial arterial line ___: Lumbar puncture ___: R PICC placement History of Present Illness: The patient is a ___ male with complicated psychiatric history including borderline/antisocial personal disorder with multiple prior suicide attempts via drug overdose, history of drug abuse (cocaine, benzos, heroin, hallucinogens all documented) as well as untreated hepatitis C who presents with altered mental status and ___ the setting of drug overdose, intubated for airway protection ___ the ED and admitted to the medical ICU for monitoring and treatment. Per ED documentation, on arrival he endorsed SI. His initial vitals were: 97.1 \| 110 \| 123/77 \| 19 \| 100% RA. He reported a plan to take lithium, and using heroin and crack cocaine as well as benzodiazepines, from which he was requesting detoxification. He is quoted as having taken "a few" extra gabapentin earlier today, though unclear amount. At the time, ED exam noted HR 88 \| BP 121/76 \| RR 13 \| 97% RA, with "pupils mid range equal and reactive, sleepy but arousable to voice. No rigidity or clonus." Tox screen was positive only for cocaine (serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc negative; Urine Benzos, Barbs, Opiates, Amphet, Mthdne, Oxycodone negative). When he was reassessed 2 hours later, his exam noted "more difficult to arouse, continuous clonus, reddened skin, ocular clonus." He was intubated for airway protection. ___ the ED, he was given: - 2L NS - propofol, fentanyl and rocuronium for intubation Imaging notable for: ___ CXR: AP portable supine view of the chest. An endotracheal tube is seen with its tip located 3.8 cm above the carina. An NG tube courses into the left upper abdomen, tip outside of field of view. Lung volumes are low. No large consolidation, effusion or pneumothorax seen. Cardiomediastinal silhouette appears grossly unremarkable allowing for supine portable technique. No acute osseous abnormality seen. Consults: psychiatry (unable to assess prior to intubation) VS prior to transfer: 97.2 \| 62 \| 118/53 \| 15 \| 100% Intubation On arrival to the MICU, he is intubated and sedated. He does not rouse to voice although he had received rocuronium. Past Medical History: Hepatitis C, untreated Kyphosis and scoliosis (no surgical interventions); c/b chronic back pain History of benzodiazepine withdrawal seizures Asthma Denies history of head injury Social History: ___ Family History: -Father- depression requiring inpatient hospitalization (___), bipolar, h/o chemical dependency -Denied other family history of psychiatric illness, completed suicides, suicide attempts, or addiction. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 97.6 \| 50-66 \| 113/75 \| 18 \| 98% on CMV GENERAL: Intubated, sedated, not rousing to voice HEENT: Sclera anicteric, MMM LUNGS: Clear to auscultation bilaterally ___ lateral and anterior fields without wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present but hypoactive, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: Blanching sunburn sparing shirt straps, no other rash NEURO: Pupils dilated but sluggish and reactive, 30 seconds at least of sustained clonus at bilateral ankles DISCHARGE PHYSICAL EXAM: VS: 98.8, 118/70, 110, 18, 96% RA GENERAL: Sitting ___ chair, appears anxious an sweating, calm and appropriate. HEENT: AT/NC, EOMI, PERRL, anicteric sclera,, MMM NECK: nontender supple neck, no JVD, R CVL ___ place HEART: tachycardia, RRR, S1/S2, no M/R/G LUNGS: CTAB, no wheezes, rales, rhonchi ABDOMEN: Soft, NT/ND, normal bowel sounds, no rebound or guarding EXTREMITIES: Warm, well-perfused, no edema, vein ___ R arm is hard to palpation NEURO: CN II-XII grossly intact SKIN: warm and well perfused. Scattered red papules over back. Pertinent Results: ADMISSION LABS ------------------ ___ 07:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS* amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 07:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 08:00PM WBC-8.9 RBC-4.99 HGB-14.2 HCT-42.0 MCV-84 MCH-28.5 MCHC-33.8 RDW-13.2 RDWSD-40.4 ___ 08:00PM NEUTS-53.0 ___ MONOS-12.9 EOS-5.0 BASOS-0.7 IM ___ AbsNeut-4.73 AbsLymp-2.52 AbsMono-1.15* AbsEos-0.45 AbsBaso-0.06 ___ 08:00PM PLT COUNT-261 ___ 08:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 08:00PM LITHIUM-<0.1* ___ 08:00PM CK-MB-9 cTropnT-<0.01 ___ 08:00PM GLUCOSE-80 UREA N-13 CREAT-1.0 SODIUM-138 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-26 ANION GAP-12 ___ 10:35PM TYPE-ART PO2-511* PCO2-56* PH-7.29* TOTAL CO2-28 BASE XS-0 PERTINENT LABS: ---------------- ___ 02:56AM BLOOD HBsAg-Negative ___ 05:10AM BLOOD HBsAg-Negative ___ 05:10AM BLOOD HCV VL-6.9* ___ 05:10AM BLOOD HCV Ab-Positive* DISCHARGE LABS ------------------- ___ 08:20AM BLOOD WBC-9.7 RBC-4.30* Hgb-12.0* Hct-36.4* MCV-85 MCH-27.9 MCHC-33.0 RDW-13.6 RDWSD-41.8 Plt ___ ___ 08:20AM BLOOD Glucose-101* UreaN-13 Creat-0.8 Na-139 K-4.7 Cl-103 HCO3-19* AnGap-22 IMPORTANT MICRO -------------------- ___ 05:10AM BLOOD HIV Ab-Negative ___ 02:56AM BLOOD HBsAg-Negative ___ 05:10AM BLOOD HCV Ab-Positive* ___ 03:17PM CEREBROSPINAL FLUID (CSF) TNC-3 RBC-74* Polys-0 ___ ___ 03:17PM CEREBROSPINAL FLUID (CSF) TNC-6* RBC-1 Polys-3 ___ ___ 03:17PM CEREBROSPINAL FLUID (CSF) TotProt-28 Glucose-70 __________________________________________________________ ___ 3:17 pm CSF;SPINAL FLUID Source: LP. Enterovirus Culture (Preliminary): No Enterovirus isolated. __________________________________________________________ ___ 3:17 pm CSF;SPINAL FLUID Source: LP #3. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. __________________________________________________________ ___ 3:17 pm CSF;SPINAL FLUID Source: LP. FINAL REPORT ___ CRYPTOCOCCAL ANTIGEN (Final ___: CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Test performed by Lateral Flow Assay. Results should be evaluated ___ light of culture results and clinical presentation. __________________________________________________________ ___ 6:40 am SPUTUM Source: Endotracheal. FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: __________________________________________________________ ___ 6:30 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 6:20 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 5:10 am URINE Source: Catheter. FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, ___ infected patients the excretion of antigen ___ urine may vary. __________________________________________________________ ___ 6:23 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). __________________________________________________________ ___ 10:24 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 10:24 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 4:00 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 4:00 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 4:00 am URINE Source: Catheter. FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 4:56 pm SPUTUM Source: Endotracheal. FINAL REPORT ___ GRAM STAIN (Final ___: ___ PMNs and <10 epithelial cells/100X field. 3+ ___ per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final ___: MODERATE GROWTH Commensal Respiratory Flora. ESCHERICHIA COLI. MODERATE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE. MODERATE GROWTH. BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN. 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 PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S __________________________________________________________ ___ 5:28 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 2:26 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 11:56 pm SPUTUM Source: Endotracheal. *FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ CLUSTERS. RESPIRATORY CULTURE (Final ___: MODERATE GROWTH Commensal Respiratory Flora. GRAM NEGATIVE ROD(S). SPARSE GROWTH. NEGATIVE CSF HSV PCR IMPORTANT IMAGING ___ EEG This telemetry captured no pushbutton activations. The widespread ___ Hz activity ___ all areas suggested the effect of sedating medications. It may have obscured normal and abnormal findings. There were no areas of prominent focal slowing. There were no clearly epileptiform features or electrographic seizures. ___ ___ 1. No evidence of an acute intracranial abnormality on noncontrast head CT. 2. Apparent mild diffuse cutaneous thickening and subcutaneous fat stranding of uncertain etiology. 3. Paranasal sinus disease. ___ EEG This is an abnormal continuous ICU monitoring study because of generalized slowing of the background, with epochs of background attenuation, and bursts of frontally-predominant alpha activity, with diffuse superimposed beta. Such findings are consistent with a moderate-to-severe encephalopathy, which is likely secondary to pharmalogic effect (i.e. propofol). No epileptiform discharges, electrographic seizures, or pushbutton activations were recorded. ___ LEFT UPPER EXTREMITY ULTRASOUND Deep vein thrombosis which is nonocclusive is visualized ___ the two left brachial veins and also within the left basilic vein. ___ Imaging MR HEAD W & W/O CONTRAS IMPRESSION: 1. No evidence of infarction, hemorrhage, enhancing mass or abnormal enhancement. 2. Moderate paranasal sinus disease as above, with nonspecific fluid opacification of the bilateral mastoid air cells. Brief Hospital Course: MICU COURSE (___) ___ with extensive psychiatric history and drug abuse who presented with SI and tox screen positive for cocaine who became progressively altered ___ the ED and developed sustained clonus and ocular clonus, was intubated ___ the ED for airway protection and was admitted to the MICU w/ concern for serotonin syndrome. He was extubated on ___ after weaning proofol/midazolam with improvement ___ his mental status and clonus. Patient was subsequently transferred to the medical floor for further management. # Altered Mental Status # Intentional overdose # Serotonin Syndrome: presented to the ED admitting of intentional overdose. Became obtunded ___ the ED requiring intubation. Was noted to have sustained clonus concerning for serotonin syndrome. Urine tox was positive for cocaine and his medication list includes fluoxetine and bupropion. Toxicology/neurology was consulted and their exam was consistent with serotonin syndrome. He was sedated with propofol and midazolam. His clonus decreased on these medications. He was weaned off these medications and extubated on ___. At discharge from the MICU, he had ___ beats of clonus ___ his LEs. Neurology consulted, EEG showed no seizure, MRI negative. Psychiatry was consulted and will continue to follow the patient after discharge from the ICU with possible discharge to inpatient psych after medical stabilization. Patient had a ___ male sitter during his ICU stay. # Fevers: Patient began spiking fevers on ___ with intermittent high fevers through sedation on ___. Spiking to 104 on ___. His fevers seemed to briefly respond to uptitration on midazolam and propofol and were associated with increased clonus and spontaneous rigors vs tremors. Started on empiric antibiotics- CFTX and vancomycin. Was switched to zosyn from CFTX then back to CFTX as he was spiking through regardless of antibiotic. Toxicology reevaluated and thought that these fevers were of another etiology rather than serotonin syndrome. LP was performed and was negative. ID was consulted and recommended discontinuing antibiotics given negative CSF and MRI findings, making infectious causes of his CNS encephalopathy presentation unlikely. There was no other clear infectious source per ID and patient was treated with a sufficient course of antibiotics to treat CAP/acute sinusitis. #Ileus: Post-extubation pt developed vomiting and an NGT was placed to suction. = = = = = = = = = = = = = = = = = = = = = ================================================================ FLOOR COURSE (___): #Altered mental status: Completely resolved upon arrival to the floor. No further fevers. #Suicidal ideation: Upon arrival to the floor, pt evaluated by psychiatry again and expressed explicitly that polypharmacy was an attempt to get high and NOT a suicide attempt. 1:1 and ___ discontinued. Patient provided with resources for outpatient management of psychiatric illness and substance abuse. Patient discharged with plans to enroll ___ PAATHS. #Ileus: NGT pulled upon arrival to the floor and patient tolerated a regular diet, had regular bowel movements. #LUE DVT: ___ MICU pt developed LUE DVT and was started on heparin gtt ___, converted to rivaroxaban. He was discharged with medication to complete a ___lthough instructed that should he see a PCP ___ the interim and have a repeat ultrasound showing resolution of the clot, it would be reasonable for him to stop anticoagulation. #Hepatitis C: Pt w/hx untreated hepatitis C. HCV Ab positive, viral load 6.9. Pt with mild transaminitis during hospital stay, with normal bilirubin and synthetic function. Will need treatment as an outpatient. TRANSITIONAL ISSUES: ==================== - Discharged to complete a 3 month course of rivaroxaban: Will need to complete 2 more weeks of rivaroxaban 15 mg BID, then will continue on 20 mg daily thereafter to complete a 3 month course. - Can consider stopping duration of rivaroxaban treatment early, consider obtaining ultrasound to evaluate for clot. - Pt will need to establish care with new PCP and psychiatrist. - Not discharged on ANY psych meds. Please evaluate need for psych meds. - Patient had been hypertensive during hospital stay and was given labetalol while ___. Please monitor BPs as an outpatient. - Patient with history of untreated hepatitis C, will need treatment as a outpatient. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. BuPROPion 150 mg PO BID 2. CloNIDine 0.2 mg PO TID:PRN anxiety 3. Gabapentin 800 mg PO QHS 4. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea 5. OLANZapine 5 mg PO BID 6. FLUoxetine 20 mg PO DAILY Discharge Medications: 1. Rivaroxaban 15 mg PO BID RX rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice a day Disp #29 Tablet Refills:0 RX rivaroxaban [___] 20 mg 1 tablet(s) by mouth Daily Disp #63 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: - Polysubstance use and accidental overdose - Toxic-metabolic encephalopathy - Serotonin syndrome - Acute hypoxic/hypercarbic respiratory failure - Provoked catheter-associated left upper extremity DVT Secondary: - Antisocial personality disorder - Major depression/Anxiety disorder - Polysubstance and opioid use disorder - Hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, Why were you here? -You had a drug overdose. Your breathing was compromised and you needed a breathing machine. You had evidence of toxicity from the medications you took. What did we do for you? - We improved your breathing and consulted psychiatry and social work to help with your mood symptoms and drug problem. What do you do now? -Do not take SSRIs, benzos, other drugs that you were not given by a doctor -___ will need to continue taking your blood thinner rivaroxaban for 3 months, unless you are seen by a doctor before then and told to stop. You will take 15 mg twice a day (with food) for 2 weeks, and then 20 mg daily (with food) after that, to complete a 3 month course. This medication taken ___ overdose can cause life threatening bleeding. -You will be going to the ___ program to get help. We wish you the best! -Your ___ Team Followup Instructions: ___	[ "T405X2A", "J9602", "J9601", "G92", "J155", "J14", "I82622", "K567", "N390", "T82868A", "I82612", "J0190", "E160", "F419", "B1920", "T43222A", "T43292A", "Y929", "R740", "F602", "F1110", "F1410", "Z590", "Y848", "Y92230" ]	Allergies: Sulfa (Sulfonamide Antibiotics) Chief Complaint: AMS/overdose/SI Major Surgical or Invasive Procedure: [MASKED] Tracheal Intubation [MASKED] - Right IJ placement [MASKED] - Right radial arterial line [MASKED]: Lumbar puncture [MASKED]: R PICC placement History of Present Illness: The patient is a [MASKED] male with complicated psychiatric history including borderline/antisocial personal disorder with multiple prior suicide attempts via drug overdose, history of drug abuse (cocaine, benzos, heroin, hallucinogens all documented) as well as untreated hepatitis C who presents with altered mental status and [MASKED] the setting of drug overdose, intubated for airway protection [MASKED] the ED and admitted to the medical ICU for monitoring and treatment. Per ED documentation, on arrival he endorsed SI. His initial vitals were: 97.1 \| 110 \| 123/77 \| 19 \| 100% RA. He reported a plan to take lithium, and using heroin and crack cocaine as well as benzodiazepines, from which he was requesting detoxification. He is quoted as having taken "a few" extra gabapentin earlier today, though unclear amount. At the time, ED exam noted HR 88 \| BP 121/76 \| RR 13 \| 97% RA, with "pupils mid range equal and reactive, sleepy but arousable to voice. No rigidity or clonus." Tox screen was positive only for cocaine (serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc negative; Urine Benzos, Barbs, Opiates, Amphet, Mthdne, Oxycodone negative). When he was reassessed 2 hours later, his exam noted "more difficult to arouse, continuous clonus, reddened skin, ocular clonus." He was intubated for airway protection. [MASKED] the ED, he was given: - 2L NS - propofol, fentanyl and rocuronium for intubation Imaging notable for: [MASKED] CXR: AP portable supine view of the chest. An endotracheal tube is seen with its tip located 3.8 cm above the carina. An NG tube courses into the left upper abdomen, tip outside of field of view. Lung volumes are low. No large consolidation, effusion or pneumothorax seen. Cardiomediastinal silhouette appears grossly unremarkable allowing for supine portable technique. No acute osseous abnormality seen. Consults: psychiatry (unable to assess prior to intubation) VS prior to transfer: 97.2 \| 62 \| 118/53 \| 15 \| 100% Intubation On arrival to the MICU, he is intubated and sedated. He does not rouse to voice although he had received rocuronium. Past Medical History: Hepatitis C, untreated Kyphosis and scoliosis (no surgical interventions); c/b chronic back pain History of benzodiazepine withdrawal seizures Asthma Denies history of head injury Social History: [MASKED] Family History: -Father- depression requiring inpatient hospitalization ([MASKED]), bipolar, h/o chemical dependency -Denied other family history of psychiatric illness, completed suicides, suicide attempts, or addiction. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 97.6 \| 50-66 \| 113/75 \| 18 \| 98% on CMV GENERAL: Intubated, sedated, not rousing to voice HEENT: Sclera anicteric, MMM LUNGS: Clear to auscultation bilaterally [MASKED] lateral and anterior fields without wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present but hypoactive, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: Blanching sunburn sparing shirt straps, no other rash NEURO: Pupils dilated but sluggish and reactive, 30 seconds at least of sustained clonus at bilateral ankles DISCHARGE PHYSICAL EXAM: VS: 98.8, 118/70, 110, 18, 96% RA GENERAL: Sitting [MASKED] chair, appears anxious an sweating, calm and appropriate. HEENT: AT/NC, EOMI, PERRL, anicteric sclera,, MMM NECK: nontender supple neck, no JVD, R CVL [MASKED] place HEART: tachycardia, RRR, S1/S2, no M/R/G LUNGS: CTAB, no wheezes, rales, rhonchi ABDOMEN: Soft, NT/ND, normal bowel sounds, no rebound or guarding EXTREMITIES: Warm, well-perfused, no edema, vein [MASKED] R arm is hard to palpation NEURO: CN II-XII grossly intact SKIN: warm and well perfused. Scattered red papules over back. Pertinent Results: ADMISSION LABS ------------------ [MASKED] 07:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS* amphetmn-NEG oxycodn-NEG mthdone-NEG [MASKED] 07:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [MASKED] 08:00PM WBC-8.9 RBC-4.99 HGB-14.2 HCT-42.0 MCV-84 MCH-28.5 MCHC-33.8 RDW-13.2 RDWSD-40.4 [MASKED] 08:00PM NEUTS-53.0 [MASKED] MONOS-12.9 EOS-5.0 BASOS-0.7 IM [MASKED] AbsNeut-4.73 AbsLymp-2.52 AbsMono-1.15* AbsEos-0.45 AbsBaso-0.06 [MASKED] 08:00PM PLT COUNT-261 [MASKED] 08:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [MASKED] 08:00PM LITHIUM-<0.1* [MASKED] 08:00PM CK-MB-9 cTropnT-<0.01 [MASKED] 08:00PM GLUCOSE-80 UREA N-13 CREAT-1.0 SODIUM-138 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-26 ANION GAP-12 [MASKED] 10:35PM TYPE-ART PO2-511* PCO2-56* PH-7.29* TOTAL CO2-28 BASE XS-0 PERTINENT LABS: ---------------- [MASKED] 02:56AM BLOOD HBsAg-Negative [MASKED] 05:10AM BLOOD HBsAg-Negative [MASKED] 05:10AM BLOOD HCV VL-6.9* [MASKED] 05:10AM BLOOD HCV Ab-Positive* DISCHARGE LABS ------------------- [MASKED] 08:20AM BLOOD WBC-9.7 RBC-4.30* Hgb-12.0* Hct-36.4* MCV-85 MCH-27.9 MCHC-33.0 RDW-13.6 RDWSD-41.8 Plt [MASKED] [MASKED] 08:20AM BLOOD Glucose-101* UreaN-13 Creat-0.8 Na-139 K-4.7 Cl-103 HCO3-19* AnGap-22 IMPORTANT MICRO -------------------- [MASKED] 05:10AM BLOOD HIV Ab-Negative [MASKED] 02:56AM BLOOD HBsAg-Negative [MASKED] 05:10AM BLOOD HCV Ab-Positive* [MASKED] 03:17PM CEREBROSPINAL FLUID (CSF) TNC-3 RBC-74* Polys-0 [MASKED] [MASKED] 03:17PM CEREBROSPINAL FLUID (CSF) TNC-6* RBC-1 Polys-3 [MASKED] [MASKED] 03:17PM CEREBROSPINAL FLUID (CSF) TotProt-28 Glucose-70 [MASKED] [MASKED] 3:17 pm CSF;SPINAL FLUID Source: LP. Enterovirus Culture (Preliminary): No Enterovirus isolated. [MASKED] [MASKED] 3:17 pm CSF;SPINAL FLUID Source: LP #3. GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [MASKED]: NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [MASKED] [MASKED] 3:17 pm CSF;SPINAL FLUID Source: LP. FINAL REPORT [MASKED] CRYPTOCOCCAL ANTIGEN (Final [MASKED]: CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Test performed by Lateral Flow Assay. Results should be evaluated [MASKED] light of culture results and clinical presentation. [MASKED] [MASKED] 6:40 am SPUTUM Source: Endotracheal. FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [MASKED]: [MASKED] [MASKED] 6:30 am BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] [MASKED] 6:20 am BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] [MASKED] 5:10 am URINE Source: Catheter. FINAL REPORT [MASKED] Legionella Urinary Antigen (Final [MASKED]: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, [MASKED] infected patients the excretion of antigen [MASKED] urine may vary. [MASKED] [MASKED] 6:23 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). [MASKED] [MASKED] 10:24 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 10:24 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 4:00 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 4:00 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 4:00 am URINE Source: Catheter. FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 4:56 pm SPUTUM Source: Endotracheal. FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: [MASKED] PMNs and <10 epithelial cells/100X field. 3+ [MASKED] per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [MASKED]: MODERATE GROWTH Commensal Respiratory Flora. ESCHERICHIA COLI. MODERATE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE. MODERATE GROWTH. BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN. 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 PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [MASKED] [MASKED] 5:28 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 2:26 am BLOOD CULTURE FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 11:56 pm SPUTUM Source: Endotracheal. *FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: >25 PMNs and <10 epithelial cells/100X field. 3+ [MASKED] per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] PAIRS AND CHAINS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] CLUSTERS. RESPIRATORY CULTURE (Final [MASKED]: MODERATE GROWTH Commensal Respiratory Flora. GRAM NEGATIVE ROD(S). SPARSE GROWTH. NEGATIVE CSF HSV PCR IMPORTANT IMAGING [MASKED] EEG This telemetry captured no pushbutton activations. The widespread [MASKED] Hz activity [MASKED] all areas suggested the effect of sedating medications. It may have obscured normal and abnormal findings. There were no areas of prominent focal slowing. There were no clearly epileptiform features or electrographic seizures. [MASKED] [MASKED] 1. No evidence of an acute intracranial abnormality on noncontrast head CT. 2. Apparent mild diffuse cutaneous thickening and subcutaneous fat stranding of uncertain etiology. 3. Paranasal sinus disease. [MASKED] EEG This is an abnormal continuous ICU monitoring study because of generalized slowing of the background, with epochs of background attenuation, and bursts of frontally-predominant alpha activity, with diffuse superimposed beta. Such findings are consistent with a moderate-to-severe encephalopathy, which is likely secondary to pharmalogic effect (i.e. propofol). No epileptiform discharges, electrographic seizures, or pushbutton activations were recorded. [MASKED] LEFT UPPER EXTREMITY ULTRASOUND Deep vein thrombosis which is nonocclusive is visualized [MASKED] the two left brachial veins and also within the left basilic vein. [MASKED] Imaging MR HEAD W & W/O CONTRAS IMPRESSION: 1. No evidence of infarction, hemorrhage, enhancing mass or abnormal enhancement. 2. Moderate paranasal sinus disease as above, with nonspecific fluid opacification of the bilateral mastoid air cells. Brief Hospital Course: MICU COURSE ([MASKED]) [MASKED] with extensive psychiatric history and drug abuse who presented with SI and tox screen positive for cocaine who became progressively altered [MASKED] the ED and developed sustained clonus and ocular clonus, was intubated [MASKED] the ED for airway protection and was admitted to the MICU w/ concern for serotonin syndrome. He was extubated on [MASKED] after weaning proofol/midazolam with improvement [MASKED] his mental status and clonus. Patient was subsequently transferred to the medical floor for further management. # Altered Mental Status # Intentional overdose # Serotonin Syndrome: presented to the ED admitting of intentional overdose. Became obtunded [MASKED] the ED requiring intubation. Was noted to have sustained clonus concerning for serotonin syndrome. Urine tox was positive for cocaine and his medication list includes fluoxetine and bupropion. Toxicology/neurology was consulted and their exam was consistent with serotonin syndrome. He was sedated with propofol and midazolam. His clonus decreased on these medications. He was weaned off these medications and extubated on [MASKED]. At discharge from the MICU, he had [MASKED] beats of clonus [MASKED] his LEs. Neurology consulted, EEG showed no seizure, MRI negative. Psychiatry was consulted and will continue to follow the patient after discharge from the ICU with possible discharge to inpatient psych after medical stabilization. Patient had a [MASKED] male sitter during his ICU stay. # Fevers: Patient began spiking fevers on [MASKED] with intermittent high fevers through sedation on [MASKED]. Spiking to 104 on [MASKED]. His fevers seemed to briefly respond to uptitration on midazolam and propofol and were associated with increased clonus and spontaneous rigors vs tremors. Started on empiric antibiotics- CFTX and vancomycin. Was switched to zosyn from CFTX then back to CFTX as he was spiking through regardless of antibiotic. Toxicology reevaluated and thought that these fevers were of another etiology rather than serotonin syndrome. LP was performed and was negative. ID was consulted and recommended discontinuing antibiotics given negative CSF and MRI findings, making infectious causes of his CNS encephalopathy presentation unlikely. There was no other clear infectious source per ID and patient was treated with a sufficient course of antibiotics to treat CAP/acute sinusitis. #Ileus: Post-extubation pt developed vomiting and an NGT was placed to suction. = = = = = = = = = = = = = = = = = = = = = ================================================================ FLOOR COURSE ([MASKED]): #Altered mental status: Completely resolved upon arrival to the floor. No further fevers. #Suicidal ideation: Upon arrival to the floor, pt evaluated by psychiatry again and expressed explicitly that polypharmacy was an attempt to get high and NOT a suicide attempt. 1:1 and [MASKED] discontinued. Patient provided with resources for outpatient management of psychiatric illness and substance abuse. Patient discharged with plans to enroll [MASKED] PAATHS. #Ileus: NGT pulled upon arrival to the floor and patient tolerated a regular diet, had regular bowel movements. #LUE DVT: [MASKED] MICU pt developed LUE DVT and was started on heparin gtt [MASKED], converted to rivaroxaban. He was discharged with medication to complete a lthough instructed that should he see a PCP [MASKED] the interim and have a repeat ultrasound showing resolution of the clot, it would be reasonable for him to stop anticoagulation. #Hepatitis C: Pt w/hx untreated hepatitis C. HCV Ab positive, viral load 6.9. Pt with mild transaminitis during hospital stay, with normal bilirubin and synthetic function. Will need treatment as an outpatient. TRANSITIONAL ISSUES: ==================== - Discharged to complete a 3 month course of rivaroxaban: Will need to complete 2 more weeks of rivaroxaban 15 mg BID, then will continue on 20 mg daily thereafter to complete a 3 month course. - Can consider stopping duration of rivaroxaban treatment early, consider obtaining ultrasound to evaluate for clot. - Pt will need to establish care with new PCP and psychiatrist. - Not discharged on ANY psych meds. Please evaluate need for psych meds. - Patient had been hypertensive during hospital stay and was given labetalol while [MASKED]. Please monitor BPs as an outpatient. - Patient with history of untreated hepatitis C, will need treatment as a outpatient. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. BuPROPion 150 mg PO BID 2. CloNIDine 0.2 mg PO TID:PRN anxiety 3. Gabapentin 800 mg PO QHS 4. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN dyspnea 5. OLANZapine 5 mg PO BID 6. FLUoxetine 20 mg PO DAILY Discharge Medications: 1. Rivaroxaban 15 mg PO BID RX rivaroxaban [[MASKED]] 15 mg 1 tablet(s) by mouth twice a day Disp #29 Tablet Refills:0 RX rivaroxaban [[MASKED]] 20 mg 1 tablet(s) by mouth Daily Disp #63 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: - Polysubstance use and accidental overdose - Toxic-metabolic encephalopathy - Serotonin syndrome - Acute hypoxic/hypercarbic respiratory failure - Provoked catheter-associated left upper extremity DVT Secondary: - Antisocial personality disorder - Major depression/Anxiety disorder - Polysubstance and opioid use disorder - Hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], Why were you here? -You had a drug overdose. Your breathing was compromised and you needed a breathing machine. You had evidence of toxicity from the medications you took. What did we do for you? - We improved your breathing and consulted psychiatry and social work to help with your mood symptoms and drug problem. What do you do now? -Do not take SSRIs, benzos, other drugs that you were not given by a doctor -[MASKED] will need to continue taking your blood thinner rivaroxaban for 3 months, unless you are seen by a doctor before then and told to stop. You will take 15 mg twice a day (with food) for 2 weeks, and then 20 mg daily (with food) after that, to complete a 3 month course. This medication taken [MASKED] overdose can cause life threatening bleeding. -You will be going to the [MASKED] program to get help. We wish you the best! -Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "J9601", "N390", "F419", "Y929", "Y92230" ]	[ "T405X2A: Poisoning by cocaine, intentional self-harm, initial encounter", "J9602: Acute respiratory failure with hypercapnia", "J9601: Acute respiratory failure with hypoxia", "G92: Toxic encephalopathy", "J155: Pneumonia due to Escherichia coli", "J14: Pneumonia due to Hemophilus influenzae", "I82622: Acute embolism and thrombosis of deep veins of left upper extremity", "K567: Ileus, unspecified", "N390: Urinary tract infection, site not specified", "T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter", "I82612: Acute embolism and thrombosis of superficial veins of left upper extremity", "J0190: Acute sinusitis, unspecified", "E160: Drug-induced hypoglycemia without coma", "F419: Anxiety disorder, unspecified", "B1920: Unspecified viral hepatitis C without hepatic coma", "T43222A: Poisoning by selective serotonin reuptake inhibitors, intentional self-harm, initial encounter", "T43292A: Poisoning by other antidepressants, intentional self-harm, initial encounter", "Y929: Unspecified place or not applicable", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "F602: Antisocial personality disorder", "F1110: Opioid abuse, uncomplicated", "F1410: Cocaine abuse, uncomplicated", "Z590: Homelessness", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]
10,093,718	24,132,454	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PSYCHIATRY Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: "I have severe depression and suicidal ideation." Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is ___ year-old Caucasian male, with hx Hep C (untreated), polysubstance abuse (benzos and alcohol), unspecified mood and anxiety disorders, and numerous inpatient psychiatric hospitalizations for SI as well as some concern for character pathology, who self presented to the ED w/ reported worsening mood and SI in the context of substance addiction and psychosocial stressors. In the ED, he reported multiple neurovegetative symptoms of depression and increasing SI over the past week with plan to OD on rx medications. Additionally, he reported a history of SA several years ago, but it was noted in the ED psych evaluation that he denied any suicide attempts during ___ psych eval on ___ and that there have been inconsistencies in his history in the past with a documented concern for possible character pathology. Upon arriving to the unit, he reports that he's been living at ___ since ___ and that he walked to the ED on ___ due to suicidal ideation with plan to overdose on tricyclics that he has at home. One of the ED notes documented that patient also had thoughts about suicide via carbon monoxide poisoning. He states that he still feels depressed and anxious, has low energy, feels guilty over things he would rather not discuss, and doesn't have many social supports except for his son's mother. He currently denies any suicidal thoughts/plans/intent. He states the if he were to experience these types of thoughts, he would alert nursing/medical staff. He denies ever harming others or any jail time. In the ED, he reported infrequent ETOH use and "only when I can't get benzos." On the unit, he reports ___ beers every few months. In the ED, he alternated between reporting and denying Xanax and Klonopin use a few times a week. On the unit, he reports using Xanax and Klonopin up to ___ mg at a time, ___ times/week, for the past 2 months; last used Xanax 4 mg on ___. He smokes 1 cigar a couple times a week. Additionally, he reports past abuse of MJ, crack, cocaine - last used 6 months ago; past use of LSD and other hallucinogens as a teenager; past IVDU heroin - last used ___ year ago. In the ED, patient stated that gets his meds from the ___ pharmacy (prescriber PA - ___. Upon arriving to the unit, he states that he gets his meds from the ___ in ___. He denies any episodes of hypomania/mania (decreased need for sleep, increased energy, elevated or irritable mood, grandiose delusions, flight of idea, increase in goal-directed or impulsive behaviors). He denies any homicidal ideation, auditory/visual hallucinations, or grandiose/paranoid delusions. ROS: Psychiatric - as per HPI. Medical - Denies fever, night sweats, chills, fainting, dizziness, headache, rhinorrhea, cough, double or blurry vision, chest pain, SOB, palpitations, nausea, vomiting, diaphoresis, abdominal pain, constipation, diarrhea, dysuria, leg pain/swelling, tremulousness, any pain elsewhere. ED COURSE: Patient was cooperative with treatment and did not require physical/chemical restraints. He received the following medications: ___ 21:24 PO FoLIC Acid 1 mg ___ 21:24 PO Thiamine 100 mg ___ 21:24 PO Multivitamins 1 TAB ___ 21:24 PO/NG Diazepam 10 mg ___ 22:27 PO/NG Diazepam 10 mg ___ 01:27 IV Lorazepam 1 mg ___ 03:29 IV Lorazepam 1 mg ___ 09:20 PO/NG Diazepam 10 mg ___ 09:20 PO/NG BuPROPion 100 mg ___ 09:20 PO/NG Propranolol 20 mg ___ 09:20 PO Fexofenadine 180 mg ___ 09:20 PO/NG Escitalopram Oxalate 20 mg ___ 09:24 PO Oxybutynin 5 mg ___ 22:56 PO/NG Propranolol 20 mg ___ 09:36 PO/NG Propranolol 20 mg ___ 09:36 PO Fexofenadine 180 mg ___ 09:36 PO Oxybutynin 5 mg Past Medical History: Hepatitis C, untreated Kyphosis and scoliosis (no surgical interventions); c/b chronic back pain History of benzodiazepine withdrawal seizures Asthma Denies history of head injury Social History: ___ Family History: -Father- depression requiring inpatient hospitalization (___), bipolar, h/o chemical dependency -Denied other family history of psychiatric illness, completed suicides, suicide attempts, or addiction. Physical Exam: ADMISSION: VS: BP=127/85, HR=102, T=98, RR=16, SaO2=99% on RA * General: NAD. Well-nourished, well-developed. Appears stated age. * HEENT: Normocephalic. PERRL, EOMI. Oropharynx clear. * Back: Evidence of kyphosis and scoliosis. No focal tenderness. * Lungs: Clear to auscultation bilaterally. No crackles or wheezes. * CV: Regular rate and rhythm. No murmurs/rubs/gallops. 2+ pedal pulses. * Abdomen: Soft, nontender, nondistended; no masses or organomegaly. * Extremities: No clubbing, cyanosis, or edema. * Skin: Warm and dry. No readily apparent rashes, scars, or lesions. Neurological: Cranial Nerves: I: Not tested. II: Pupils equally round and reactive to light bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor- Normal bulk and tone bilaterally. No abnormal movements, no tremor. Strength full power ___ throughout. No gross focal motor or sensory deficits, normal gait. Coordination: Normal on finger-nose-finger. Sensation: Intact to light touch. Gait: Steady. No truncal ataxia. Normal stance and posture. Romberg: Negative. NEUROPSYCHIATRIC EXAMINATION: * Appearance: NAD. Caucasian man. Appears stated age. Wearing hospital gown. * Behavior: Appropriate with good eye contact, mostly cooperative, vague responses to some questions, no psychomotor agitation/retardation * Orientation: Oriented to self, location, and date. * Mood: "Low energy." "Still depressed and anxious." * Affect: Euthymic and congruent to stated mood. * Thought Process: Logical and goal directed. No loosening of associations. No apparent disorganization. * Thought Content: Denies current suicidal thoughts, plans, and actions. Denies HI. Free of any evidence of psychosis. * Judgment: Poor. * Insight: Poor. * Speech: Spontaneous. Normal conversational volume, tone, rate, and prosody. COGNITION: * Memory: Registration ___. Recall ___. Remote memory intact. * Abstraction: Apple/orange = fruits. * Proverb: When asked what it means to say, "don't judge a book by its cover," patient responds, "don't judge something by the outside." * Calculation: $1.75 = 7 quarters. * Fund of knowledge: Names ___ presidents and a play by ___ (___). * Attention span: Correctly listed MOYB without error. * Language: Fluent ___ speaker. No apparent paraphrasic errors. DISCHARGE: VS: VSS Neurological: Station and gait: Steady, without ataxia or gait disturbances. Tone and strength: No gross deficits noted in strength and tone. Cranial nerves: II-XII grossly intact. Abnormal movements: None observed. Mental Status Exam: Appearance: NAD. Appears stated age, adequate hygiene, wearing sweatshirt and sweatpants Behavior: Cooperative, -PMA/PMR, fair eye contact Mood: "Depressed." Affect: Dysthymic, slightly restricted Thought Process: Linear, goal directed, and coherent. No LOA. Thought Content: Focused on discharge. Denied suicidal thoughts, plans, and actions. Denied HI. Denied A/V hallucinations. Speech: Spontaneous, normal tone, volume, rate, prosody. Judgment and Insight: Poor/poor Cognition: Attention: Alert, inattentive during interview. Orientation: Oriented to person, place, and situation. Memory: Appears intact to recent events, limited past hx. Fund of knowledge: Adequate Language: ___, fluent, without paraphrasic errors Pertinent Results: ED labs (___): CBC- WNL BMP- WNL LFTs- ALT 49, AST 36 Alk phos, total bili- WNL Albumin- WNL UA- WNL Serum tox- Positive for benzodiazepines; otherwise, negative Urine tox- negative Brief Hospital Course: SAFETY: Patient was placed on 15 minute checks on admission and remained here on that level of observation throughout. He was unit-restricted. LEGAL: ___ PSYCHIATRIC: #) DEPRESSION: In initial ED and inpatient psychiatry unit admission exams, patient reported worsening depression and suicidal ideation with plans. Patient endorsed disturbance in neurovegetative symptoms. Patient endorsed recent substance abuse. At admission, patient reported recent benzodiazepine abuse (xanax and klonopin), alcohol, and cigar use. Patient denied current and past symptoms of hypomania/mania. Patient denied current and past symptoms of psychosis. Patient denied HI. Of note, patient provided inconsistent recent and past history at times. Patient complained of anxiety. Due to past responses to clonidine and wellbutrin ___, patient was started on these medications after the determination was made that he was not at risk for withdrawal from alcohol and GABA agonists. Patient tolerated medication changes well. Patient reported subjective improvement in anxiety symptoms. On initial interview with the primary team on the inpatient psychiatry unit (___), patient readily reported that he was not suicidal, and requested to discuss discharge planning. Patient reported his current presentation was in an effort to obtain housing. Patient reported he was recently hospitalized at ___ inpatient psychiatry unit for a similar reason. Patient stated, "I really don't want to kill myself. I just wanted a place to stay." Patient reported that he felt like he no longer required inpatient hospitalization as he had time to rest. Patient denied other associated acute stressors. Patient reported chronically depressed mood, without acute change. Patient reported he continues to experience, "Passive suicidal thoughts," which he clarified as from "Time to time, wondering why I gets up." When asked to provide further details, patient refused, and stated they these were not new feelings. Patient denied active suicidal thoughts, plans, and actions. Patient provided vague details, and required encouragement to provide clarification. Patient stated there were no further benefit he could take from the inpatient psychiatry hospital and again requested to be discharge. While on the unit, patient did not engage in groups; however, patient was observed in the milieu. Patient's current presentation is most consistent with malingering and polysubstance abuse. Patient's presentation is also concerning for substance induced mood disorder. Patient endorsed recent substance abuse throughout his admission. Notably, patient provided inconsistent reports of substance abuse. In the ED, he reported infrequent ETOH use and "only when I can't get benzos." On the unit, he reports ___ beers every few months. In the ED, he alternated between reporting and denying Xanax and Klonopin use a few times a week. On admission interview unit, patient reported using Xanax and Klonopin up to ___ mg at a time, ___ times/week, for the past 2 months; last used Xanax 4 mg on ___. On initial interview with the primary team (___), patient reported abuse of Adderall prescription from PCP. Patient also reported recent vague benzodiazepine use and denied other recent substance abuse. Patient reported past trials of suboxone, methadone, naltrexone, inpatient psychiatry, and partial programs. Patient identified naltrexone as the most helpful. Outpatient substance abuse supports were discussed at length with patient. MEDICAL: 1.) Admission medical workup: Initial labs (___) significant for WNL CBC, BMP, alk phos, total bili, and albumin; ALT 49, AST 36, positive serum tox for benzodiazepines and negative urine tox. Patient was encouraged to follow up with PCP ___ 1 week of discharge. 2.) Asthma: Patient was continued on home albuterol inhaler Q6H PRN for SOB, wheezing. 3.) Neuropathic pain: Attributed to kyphosis and scoliosis. Patient denied pain at admission and throughout hospitalization. Patient reported he last took Gabapentin 1 month prior to hospitalization, with unclear efficacy. Gabapentin was not restarted to absence of symptoms and unclear efficacy. 4.) Hepatitis C: Patient was encouraged to follow up with PCP ___ 1 week of discharge for further care. PSYCHOSOCIAL: #) GROUPS/MILIEU: Patient was encouraged to participate in units groups, milieu, and therapy opportunities. Usage of coping skills, mindfulness, and relaxation methods were encouraged. Therapy addressed family, social, work, and housing issues. Despite repeated requests, patient declined engagement in groups. #) COLLATERAL CONTACTS: Attempted to contact patient's primary care provider, ___ ___ (___) multiple times prior to discharge. #) FAMILY INVOLVEMENT: Patient identified his mother, ___ and ___ as his primary supports, but refused contact. Patient refused contact with other family and friend supports. INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of starting this medication, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team, and I answered the patient's questions. The patient appeared able to understand and consented to begin the medication. RISK ASSESSMENT: At time of discharge, patient was regarded as at low imminent risk of harm/violence to self/others. Risk factors include history of suicide attempts, recent suicidal ideation (though patient later stated he fabricated this), active substance abuse, history of trauma, family history of mental illness, lack of day structure, male gender, single status, chronic medical illness, lack of established outpatient psychiatric providers, history of noncompliance, evidence of impulsivity, history of violence towards others, constricted psychosocial support network, and chronic mental illness. Protective factors include help seeking behavior for own safety, motivation to obtain treatment, plans for the future (to see child), connection to family, child, and strong knowledge on how to navigate the mental healthcare system. PROGNOSIS: Guarded: Patient is prone to decompensation given nature of illness, with active ongoing substance abuse, and history of many inpatient psychiatry hospitalizations and unclear benefit. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH ___ TIMES/DAILY SOB, wheezing Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH ___ TIMES/DAILY SOB, wheezing 2. BuPROPion 75 mg PO Q8AM AND Q1PM RX bupropion HCl 75 mg 1 (One) tablet(s) by mouth twice daily Disp #60 Tablet Refills:0 3. CloNIDine 0.1 mg PO BID RX clonidine HCl 0.1 mg 1 (One) tablet(s) by mouth twice daily Disp #60 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Depression, substance abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were hospitalized at ___ for worsening depression, suicidal ideation, and polysubstance abuse. We adjusted your medications, and you are now ready for discharge and continued treatment. -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Please continue all medications as directed. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call ___ or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. We strongly recommend engaging in AA/NA/SMART recovery meetings for ongoing help with sobriety. Here is a website with links to meetings near your area: ___ Followup Instructions: ___	[ "F329", "R45851", "M419", "B1920", "Z590", "F17210", "F1010", "F1310", "J45909", "F419", "M40209", "M792" ]	Allergies: Sulfa (Sulfonamide Antibiotics) Chief Complaint: "I have severe depression and suicidal ideation." Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is [MASKED] year-old Caucasian male, with hx Hep C (untreated), polysubstance abuse (benzos and alcohol), unspecified mood and anxiety disorders, and numerous inpatient psychiatric hospitalizations for SI as well as some concern for character pathology, who self presented to the ED w/ reported worsening mood and SI in the context of substance addiction and psychosocial stressors. In the ED, he reported multiple neurovegetative symptoms of depression and increasing SI over the past week with plan to OD on rx medications. Additionally, he reported a history of SA several years ago, but it was noted in the ED psych evaluation that he denied any suicide attempts during [MASKED] psych eval on [MASKED] and that there have been inconsistencies in his history in the past with a documented concern for possible character pathology. Upon arriving to the unit, he reports that he's been living at [MASKED] since [MASKED] and that he walked to the ED on [MASKED] due to suicidal ideation with plan to overdose on tricyclics that he has at home. One of the ED notes documented that patient also had thoughts about suicide via carbon monoxide poisoning. He states that he still feels depressed and anxious, has low energy, feels guilty over things he would rather not discuss, and doesn't have many social supports except for his son's mother. He currently denies any suicidal thoughts/plans/intent. He states the if he were to experience these types of thoughts, he would alert nursing/medical staff. He denies ever harming others or any jail time. In the ED, he reported infrequent ETOH use and "only when I can't get benzos." On the unit, he reports [MASKED] beers every few months. In the ED, he alternated between reporting and denying Xanax and Klonopin use a few times a week. On the unit, he reports using Xanax and Klonopin up to [MASKED] mg at a time, [MASKED] times/week, for the past 2 months; last used Xanax 4 mg on [MASKED]. He smokes 1 cigar a couple times a week. Additionally, he reports past abuse of MJ, crack, cocaine - last used 6 months ago; past use of LSD and other hallucinogens as a teenager; past IVDU heroin - last used [MASKED] year ago. In the ED, patient stated that gets his meds from the [MASKED] pharmacy (prescriber PA - [MASKED]. Upon arriving to the unit, he states that he gets his meds from the [MASKED] in [MASKED]. He denies any episodes of hypomania/mania (decreased need for sleep, increased energy, elevated or irritable mood, grandiose delusions, flight of idea, increase in goal-directed or impulsive behaviors). He denies any homicidal ideation, auditory/visual hallucinations, or grandiose/paranoid delusions. ROS: Psychiatric - as per HPI. Medical - Denies fever, night sweats, chills, fainting, dizziness, headache, rhinorrhea, cough, double or blurry vision, chest pain, SOB, palpitations, nausea, vomiting, diaphoresis, abdominal pain, constipation, diarrhea, dysuria, leg pain/swelling, tremulousness, any pain elsewhere. ED COURSE: Patient was cooperative with treatment and did not require physical/chemical restraints. He received the following medications: [MASKED] 21:24 PO FoLIC Acid 1 mg [MASKED] 21:24 PO Thiamine 100 mg [MASKED] 21:24 PO Multivitamins 1 TAB [MASKED] 21:24 PO/NG Diazepam 10 mg [MASKED] 22:27 PO/NG Diazepam 10 mg [MASKED] 01:27 IV Lorazepam 1 mg [MASKED] 03:29 IV Lorazepam 1 mg [MASKED] 09:20 PO/NG Diazepam 10 mg [MASKED] 09:20 PO/NG BuPROPion 100 mg [MASKED] 09:20 PO/NG Propranolol 20 mg [MASKED] 09:20 PO Fexofenadine 180 mg [MASKED] 09:20 PO/NG Escitalopram Oxalate 20 mg [MASKED] 09:24 PO Oxybutynin 5 mg [MASKED] 22:56 PO/NG Propranolol 20 mg [MASKED] 09:36 PO/NG Propranolol 20 mg [MASKED] 09:36 PO Fexofenadine 180 mg [MASKED] 09:36 PO Oxybutynin 5 mg Past Medical History: Hepatitis C, untreated Kyphosis and scoliosis (no surgical interventions); c/b chronic back pain History of benzodiazepine withdrawal seizures Asthma Denies history of head injury Social History: [MASKED] Family History: -Father- depression requiring inpatient hospitalization ([MASKED]), bipolar, h/o chemical dependency -Denied other family history of psychiatric illness, completed suicides, suicide attempts, or addiction. Physical Exam: ADMISSION: VS: BP=127/85, HR=102, T=98, RR=16, SaO2=99% on RA * General: NAD. Well-nourished, well-developed. Appears stated age. * HEENT: Normocephalic. PERRL, EOMI. Oropharynx clear. * Back: Evidence of kyphosis and scoliosis. No focal tenderness. * Lungs: Clear to auscultation bilaterally. No crackles or wheezes. * CV: Regular rate and rhythm. No murmurs/rubs/gallops. 2+ pedal pulses. * Abdomen: Soft, nontender, nondistended; no masses or organomegaly. * Extremities: No clubbing, cyanosis, or edema. * Skin: Warm and dry. No readily apparent rashes, scars, or lesions. Neurological: Cranial Nerves: I: Not tested. II: Pupils equally round and reactive to light bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor- Normal bulk and tone bilaterally. No abnormal movements, no tremor. Strength full power [MASKED] throughout. No gross focal motor or sensory deficits, normal gait. Coordination: Normal on finger-nose-finger. Sensation: Intact to light touch. Gait: Steady. No truncal ataxia. Normal stance and posture. Romberg: Negative. NEUROPSYCHIATRIC EXAMINATION: * Appearance: NAD. Caucasian man. Appears stated age. Wearing hospital gown. * Behavior: Appropriate with good eye contact, mostly cooperative, vague responses to some questions, no psychomotor agitation/retardation * Orientation: Oriented to self, location, and date. * Mood: "Low energy." "Still depressed and anxious." * Affect: Euthymic and congruent to stated mood. * Thought Process: Logical and goal directed. No loosening of associations. No apparent disorganization. * Thought Content: Denies current suicidal thoughts, plans, and actions. Denies HI. Free of any evidence of psychosis. * Judgment: Poor. * Insight: Poor. * Speech: Spontaneous. Normal conversational volume, tone, rate, and prosody. COGNITION: * Memory: Registration [MASKED]. Recall [MASKED]. Remote memory intact. * Abstraction: Apple/orange = fruits. * Proverb: When asked what it means to say, "don't judge a book by its cover," patient responds, "don't judge something by the outside." * Calculation: $1.75 = 7 quarters. * Fund of knowledge: Names [MASKED] presidents and a play by [MASKED] ([MASKED]). * Attention span: Correctly listed MOYB without error. * Language: Fluent [MASKED] speaker. No apparent paraphrasic errors. DISCHARGE: VS: VSS Neurological: Station and gait: Steady, without ataxia or gait disturbances. Tone and strength: No gross deficits noted in strength and tone. Cranial nerves: II-XII grossly intact. Abnormal movements: None observed. Mental Status Exam: Appearance: NAD. Appears stated age, adequate hygiene, wearing sweatshirt and sweatpants Behavior: Cooperative, -PMA/PMR, fair eye contact Mood: "Depressed." Affect: Dysthymic, slightly restricted Thought Process: Linear, goal directed, and coherent. No LOA. Thought Content: Focused on discharge. Denied suicidal thoughts, plans, and actions. Denied HI. Denied A/V hallucinations. Speech: Spontaneous, normal tone, volume, rate, prosody. Judgment and Insight: Poor/poor Cognition: Attention: Alert, inattentive during interview. Orientation: Oriented to person, place, and situation. Memory: Appears intact to recent events, limited past hx. Fund of knowledge: Adequate Language: [MASKED], fluent, without paraphrasic errors Pertinent Results: ED labs ([MASKED]): CBC- WNL BMP- WNL LFTs- ALT 49, AST 36 Alk phos, total bili- WNL Albumin- WNL UA- WNL Serum tox- Positive for benzodiazepines; otherwise, negative Urine tox- negative Brief Hospital Course: SAFETY: Patient was placed on 15 minute checks on admission and remained here on that level of observation throughout. He was unit-restricted. LEGAL: [MASKED] PSYCHIATRIC: #) DEPRESSION: In initial ED and inpatient psychiatry unit admission exams, patient reported worsening depression and suicidal ideation with plans. Patient endorsed disturbance in neurovegetative symptoms. Patient endorsed recent substance abuse. At admission, patient reported recent benzodiazepine abuse (xanax and klonopin), alcohol, and cigar use. Patient denied current and past symptoms of hypomania/mania. Patient denied current and past symptoms of psychosis. Patient denied HI. Of note, patient provided inconsistent recent and past history at times. Patient complained of anxiety. Due to past responses to clonidine and wellbutrin [MASKED], patient was started on these medications after the determination was made that he was not at risk for withdrawal from alcohol and GABA agonists. Patient tolerated medication changes well. Patient reported subjective improvement in anxiety symptoms. On initial interview with the primary team on the inpatient psychiatry unit ([MASKED]), patient readily reported that he was not suicidal, and requested to discuss discharge planning. Patient reported his current presentation was in an effort to obtain housing. Patient reported he was recently hospitalized at [MASKED] inpatient psychiatry unit for a similar reason. Patient stated, "I really don't want to kill myself. I just wanted a place to stay." Patient reported that he felt like he no longer required inpatient hospitalization as he had time to rest. Patient denied other associated acute stressors. Patient reported chronically depressed mood, without acute change. Patient reported he continues to experience, "Passive suicidal thoughts," which he clarified as from "Time to time, wondering why I gets up." When asked to provide further details, patient refused, and stated they these were not new feelings. Patient denied active suicidal thoughts, plans, and actions. Patient provided vague details, and required encouragement to provide clarification. Patient stated there were no further benefit he could take from the inpatient psychiatry hospital and again requested to be discharge. While on the unit, patient did not engage in groups; however, patient was observed in the milieu. Patient's current presentation is most consistent with malingering and polysubstance abuse. Patient's presentation is also concerning for substance induced mood disorder. Patient endorsed recent substance abuse throughout his admission. Notably, patient provided inconsistent reports of substance abuse. In the ED, he reported infrequent ETOH use and "only when I can't get benzos." On the unit, he reports [MASKED] beers every few months. In the ED, he alternated between reporting and denying Xanax and Klonopin use a few times a week. On admission interview unit, patient reported using Xanax and Klonopin up to [MASKED] mg at a time, [MASKED] times/week, for the past 2 months; last used Xanax 4 mg on [MASKED]. On initial interview with the primary team ([MASKED]), patient reported abuse of Adderall prescription from PCP. Patient also reported recent vague benzodiazepine use and denied other recent substance abuse. Patient reported past trials of suboxone, methadone, naltrexone, inpatient psychiatry, and partial programs. Patient identified naltrexone as the most helpful. Outpatient substance abuse supports were discussed at length with patient. MEDICAL: 1.) Admission medical workup: Initial labs ([MASKED]) significant for WNL CBC, BMP, alk phos, total bili, and albumin; ALT 49, AST 36, positive serum tox for benzodiazepines and negative urine tox. Patient was encouraged to follow up with PCP [MASKED] 1 week of discharge. 2.) Asthma: Patient was continued on home albuterol inhaler Q6H PRN for SOB, wheezing. 3.) Neuropathic pain: Attributed to kyphosis and scoliosis. Patient denied pain at admission and throughout hospitalization. Patient reported he last took Gabapentin 1 month prior to hospitalization, with unclear efficacy. Gabapentin was not restarted to absence of symptoms and unclear efficacy. 4.) Hepatitis C: Patient was encouraged to follow up with PCP [MASKED] 1 week of discharge for further care. PSYCHOSOCIAL: #) GROUPS/MILIEU: Patient was encouraged to participate in units groups, milieu, and therapy opportunities. Usage of coping skills, mindfulness, and relaxation methods were encouraged. Therapy addressed family, social, work, and housing issues. Despite repeated requests, patient declined engagement in groups. #) COLLATERAL CONTACTS: Attempted to contact patient's primary care provider, [MASKED] [MASKED] ([MASKED]) multiple times prior to discharge. #) FAMILY INVOLVEMENT: Patient identified his mother, [MASKED] and [MASKED] as his primary supports, but refused contact. Patient refused contact with other family and friend supports. INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of starting this medication, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team, and I answered the patient's questions. The patient appeared able to understand and consented to begin the medication. RISK ASSESSMENT: At time of discharge, patient was regarded as at low imminent risk of harm/violence to self/others. Risk factors include history of suicide attempts, recent suicidal ideation (though patient later stated he fabricated this), active substance abuse, history of trauma, family history of mental illness, lack of day structure, male gender, single status, chronic medical illness, lack of established outpatient psychiatric providers, history of noncompliance, evidence of impulsivity, history of violence towards others, constricted psychosocial support network, and chronic mental illness. Protective factors include help seeking behavior for own safety, motivation to obtain treatment, plans for the future (to see child), connection to family, child, and strong knowledge on how to navigate the mental healthcare system. PROGNOSIS: Guarded: Patient is prone to decompensation given nature of illness, with active ongoing substance abuse, and history of many inpatient psychiatry hospitalizations and unclear benefit. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler [MASKED] PUFF IH [MASKED] TIMES/DAILY SOB, wheezing Discharge Medications: 1. Albuterol Inhaler [MASKED] PUFF IH [MASKED] TIMES/DAILY SOB, wheezing 2. BuPROPion 75 mg PO Q8AM AND Q1PM RX bupropion HCl 75 mg 1 (One) tablet(s) by mouth twice daily Disp #60 Tablet Refills:0 3. CloNIDine 0.1 mg PO BID RX clonidine HCl 0.1 mg 1 (One) tablet(s) by mouth twice daily Disp #60 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Depression, substance abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were hospitalized at [MASKED] for worsening depression, suicidal ideation, and polysubstance abuse. We adjusted your medications, and you are now ready for discharge and continued treatment. -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Please continue all medications as directed. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call [MASKED] or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. We strongly recommend engaging in AA/NA/SMART recovery meetings for ongoing help with sobriety. Here is a website with links to meetings near your area: [MASKED] Followup Instructions: [MASKED]	[]	[ "F329", "F17210", "J45909", "F419" ]	[ "F329: Major depressive disorder, single episode, unspecified", "R45851: Suicidal ideations", "M419: Scoliosis, unspecified", "B1920: Unspecified viral hepatitis C without hepatic coma", "Z590: Homelessness", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F1010: Alcohol abuse, uncomplicated", "F1310: Sedative, hypnotic or anxiolytic abuse, uncomplicated", "J45909: Unspecified asthma, uncomplicated", "F419: Anxiety disorder, unspecified", "M40209: Unspecified kyphosis, site unspecified", "M792: Neuralgia and neuritis, unspecified" ]
10,094,091	22,012,438	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Mrs ___ is a ___ with hypothyroidism, intermittent low back pain, prior ex-lap for Schwannoma resection, and diagnosis of H pylori in ___ s/p treatment with triple therapy, who presents with diarrhea and intermittent crampy abdominal pain that has been persistent for nearly 2 months. She says she was in her usual state of good health until her annual visit with her PCP, when she endorsed some dyspepsia/GERD symptoms. She was diagnosed with H. pylori, and started on triple therapy. She says that within 2 days of starting treatment, she began to have crampy abdominal pain and diarrhea. The diarrhea was very robust, voluminous, nonbloody, generally watery. There would be good days and bad days, but at its worst she would have too numerous to count BMs, including at night. She was referred to Dr ___ did an upper endoscopy, which was reportedly normal. He sent her for an abdominal CT, which was negative. Various treatments were attempted, including BRAT diet, modified BRAT diet, Imodium, etc. All work for a day or two but then fail. She occasionally notices that with fasting her abdominal pain is improved. She has crampy diffuse abdominal pain, which is perhaps worst in the epigastrum. There is also a soreness that is occasionally present in her epigastrum. Pain is generally improved with BM, though the soreness often persists. Over the course of these past several weeks, going on two months, she has had significant weight loss, fatigue, weakness. She saw Dr ___ in GI clinic on ___. He recommended expedited workup with colonoscopy. She initially refused, but symptoms worsened somewhat and she decided to seek care, so her PCP referred her to the ED. Past Medical History: Hypothyroidism Intermittent low back pain Vaginal delivery x2 Ex lap for schwannoma 10 or so years ago Social History: ___ Family History: Lung cancer in her brother. There is a family history of gallbladder disease. Physical Exam: Vitals AF, AVSS, BP 150/70s, HR 100, RR 18 Gen NAD, quite pleasant Abd soft, ND, bs+, NT CV tachycardic, RRR, seemingly fixed split sound vs summation ___? Lungs entirely CTA ___, breathing unlabored Ext WWP, no edema Skin no rash, anicteric GU no foley Eyes EOMI HENT MMM, OP clear Neuro nonfocal, moves all extremities, steady gait Psych normal affect, pleasant DISCHARGE EXAM: Vitals: 98.6, 118/63, 16, 99%RA Gen: NAD, sitting on the edge of the bed, pleasant Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR Resp: normal effort, no accessory muscle use, lungs CTA ___. GI: soft, non-tender, ND, BS+ Skin: No visible rash. Neuro: AAOx3. No facial droop. Gait normal Psych: Full range of affect Pertinent Results: ___ 01:00PM BLOOD WBC-12.6# RBC-3.66 Hgb-10.9* Hct-33.6* MCV-92 MCH-29.8 MCHC-32.4 RDW-12.4 RDWSD-41.6 Plt Ct-ERROR ___ 01:00PM BLOOD Neuts-82* Bands-0 Lymphs-11* Monos-7 Eos-0 Baso-0 ___ Myelos-0 AbsNeut-10.33* AbsLymp-1.39 AbsMono-0.88* AbsEos-0.00* AbsBaso-0.00* ___ 01:00PM BLOOD Glucose-92 UreaN-11 Creat-0.6 Na-135 K-3.7 Cl-98 HCO3-22 AnGap-19 CT abdomen/pelvis with contrast ___: 1. No radiographic evidence for the patient's abdominal pain. 2. Status post para-aortic schwannoma resection without evidence of local recurrence or lymphadenopathy. *FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Reported to and read back by ___ ___ 10:58AM. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND DISCHARGE LABS: ___ 07:15AM BLOOD WBC-5.9 RBC-3.21 Hgb-9.6* Hct-29.3* MCV-91 MCH-29.9 MCHC-32.8 RDW-12.4 RDWSD-41.6 Plt ___ ___ 07:15AM BLOOD Glucose-106* UreaN-3* Creat-0.6 Na-141 K-4.2 Cl-107 HCO3-25 AnGap-13 ___ 07:15AM BLOOD Phos-3.2 Mg-1.___ w hypothyroidism, intermittent low back pain, prior ex-lap for Schwannoma resection, and diagnosis of H pylori in ___ s/p treatment with triple therapy, who presents with diarrhea and intermittent crampy abdominal pain that has been persistent for nearly 2 months. # Weight loss with # Dehydration and hypovolemia from # Diarrhea, ? acute on chronic perhaps due to # C difficile infection: While she was initially admitted with plan for workup of chronic diarrhea, her C diff has come back positive for toxigenic c diff. She was treated with IVF, po vancomycin with plan to end the course on ___ for a 14 day course. GI followed. Other stool studies were negative. TSH wnl. In discussion with GI the plan for possible colonoscopy with random biopsy was deferred in the setting of the c. diff and can be consider following competition of treatment. # Hypothyroidism: ___ wnl. Continued levoxyl # anemia: new, unknown cause. B12/celiac serologies/haptoglobin not consistent with a cause, iron c/w chronic disease v acute infection. Her counts were stable during her admission. # hypokalemia: likely ___ diarrhea. Improved with repletion. # microscopic hematuria: She was noted to have microscopic hematuria. CT ABD/Pelvis was done in ___ with only a simpe cyst noted. The patient will need follow up as outpatient. Greater than 30 minutes was spent in care coordination and counseling on the day of discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Levothyroxine Sodium 62 mcg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Omeprazole 40 mg PO DAILY 4. Citracal Regular (calcium citrate-vitamin D3) 250 mg calcium- 200 unit oral DAILY Discharge Medications: 1. Levothyroxine Sodium 62 mcg PO DAILY 2. Citracal Regular (calcium citrate-vitamin D3) 250 mg calcium- 200 unit oral DAILY 3. Multivitamins 1 TAB PO DAILY 4. Omeprazole 40 mg PO DAILY 5. Vancomycin Oral Liquid ___ mg PO Q6H RX vancomycin 125 mg 1 capsule(s) by mouth Every 6 hours Disp #40 Capsule Refills:0 6. Florajen3 (L.acidoph-B.lactis-B.longum) 460 mg (7.5-6- 1.5 ___. cell) oral DAILY RX L.acidoph-B.lactis-B.longum [___] 460 mg (7.5-6-1.5 billion cell) 1 capsule(s) by mouth Daily Disp #30 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: Sepsis due to C difficile colitis with diarrhea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with diarrhea and weight loss. You were found to have infection with C difficile. You were treated with antibiotics and your diarrhea improved slightly. The case was discussed with GI who felt that performing colonoscopy to help evaluate the diarrhea would not be helpful until after the treatment of the C.diff. You continued to have diarrhea but your electrolytes were stable. It was recommended that you follow up following treatment of the C.diff for evaluation of the diarrhea if it persists. Please do not take any Imodium until after you follow up with your PCP as it is not a good medication to take in the setting of your c. diff infection. Please take all your medications as directed and follow up as directed with your PCP and GI provider. Followup Instructions: ___	[ "A047", "Z681", "D649", "E860", "R312", "E039", "E861", "R634", "Z86718", "E876" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Mrs [MASKED] is a [MASKED] with hypothyroidism, intermittent low back pain, prior ex-lap for Schwannoma resection, and diagnosis of H pylori in [MASKED] s/p treatment with triple therapy, who presents with diarrhea and intermittent crampy abdominal pain that has been persistent for nearly 2 months. She says she was in her usual state of good health until her annual visit with her PCP, when she endorsed some dyspepsia/GERD symptoms. She was diagnosed with H. pylori, and started on triple therapy. She says that within 2 days of starting treatment, she began to have crampy abdominal pain and diarrhea. The diarrhea was very robust, voluminous, nonbloody, generally watery. There would be good days and bad days, but at its worst she would have too numerous to count BMs, including at night. She was referred to Dr [MASKED] did an upper endoscopy, which was reportedly normal. He sent her for an abdominal CT, which was negative. Various treatments were attempted, including BRAT diet, modified BRAT diet, Imodium, etc. All work for a day or two but then fail. She occasionally notices that with fasting her abdominal pain is improved. She has crampy diffuse abdominal pain, which is perhaps worst in the epigastrum. There is also a soreness that is occasionally present in her epigastrum. Pain is generally improved with BM, though the soreness often persists. Over the course of these past several weeks, going on two months, she has had significant weight loss, fatigue, weakness. She saw Dr [MASKED] in GI clinic on [MASKED]. He recommended expedited workup with colonoscopy. She initially refused, but symptoms worsened somewhat and she decided to seek care, so her PCP referred her to the ED. Past Medical History: Hypothyroidism Intermittent low back pain Vaginal delivery x2 Ex lap for schwannoma 10 or so years ago Social History: [MASKED] Family History: Lung cancer in her brother. There is a family history of gallbladder disease. Physical Exam: Vitals AF, AVSS, BP 150/70s, HR 100, RR 18 Gen NAD, quite pleasant Abd soft, ND, bs+, NT CV tachycardic, RRR, seemingly fixed split sound vs summation [MASKED]? Lungs entirely CTA [MASKED], breathing unlabored Ext WWP, no edema Skin no rash, anicteric GU no foley Eyes EOMI HENT MMM, OP clear Neuro nonfocal, moves all extremities, steady gait Psych normal affect, pleasant DISCHARGE EXAM: Vitals: 98.6, 118/63, 16, 99%RA Gen: NAD, sitting on the edge of the bed, pleasant Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR Resp: normal effort, no accessory muscle use, lungs CTA [MASKED]. GI: soft, non-tender, ND, BS+ Skin: No visible rash. Neuro: AAOx3. No facial droop. Gait normal Psych: Full range of affect Pertinent Results: [MASKED] 01:00PM BLOOD WBC-12.6# RBC-3.66 Hgb-10.9* Hct-33.6* MCV-92 MCH-29.8 MCHC-32.4 RDW-12.4 RDWSD-41.6 Plt Ct-ERROR [MASKED] 01:00PM BLOOD Neuts-82* Bands-0 Lymphs-11* Monos-7 Eos-0 Baso-0 [MASKED] Myelos-0 AbsNeut-10.33* AbsLymp-1.39 AbsMono-0.88* AbsEos-0.00* AbsBaso-0.00* [MASKED] 01:00PM BLOOD Glucose-92 UreaN-11 Creat-0.6 Na-135 K-3.7 Cl-98 HCO3-22 AnGap-19 CT abdomen/pelvis with contrast [MASKED]: 1. No radiographic evidence for the patient's abdominal pain. 2. Status post para-aortic schwannoma resection without evidence of local recurrence or lymphadenopathy. *FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Reported to and read back by [MASKED] [MASKED] 10:58AM. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). FECAL CULTURE (Final [MASKED]: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [MASKED]: NO CAMPYLOBACTER FOUND DISCHARGE LABS: [MASKED] 07:15AM BLOOD WBC-5.9 RBC-3.21 Hgb-9.6* Hct-29.3* MCV-91 MCH-29.9 MCHC-32.8 RDW-12.4 RDWSD-41.6 Plt [MASKED] [MASKED] 07:15AM BLOOD Glucose-106* UreaN-3* Creat-0.6 Na-141 K-4.2 Cl-107 HCO3-25 AnGap-13 [MASKED] 07:15AM BLOOD Phos-3.2 Mg-1.[MASKED] w hypothyroidism, intermittent low back pain, prior ex-lap for Schwannoma resection, and diagnosis of H pylori in [MASKED] s/p treatment with triple therapy, who presents with diarrhea and intermittent crampy abdominal pain that has been persistent for nearly 2 months. # Weight loss with # Dehydration and hypovolemia from # Diarrhea, ? acute on chronic perhaps due to # C difficile infection: While she was initially admitted with plan for workup of chronic diarrhea, her C diff has come back positive for toxigenic c diff. She was treated with IVF, po vancomycin with plan to end the course on [MASKED] for a 14 day course. GI followed. Other stool studies were negative. TSH wnl. In discussion with GI the plan for possible colonoscopy with random biopsy was deferred in the setting of the c. diff and can be consider following competition of treatment. # Hypothyroidism: [MASKED] wnl. Continued levoxyl # anemia: new, unknown cause. B12/celiac serologies/haptoglobin not consistent with a cause, iron c/w chronic disease v acute infection. Her counts were stable during her admission. # hypokalemia: likely [MASKED] diarrhea. Improved with repletion. # microscopic hematuria: She was noted to have microscopic hematuria. CT ABD/Pelvis was done in [MASKED] with only a simpe cyst noted. The patient will need follow up as outpatient. Greater than 30 minutes was spent in care coordination and counseling on the day of discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Levothyroxine Sodium 62 mcg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Omeprazole 40 mg PO DAILY 4. Citracal Regular (calcium citrate-vitamin D3) 250 mg calcium- 200 unit oral DAILY Discharge Medications: 1. Levothyroxine Sodium 62 mcg PO DAILY 2. Citracal Regular (calcium citrate-vitamin D3) 250 mg calcium- 200 unit oral DAILY 3. Multivitamins 1 TAB PO DAILY 4. Omeprazole 40 mg PO DAILY 5. Vancomycin Oral Liquid [MASKED] mg PO Q6H RX vancomycin 125 mg 1 capsule(s) by mouth Every 6 hours Disp #40 Capsule Refills:0 6. Florajen3 (L.acidoph-B.lactis-B.longum) 460 mg (7.5-6- 1.5 [MASKED]. cell) oral DAILY RX L.acidoph-B.lactis-B.longum [[MASKED]] 460 mg (7.5-6-1.5 billion cell) 1 capsule(s) by mouth Daily Disp #30 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: Sepsis due to C difficile colitis with diarrhea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with diarrhea and weight loss. You were found to have infection with C difficile. You were treated with antibiotics and your diarrhea improved slightly. The case was discussed with GI who felt that performing colonoscopy to help evaluate the diarrhea would not be helpful until after the treatment of the C.diff. You continued to have diarrhea but your electrolytes were stable. It was recommended that you follow up following treatment of the C.diff for evaluation of the diarrhea if it persists. Please do not take any Imodium until after you follow up with your PCP as it is not a good medication to take in the setting of your c. diff infection. Please take all your medications as directed and follow up as directed with your PCP and GI provider. Followup Instructions: [MASKED]	[]	[ "D649", "E039", "Z86718" ]	[ "A047: Enterocolitis due to Clostridium difficile", "Z681: Body mass index [BMI] 19.9 or less, adult", "D649: Anemia, unspecified", "E860: Dehydration", "R312: Other microscopic hematuria", "E039: Hypothyroidism, unspecified", "E861: Hypovolemia", "R634: Abnormal weight loss", "Z86718: Personal history of other venous thrombosis and embolism", "E876: Hypokalemia" ]
10,094,132	20,310,837	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: ___: laparoscopic appendectomy History of Present Illness: Patient presents to the emergency room with a 1-day history of abdominal pain. It is located in the rightflank. Further diagnostic studies including CAT scan are suggestive of a retrocecal appendicitis. The patient was hydrated and brought urgently to the operating room in the morning. Past Medical History: OSA, Obesity PSH: laparoscopic sleeve gastrectomy, total hysterectomy and L oophorectomy for large fibroids ___ C-section x 3, abdominoplasty, breast reduction, back surgery Social History: ___ Family History: FH: Mother - diabetes, Father - diabetes, ___. No hx of cancer, CVD Physical Exam: VS: T 98 P 73 BP 107/64 RR 20 O2 95%RA Constitutional: NAD Neuro: Alert and oriented x 3 Cardiac: Regular rate and rhythm, no murmurs appreciated Resp: Clear to auscultation, bilaterally Abdomen: Soft, appropriately tender to palpation, non-distended, no rebound tenderness or guarding Wounds: Abd lap sites with primary dressing, CDI Ext: no edema Pertinent Results: LABS: ___ 12:25PM BLOOD WBC-11.6# RBC-4.86 Hgb-15.2 Hct-44.4 MCV-91 MCH-31.3 MCHC-34.2 RDW-12.3 RDWSD-40.4 Plt ___ Neuts-84.4 Lymphs-8.9* Monos-6.0 Eos-0.1* Baso-0.3 Im ___ AbsNeut-9.81* AbsLymp-1.03* AbsMono-0.70 AbsEos-0.01* AbsBaso-0.03 Glucose-109* UreaN-6 Creat-0.8 Na-138 K-4.5 Cl-101 HCO___-27 AnGap-15 ALT-47* AST-25 AlkPhos-95 TotBili-0.9 ___ Lipase-32 IMAGING: ___ CT ABD & PELVIS WITH CONTRAST: 1. Acute uncomplicated retrocecal appendicitis with adjacent fat stranding and associated inflammation of cecal base. 2. Mildly complex right ovarian cystic lesion measuring 5 cm. 3. Cholelithiasis without evidence of acute cholecystitis. Brief Hospital Course: Ms. ___ was admitted to the ___ Surgical Service on ___ for evaluation and treatment of abdominal pain. Admission abdominal/pelvic CT revealed acute appendicitis; wbc was mildly elevated at 11.6. The patient underwent laparoscopic appendectomy, which went well without complication; please see operative note for details. After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating clear liquids, on IV fluids, and oxycodone for pain control. The patient was hemodynamically stable. . Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Ibuprofen 800 mg PO Q8H 2. Calcium Carbonate 500 mg PO Frequency is Unknown mg 3. Sumatriptan Succinate ___ mg PO DAILY:PRN headache 4. Cyanocobalamin Dose is Unknown PO DAILY 5. Riboflavin (Vitamin B-2) 200 mg PO BID 6. Vitamin D Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #10 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:0 4. MetroNIDAZOLE 500 mg PO TID Duration: 5 Days RX metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #15 Tablet Refills:0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg ___ tablet(s) by mouth q 4 hours Disp #30 Tablet Refills:0 6. Calcium Carbonate 500 mg PO UNKNOWN MG mg 7. Cyanocobalamin unknown PO DAILY 8. Vitamin D unknown PO DAILY 9. Riboflavin (Vitamin B-2) 200 mg PO BID 10. Sumatriptan Succinate ___ mg PO DAILY:PRN headache Discharge Disposition: Home Discharge Diagnosis: Acute appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You presented to the hospital with acute appendicitis, underwent surgical removal of your appendix and recovered in the hospital. You are now preparing for discharge to home 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 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. You have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. Additionally, as discussed, there was an incidental finding on your CT scan showing an ovarian cyst with recommendation for a follow-up ultrasound. An appointment with our gynecologist, Dr. ___, has been scheduled for you on ___ at 8:00 am. Followup Instructions: ___	[ "K3580", "E669", "Z6834", "M545", "G8929", "G4733", "Z9884" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [MASKED]: laparoscopic appendectomy History of Present Illness: Patient presents to the emergency room with a 1-day history of abdominal pain. It is located in the rightflank. Further diagnostic studies including CAT scan are suggestive of a retrocecal appendicitis. The patient was hydrated and brought urgently to the operating room in the morning. Past Medical History: OSA, Obesity PSH: laparoscopic sleeve gastrectomy, total hysterectomy and L oophorectomy for large fibroids [MASKED] C-section x 3, abdominoplasty, breast reduction, back surgery Social History: [MASKED] Family History: FH: Mother - diabetes, Father - diabetes, [MASKED]. No hx of cancer, CVD Physical Exam: VS: T 98 P 73 BP 107/64 RR 20 O2 95%RA Constitutional: NAD Neuro: Alert and oriented x 3 Cardiac: Regular rate and rhythm, no murmurs appreciated Resp: Clear to auscultation, bilaterally Abdomen: Soft, appropriately tender to palpation, non-distended, no rebound tenderness or guarding Wounds: Abd lap sites with primary dressing, CDI Ext: no edema Pertinent Results: LABS: [MASKED] 12:25PM BLOOD WBC-11.6# RBC-4.86 Hgb-15.2 Hct-44.4 MCV-91 MCH-31.3 MCHC-34.2 RDW-12.3 RDWSD-40.4 Plt [MASKED] Neuts-84.4 Lymphs-8.9* Monos-6.0 Eos-0.1* Baso-0.3 Im [MASKED] AbsNeut-9.81* AbsLymp-1.03* AbsMono-0.70 AbsEos-0.01* AbsBaso-0.03 Glucose-109* UreaN-6 Creat-0.8 Na-138 K-4.5 Cl-101 HCO -27 AnGap-15 ALT-47* AST-25 AlkPhos-95 TotBili-0.9 [MASKED] Lipase-32 IMAGING: [MASKED] CT ABD & PELVIS WITH CONTRAST: 1. Acute uncomplicated retrocecal appendicitis with adjacent fat stranding and associated inflammation of cecal base. 2. Mildly complex right ovarian cystic lesion measuring 5 cm. 3. Cholelithiasis without evidence of acute cholecystitis. Brief Hospital Course: Ms. [MASKED] was admitted to the [MASKED] Surgical Service on [MASKED] for evaluation and treatment of abdominal pain. Admission abdominal/pelvic CT revealed acute appendicitis; wbc was mildly elevated at 11.6. The patient underwent laparoscopic appendectomy, which went well without complication; please see operative note for details. After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating clear liquids, on IV fluids, and oxycodone for pain control. The patient was hemodynamically stable. . Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Ibuprofen 800 mg PO Q8H 2. Calcium Carbonate 500 mg PO Frequency is Unknown mg 3. Sumatriptan Succinate [MASKED] mg PO DAILY:PRN headache 4. Cyanocobalamin Dose is Unknown PO DAILY 5. Riboflavin (Vitamin B-2) 200 mg PO BID 6. Vitamin D Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #10 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:0 4. MetroNIDAZOLE 500 mg PO TID Duration: 5 Days RX metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #15 Tablet Refills:0 5. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg [MASKED] tablet(s) by mouth q 4 hours Disp #30 Tablet Refills:0 6. Calcium Carbonate 500 mg PO UNKNOWN MG mg 7. Cyanocobalamin unknown PO DAILY 8. Vitamin D unknown PO DAILY 9. Riboflavin (Vitamin B-2) 200 mg PO BID 10. Sumatriptan Succinate [MASKED] mg PO DAILY:PRN headache Discharge Disposition: Home Discharge Diagnosis: Acute appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You presented to the hospital with acute appendicitis, underwent surgical removal of your appendix and recovered in the hospital. You are now preparing for discharge to home 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 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. You have steri-strips, they will fall off on their own. Please remove any remaining strips [MASKED] days after surgery. Additionally, as discussed, there was an incidental finding on your CT scan showing an ovarian cyst with recommendation for a follow-up ultrasound. An appointment with our gynecologist, Dr. [MASKED], has been scheduled for you on [MASKED] at 8:00 am. Followup Instructions: [MASKED]	[]	[ "E669", "G8929", "G4733" ]	[ "K3580: Unspecified acute appendicitis", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult", "M545: Low back pain", "G8929: Other chronic pain", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z9884: Bariatric surgery status" ]
10,094,132	24,212,330	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: intra-abdominal abscess Major Surgical or Invasive Procedure: ___ fluid drainage ___ History of Present Illness: From admission note: ___ is a ___ s/p laparoscopic sleeve gastrectomy on ___ with Dr. ___ at ___ and s/p laparoscopic appendectomy with Dr. ___ on ___ who presents with RLQ pain. Intraoperatively, an inflamed necrotic appendix with perforation at the tip, contamination relatively confined and contained was found. She was further found to have extensive pelvic adhesions and a right ovarian cyst. She recovered well from surgery, until she started experiencing gradual onset RLQ pain two days ago that became very severe today. She had subjective chills yesterday, no fevers and experienced some burning on urination. Currently, she is in ___ pain after receiving pain medication. Vaginal US shows a right ovarian cyst, renal US is negative and CBC is normal. She denies any other symptoms including nausea, vomiting, diarrhea, constipation and blood in stool. Past Medical History: OSA, Obesity PSH: laparoscopic sleeve gastrectomy, total hysterectomy and L oophorectomy for large fibroids ___ C-section x 3, abdominoplasty, breast reduction, back surgery Social History: ___ Family History: FH: Mother - diabetes, Father - diabetes, ___. No hx of cancer, CVD Physical Exam: Admission Physical Exam: Vitals: Tmax 98.2 Temp 98.0 HR 91 BP 126/81 RR 18 100% RA General: AOx3, NAD, though lying on stretcher uncomfortably Cor: RRR, Nl S1,S2 Pulm: CTAB Abd: soft, ND. TTP in RUQ/RLQ. Back: R CVA tenderness Discharge Physical Exam: Vitals: Afebrile, all vital signs stable Gen: AOx3, NAD CV: RRR, nl s1/s2, no m/r/g Pulm: CTAB, no rales, wheezes, rhonchi Abd: Soft, nontender, nondistended. Drain in place in RLQ. Extr: WWP Pertinent Results: ___ 12:25PM LACTATE-0.8 ___ 12:20PM GLUCOSE-101* UREA N-9 CREAT-0.8 SODIUM-138 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13 ___ 12:20PM estGFR-Using this ___ 12:20PM WBC-7.1 RBC-4.18 HGB-12.8 HCT-38.9 MCV-93 MCH-30.6 MCHC-32.9 RDW-12.2 RDWSD-41.5 ___ 12:20PM NEUTS-74.1* LYMPHS-16.1* MONOS-8.2 EOS-0.7* BASOS-0.6 IM ___ AbsNeut-5.26 AbsLymp-1.14* AbsMono-0.58 AbsEos-0.05 AbsBaso-0.04 ___ 12:20PM PLT COUNT-276# ___ 11:55AM URINE HOURS-RANDOM ___ 11:55AM URINE HOURS-RANDOM ___ 11:55AM URINE UCG-NEG ___ 11:55AM URINE GR HOLD-HOLD ___ 11:55AM URINE COLOR-Amber APPEAR-SlHazy SP ___ ___ 11:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-8* PH-6.0 LEUK-NEG ___ 11:55AM URINE RBC-15* WBC-1 BACTERIA-FEW YEAST-NONE EPI-4 ___ 11:55AM URINE GRANULAR-1* ___ 11:55AM URINE MUCOUS-MANY Brief Hospital Course: Ms. ___ was admitted to the ___ after presenting to the ED on ___ for complaints of chills, fever, and burning on urination. She was s/p laparoscopic sleeve gastrectomy on ___ with Dr. ___ at ___ and s/p laparoscopic appendectomy with Dr. ___ on ___. In the ED, her WBC count was normal and a transvaginal US demonstrated a R ovarian cyst. A CT abdomen/pelvis demonstrated a peripherally enhancing irregularly shaped fluid collection in the right lower quadrant adjacent to surgical suture from her prior appendectomy with dominant components measuring 3.3 x 2.0 and 3.2 x 2.4 cm. This was worrisome for abscess with surrounding phlegmon. She was started on cipro/flagyl and received an ___ drainage of the abscess, resulting in a pigtail drain in place in her RLQ. She had improvement of her symptoms and was stable overnight. Her diet was advanced and she was without pain, fever, or other complaints. On ___, she was afebrile, tolerating a regular diet, voiding spontaneously, and ambulating without issues. She was given a 2 week course of ciprofloxacin and flagyl and provided with teaching for her drain. She also had ___ arranged to help her with drain management. Medications on Admission: Amitriptyline 25 mg PO QHS Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 500 mg PO/NG Q12H 3. MetroNIDAZOLE 500 mg PO TID 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 5. Amitriptyline 25 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: RLQ abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the ___ on ___ for chills, fever, and burning on urination. You were found to have two fluid collections in your right lower abdomen that were infected and subsequently drained by interventional radiology on ___ without issue. You are now doing well and ready to go home. You have a drain that should be left in until you follow up in clinic with Dr. ___. You will also be prescribed antibiotics. You should take these both (flagyl, ciprofloxacin) for two weeks. Please record your drain output daily, and strip the drain several times per day as shown to you by the nurse before your discharge. You will also have a visitng nurse who can help with this. You will be prescribed Tylenol and oxycodone. You may take Tylenol but do not take more than 4gm per day. Take oxycodone as needed for pain not controlled by Tylenol. You should also take an over the counter stool softener such as Colace while taking oxycodone to prevent constipation. Please do not drive or operate heavy machinery when taking oxycodone. Please call if you have any questions or concerns. Thank you! Followup Instructions: ___	[ "T814XXA", "K651", "B9689", "Y836", "Y92019", "Z980", "Z9884", "N8320", "G4733", "E669", "Z6834" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: intra-abdominal abscess Major Surgical or Invasive Procedure: [MASKED] fluid drainage [MASKED] History of Present Illness: From admission note: [MASKED] is a [MASKED] s/p laparoscopic sleeve gastrectomy on [MASKED] with Dr. [MASKED] at [MASKED] and s/p laparoscopic appendectomy with Dr. [MASKED] on [MASKED] who presents with RLQ pain. Intraoperatively, an inflamed necrotic appendix with perforation at the tip, contamination relatively confined and contained was found. She was further found to have extensive pelvic adhesions and a right ovarian cyst. She recovered well from surgery, until she started experiencing gradual onset RLQ pain two days ago that became very severe today. She had subjective chills yesterday, no fevers and experienced some burning on urination. Currently, she is in [MASKED] pain after receiving pain medication. Vaginal US shows a right ovarian cyst, renal US is negative and CBC is normal. She denies any other symptoms including nausea, vomiting, diarrhea, constipation and blood in stool. Past Medical History: OSA, Obesity PSH: laparoscopic sleeve gastrectomy, total hysterectomy and L oophorectomy for large fibroids [MASKED] C-section x 3, abdominoplasty, breast reduction, back surgery Social History: [MASKED] Family History: FH: Mother - diabetes, Father - diabetes, [MASKED]. No hx of cancer, CVD Physical Exam: Admission Physical Exam: Vitals: Tmax 98.2 Temp 98.0 HR 91 BP 126/81 RR 18 100% RA General: AOx3, NAD, though lying on stretcher uncomfortably Cor: RRR, Nl S1,S2 Pulm: CTAB Abd: soft, ND. TTP in RUQ/RLQ. Back: R CVA tenderness Discharge Physical Exam: Vitals: Afebrile, all vital signs stable Gen: AOx3, NAD CV: RRR, nl s1/s2, no m/r/g Pulm: CTAB, no rales, wheezes, rhonchi Abd: Soft, nontender, nondistended. Drain in place in RLQ. Extr: WWP Pertinent Results: [MASKED] 12:25PM LACTATE-0.8 [MASKED] 12:20PM GLUCOSE-101* UREA N-9 CREAT-0.8 SODIUM-138 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13 [MASKED] 12:20PM estGFR-Using this [MASKED] 12:20PM WBC-7.1 RBC-4.18 HGB-12.8 HCT-38.9 MCV-93 MCH-30.6 MCHC-32.9 RDW-12.2 RDWSD-41.5 [MASKED] 12:20PM NEUTS-74.1* LYMPHS-16.1* MONOS-8.2 EOS-0.7* BASOS-0.6 IM [MASKED] AbsNeut-5.26 AbsLymp-1.14* AbsMono-0.58 AbsEos-0.05 AbsBaso-0.04 [MASKED] 12:20PM PLT COUNT-276# [MASKED] 11:55AM URINE HOURS-RANDOM [MASKED] 11:55AM URINE HOURS-RANDOM [MASKED] 11:55AM URINE UCG-NEG [MASKED] 11:55AM URINE GR HOLD-HOLD [MASKED] 11:55AM URINE COLOR-Amber APPEAR-SlHazy SP [MASKED] [MASKED] 11:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-8* PH-6.0 LEUK-NEG [MASKED] 11:55AM URINE RBC-15* WBC-1 BACTERIA-FEW YEAST-NONE EPI-4 [MASKED] 11:55AM URINE GRANULAR-1* [MASKED] 11:55AM URINE MUCOUS-MANY Brief Hospital Course: Ms. [MASKED] was admitted to the [MASKED] after presenting to the ED on [MASKED] for complaints of chills, fever, and burning on urination. She was s/p laparoscopic sleeve gastrectomy on [MASKED] with Dr. [MASKED] at [MASKED] and s/p laparoscopic appendectomy with Dr. [MASKED] on [MASKED]. In the ED, her WBC count was normal and a transvaginal US demonstrated a R ovarian cyst. A CT abdomen/pelvis demonstrated a peripherally enhancing irregularly shaped fluid collection in the right lower quadrant adjacent to surgical suture from her prior appendectomy with dominant components measuring 3.3 x 2.0 and 3.2 x 2.4 cm. This was worrisome for abscess with surrounding phlegmon. She was started on cipro/flagyl and received an [MASKED] drainage of the abscess, resulting in a pigtail drain in place in her RLQ. She had improvement of her symptoms and was stable overnight. Her diet was advanced and she was without pain, fever, or other complaints. On [MASKED], she was afebrile, tolerating a regular diet, voiding spontaneously, and ambulating without issues. She was given a 2 week course of ciprofloxacin and flagyl and provided with teaching for her drain. She also had [MASKED] arranged to help her with drain management. Medications on Admission: Amitriptyline 25 mg PO QHS Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 500 mg PO/NG Q12H 3. MetroNIDAZOLE 500 mg PO TID 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 5. Amitriptyline 25 mg PO QHS Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: RLQ abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the [MASKED] on [MASKED] for chills, fever, and burning on urination. You were found to have two fluid collections in your right lower abdomen that were infected and subsequently drained by interventional radiology on [MASKED] without issue. You are now doing well and ready to go home. You have a drain that should be left in until you follow up in clinic with Dr. [MASKED]. You will also be prescribed antibiotics. You should take these both (flagyl, ciprofloxacin) for two weeks. Please record your drain output daily, and strip the drain several times per day as shown to you by the nurse before your discharge. You will also have a visitng nurse who can help with this. You will be prescribed Tylenol and oxycodone. You may take Tylenol but do not take more than 4gm per day. Take oxycodone as needed for pain not controlled by Tylenol. You should also take an over the counter stool softener such as Colace while taking oxycodone to prevent constipation. Please do not drive or operate heavy machinery when taking oxycodone. Please call if you have any questions or concerns. Thank you! Followup Instructions: [MASKED]	[]	[ "G4733", "E669" ]	[ "T814XXA: Infection following a procedure", "K651: Peritoneal abscess", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92019: Unspecified place in single-family (private) house as the place of occurrence of the external cause", "Z980: Intestinal bypass and anastomosis status", "Z9884: Bariatric surgery status", "N8320: Unspecified ovarian cysts", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult" ]
10,094,133	21,785,799	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: n/a History of Present Illness: Ms. ___ is a ___ w/ PMH only notable for high-grade squamous intra-epithelial lesion on biopsy ___ s/p LEEP who presents w/ a several day history of chest pain. This was first reported at routine primary care visit ___. At that time, the patient had had 1 day of persistent, dull chest pain, ___ in intensity, substernal, with some radiation across the right chest. At that time, she was having no other symptoms, notably no shortness of breath, palpitations, diaphoresis, nausea, jaw or arm pain, lightheadedness. An EKG obtained at that visit showed nonspecific T wave abnormalities, so the patient was referred for stress testing. The patient underwent routine exercise stress testing ___ and exercised for 12 minutes of ___ protocol to a workload of ___ METS, and stopped for fatigue. Her chest pain was unaltered during testing. Per Cardiology, her baseline EKG showed biphasic T waves in III, AVF, V3-5, and at peak exercise, there was 0.5-___epression in these same leads, w/ T wave normalization in early recovery and returning to baseline morphology by 10 minutes post-exercise. Ultimately this was thought to represent non-specific ST segment changes in the setting of atypical chest discomfort. In the ED, the patient had negative troponin. However, given new T wave inversions, Cardiology recommended admission for further monitoring and workup. In the ED, - Initial vitals: T 98.7 HR 68 BP 120/83 RR 16 O2100% RA - Exam notable for: "Con: Comfortable, in no acute distress HEENT: NCAT. PERRLA, no icterus. EOMI Neck: no JVD Resp: No incr WOB, CTAB. CV: RRR. Normal S1/S2. 2+ radial pulse bilaterally Abd: Soft, Nontender, Nondistended. MSK: ___ without edema. Skin: No rash, Warm and dry, No petechiae Neuro: AOx3, speech fluent, no obvious facial asymmetry, moves all 4 ext to command. Psych: Normal mentation" - Labs notable for: WBC 6.4 HGB 14.0 platelets 224 Na 136 K 4.6 Cl 105 HCO3- 25 BUN 16 Cr 0.8 INR 1.0 - Imaging notable for: Patient refused CXR given concerns for radiation. - Patient given: PO Aspirin 324 mg PO/NG Atorvastatin 80 mg On admission, the patient confirmed the above, and stated that she feet chest pain-free. She does however note that for the past month, she has been quite stressed regarding her positive HPV test and LEEP, and then laryngoscopy for globus sensation. She states that the chest pain comes and goes, although she can identify no truly aggravating factor, except possibly stress. Only alleviating factor is sleep. She never has associated symptoms of the chest pain, although she does note some right-sided jaw pain which began yesterday. She has specifically had no headaches, vision changes, mouth sores, shortness of breath, abdominal pain, N/V/D, diaphoresis, dysuria, constipation, skin changes, or arthralgias. Past Medical History: -high-grade squamous intra-epithelial lesion on biopsy ___ s/p LEEP Social History: ___ Family History: Mother: deceased, ___ syndrome Father: deceased, ___ disease Siblings: 1 brother w/ T2DM, 1 healthy Children: 2 children, healthy. Physical Exam: On Admission: T 98.2 HR 143/82 HR 75 RR 20 O299 Ra GENERAL: WN/WD, NAD. HEAD: NC/AT, conjunctiva clear, EOMI, pupils reactive, sclera anicteric, oral mucosa w/o lesions. NECK: Supple, no LAD, no thyromegaly. JVP is 5 cm. CARDIAC: Precordium is quiet, PMI non-displaced, RRR, S1S2 w/o m/r/g. RESPIRATORY: Speaking in full sentences, CTABL. ABDOMEN: Unremarkable inspection, soft, NT, +BS. No palpable organomegaly. EXTREMITIES: Warm, no edema, peripheral pulses are strong and full. SKIN: No obvious lesions over the face, thorax, abdomen, extremities. NEUROLOGIC: Grossly intact, face symmetric, speech fluent, stands from seated position, gait normal. PSYCHIATRIC: Pleasant and cooperative. At Discharge: VS: 97.8, 105128/7081, 65, 16, 97% RA Weight: 58.3 kg / 128 lb Tele: Sinus rhythm ___ Gen: Sitting up in bed, NAD, ++ anxiety Neuro: alert and oriented, anxious, asking questions appropriately. Gait steady. HEENT: normocaphalic, anicteric, good dentition. Symmetrical facial movements. Conjuncitiva pink. Neck: supple, trachea midline, no carotid bruits CV: S1,S2, RRR, no rubs/murmers Chest: Eupneic. LS CTA ABD: flat, soft, nondistended. (+) bowel sounds x 4 quarters Extr: no pedal edema. Gross FROM. No obvious deformities Skin: turgor good, skin warm and dry, color pink. No obvious lesions. Access sites: HL, site benign. GU: voiding indep. Pertinent Results: Admission Labs: ___ 12:25PM BLOOD WBC-6.4 RBC-4.51 Hgb-14.0 Hct-42.3 MCV-94 MCH-31.0 MCHC-33.1 RDW-12.2 RDWSD-42.3 Plt ___ ___ 12:25PM BLOOD Neuts-75.9* ___ Monos-4.0* Eos-0.3* Baso-0.3 Im ___ AbsNeut-4.87 AbsLymp-1.22 AbsMono-0.26 AbsEos-0.02* AbsBaso-0.02 ___ 12:25PM BLOOD ___ PTT-29.1 ___ ___ 12:25PM BLOOD Plt ___ ___ 12:25PM BLOOD Glucose-99 UreaN-16 Creat-0.8 Na-136 K-4.6 Cl-105 HCO3-25 AnGap-6* ___ 04:08PM BLOOD ALT-12 AST-20 AlkPhos-63 TotBili-0.7 ___ 09:12AM BLOOD Calcium-9.7 Phos-3.2 Mg-2.4 Cholest-213* ___ 12:15PM BLOOD %HbA1c-5.3 eAG-105 ___ 09:12AM BLOOD Triglyc-71 HDL-67 CHOL/HD-3.2 LDLcalc-132* ___ 09:12AM BLOOD HCG-<5 ___ 04:08PM BLOOD CRP-0.6 Troponins: ___ 09:12AM BLOOD cTropnT-<0.01 ___ 04:08PM BLOOD cTropnT-<0.01 ___ 12:25PM BLOOD cTropnT-<0.01 Discharge Labs: ___ 07:41AM BLOOD WBC-5.5 RBC-4.68 Hgb-14.5 Hct-43.2 MCV-92 MCH-31.0 MCHC-33.6 RDW-12.3 RDWSD-41.7 Plt ___ ___ 07:41AM BLOOD Glucose-100 UreaN-11 Creat-0.9 Na-141 K-4.1 Cl-104 HCO3-25 AnGap-12 ___ CTA CORONARY ARTERIES Calcium score: 0 Questionable CAD-RADS 2- Mild stenosis (___) of the left circumflex, raising concern for mild non-obstructive CAD. ___ Cardiovascular Transthoracic Echo Report CONCLUSION: The left atrial volume index is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Overall left ventricular systolic function is hyperdynamic. The visually estimated left ventricular ejection fraction is 75%. There is no resting left ventricular outflow tract gradient. Tissue Doppler suggests a normal left ventricular filling pressure (PCWP less than 12mmHg). Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. There is no pericardial effusion. IMPRESSION: Normal left ventricular wall thickness and biventricular cavity sizes and regional/ global systolic function. FINDINGS: LEFT ATRIUM (LA)/PULMONARY VEINS: Normal LA volume index. RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC): Normal RA size. No atrial septal defect by 2D/color Doppler. Normal IVC diameter with normal inspiratory collapse==>RA pressure ___ mmHg. LEFT VENTRICLE (LV): Normal wall thicknesses. Normal cavity size. Normal regional/global systolic function. The visually estimated left ventricular ejection fraction is 75%. Hyperdynamic ejection fraction. No resting outflow tract gradient. Tissue Doppler suggests normal PCWP. RIGHT VENTRICLE (RV): Normal cavity size. Normal free wall motion. AORTA: Normal sinus diameter for gender. Normal ascending diameter for gender. Normal arch diameter. AORTIC VALVE (AV): Normal/thin (3) leaflets. No stenosis. No regurgitation. MITRAL VALVE (MV): Normal leaflets. No systolic prolapse. Trivial regurgitation. PULMONIC VALVE (PV): Normal leaflets. Physiologic regurgitation. TRICUSPID VALVE (TV): Normal leaflets. Physiologic regurgitation. Indeterminate pulmonary artery systolic pressure. PERICARDIUM: No effusion. ___ Imaging CHEST (PA & LAT) FINDINGS: Costophrenic angles are sharp. Cardiomediastinal silhouette is normal in contour and size. No focal consolidation or pneumothorax. Osseous structures are intact. IMPRESSION: No acute cardiopulmonary process. ___ Cardiovascular STRESS EXERCISE RESULTS RESTING DATA EKG: SR, NSSTTWS HEART RATE: 61 BLOOD PRESSURE: 162/72 PROTOCOL ___ - TREADMILL STAGE TIME SPEED ELEVATION HEART BLOOD RPP (MIN) (MPH) (%) RATE PRESSURE 1 ___ 1.7 10 107 178/74 ___ 2 ___ 2.5 12 123 178/80 ___ 3.4 14 144 182/76 ___ 4.2 16 169 196/80 ___ TOTAL EXERCISE TIME: 12 % MAX HRT RATE ACHIEVED: 99 INTERPRETATION: This ___ year old woman was referred to the lab for evaluation of chest discomfort and dizziness. The patient exercised for 12 minutes of ___ protocol to a workload of ___ METS and stopped for fatigue. This represents a good functional capacity for her age. The patient presented with ___ left sided chest discomfort which has been present constantly for the past week. This discomfort remained unchanged throughout the exercise and recovery periods. Baseline EKG shows biphasic T waves in III, AVF, V3-5. At peak exercise, there was 0.5-___epression in these same leads. The T waves normalized in early recovery and returned to baseline morphology by 10 minutes post exercise. IMPRESSION: Non-specific ST segment changes in the setting of atypical chest discomfort. Brief Hospital Course: ___ female presents with atypical chest pain, but with new anterior T wave inversions, negative troponins. # Atypical Chest Pain: EKG with nonspecific T wave abnormalities. Troponin negative x3. Stress test with nonspecific ST segment changes with no alteration in atypical chest discomfort. Coronary CTA ___ reveals calcium score of 0, mild stenosis (___) of the left circumflex, raising concern for mild non-obstructive CAD that is unlikely to be contributing to her pain. Lipid panel ___: TC 213, Tg 71, HDL 67, LDL 132. HgA1c: 5.3. Persistent right-sided chest pain unlikely to be of cardiac origin. No tachycardia, dyspnea, or hypoxemia to suggest PE. No tenderness of jaw to suggest arteritis. - Recommend primary prevention with ASA 81mg daily and atorvastatin - Follow-up with PCP ___ # Anxiety: Realized anxiety about health status - Multiple conversations offering support and reassurance - Social work consult Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Chest Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ to evaluate the cause of your chest pain. Cardiac blood tests and EKGs confirmed you were not having a heart attack. An echocardiogram showed normal heart structure and function. You had a coronary CT scan. The preliminary read showed no significant stenosis and minimal coronary calcium deposits. Please make the following changes to your pre-hospitalization medicine list: - Start ASA 81 mg daily - Start atorvastatin 20 mg daily Your PCP may choose to stop these medications if it is felt that you are low risk. If you have any urgent questions that are related to your recovery from your medical issues 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! Your ___ Cardiac Care Team Followup Instructions: ___	[ "R0789", "F064", "R9431" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest pain Major Surgical or Invasive Procedure: n/a History of Present Illness: Ms. [MASKED] is a [MASKED] w/ PMH only notable for high-grade squamous intra-epithelial lesion on biopsy [MASKED] s/p LEEP who presents w/ a several day history of chest pain. This was first reported at routine primary care visit [MASKED]. At that time, the patient had had 1 day of persistent, dull chest pain, [MASKED] in intensity, substernal, with some radiation across the right chest. At that time, she was having no other symptoms, notably no shortness of breath, palpitations, diaphoresis, nausea, jaw or arm pain, lightheadedness. An EKG obtained at that visit showed nonspecific T wave abnormalities, so the patient was referred for stress testing. The patient underwent routine exercise stress testing [MASKED] and exercised for 12 minutes of [MASKED] protocol to a workload of [MASKED] METS, and stopped for fatigue. Her chest pain was unaltered during testing. Per Cardiology, her baseline EKG showed biphasic T waves in III, AVF, V3-5, and at peak exercise, there was 0.5- epression in these same leads, w/ T wave normalization in early recovery and returning to baseline morphology by 10 minutes post-exercise. Ultimately this was thought to represent non-specific ST segment changes in the setting of atypical chest discomfort. In the ED, the patient had negative troponin. However, given new T wave inversions, Cardiology recommended admission for further monitoring and workup. In the ED, - Initial vitals: T 98.7 HR 68 BP 120/83 RR 16 O2100% RA - Exam notable for: "Con: Comfortable, in no acute distress HEENT: NCAT. PERRLA, no icterus. EOMI Neck: no JVD Resp: No incr WOB, CTAB. CV: RRR. Normal S1/S2. 2+ radial pulse bilaterally Abd: Soft, Nontender, Nondistended. MSK: [MASKED] without edema. Skin: No rash, Warm and dry, No petechiae Neuro: AOx3, speech fluent, no obvious facial asymmetry, moves all 4 ext to command. Psych: Normal mentation" - Labs notable for: WBC 6.4 HGB 14.0 platelets 224 Na 136 K 4.6 Cl 105 HCO3- 25 BUN 16 Cr 0.8 INR 1.0 - Imaging notable for: Patient refused CXR given concerns for radiation. - Patient given: PO Aspirin 324 mg PO/NG Atorvastatin 80 mg On admission, the patient confirmed the above, and stated that she feet chest pain-free. She does however note that for the past month, she has been quite stressed regarding her positive HPV test and LEEP, and then laryngoscopy for globus sensation. She states that the chest pain comes and goes, although she can identify no truly aggravating factor, except possibly stress. Only alleviating factor is sleep. She never has associated symptoms of the chest pain, although she does note some right-sided jaw pain which began yesterday. She has specifically had no headaches, vision changes, mouth sores, shortness of breath, abdominal pain, N/V/D, diaphoresis, dysuria, constipation, skin changes, or arthralgias. Past Medical History: -high-grade squamous intra-epithelial lesion on biopsy [MASKED] s/p LEEP Social History: [MASKED] Family History: Mother: deceased, [MASKED] syndrome Father: deceased, [MASKED] disease Siblings: 1 brother w/ T2DM, 1 healthy Children: 2 children, healthy. Physical Exam: On Admission: T 98.2 HR 143/82 HR 75 RR 20 O299 Ra GENERAL: WN/WD, NAD. HEAD: NC/AT, conjunctiva clear, EOMI, pupils reactive, sclera anicteric, oral mucosa w/o lesions. NECK: Supple, no LAD, no thyromegaly. JVP is 5 cm. CARDIAC: Precordium is quiet, PMI non-displaced, RRR, S1S2 w/o m/r/g. RESPIRATORY: Speaking in full sentences, CTABL. ABDOMEN: Unremarkable inspection, soft, NT, +BS. No palpable organomegaly. EXTREMITIES: Warm, no edema, peripheral pulses are strong and full. SKIN: No obvious lesions over the face, thorax, abdomen, extremities. NEUROLOGIC: Grossly intact, face symmetric, speech fluent, stands from seated position, gait normal. PSYCHIATRIC: Pleasant and cooperative. At Discharge: VS: 97.8, 105128/7081, 65, 16, 97% RA Weight: 58.3 kg / 128 lb Tele: Sinus rhythm [MASKED] Gen: Sitting up in bed, NAD, ++ anxiety Neuro: alert and oriented, anxious, asking questions appropriately. Gait steady. HEENT: normocaphalic, anicteric, good dentition. Symmetrical facial movements. Conjuncitiva pink. Neck: supple, trachea midline, no carotid bruits CV: S1,S2, RRR, no rubs/murmers Chest: Eupneic. LS CTA ABD: flat, soft, nondistended. (+) bowel sounds x 4 quarters Extr: no pedal edema. Gross FROM. No obvious deformities Skin: turgor good, skin warm and dry, color pink. No obvious lesions. Access sites: HL, site benign. GU: voiding indep. Pertinent Results: Admission Labs: [MASKED] 12:25PM BLOOD WBC-6.4 RBC-4.51 Hgb-14.0 Hct-42.3 MCV-94 MCH-31.0 MCHC-33.1 RDW-12.2 RDWSD-42.3 Plt [MASKED] [MASKED] 12:25PM BLOOD Neuts-75.9* [MASKED] Monos-4.0* Eos-0.3* Baso-0.3 Im [MASKED] AbsNeut-4.87 AbsLymp-1.22 AbsMono-0.26 AbsEos-0.02* AbsBaso-0.02 [MASKED] 12:25PM BLOOD [MASKED] PTT-29.1 [MASKED] [MASKED] 12:25PM BLOOD Plt [MASKED] [MASKED] 12:25PM BLOOD Glucose-99 UreaN-16 Creat-0.8 Na-136 K-4.6 Cl-105 HCO3-25 AnGap-6* [MASKED] 04:08PM BLOOD ALT-12 AST-20 AlkPhos-63 TotBili-0.7 [MASKED] 09:12AM BLOOD Calcium-9.7 Phos-3.2 Mg-2.4 Cholest-213* [MASKED] 12:15PM BLOOD %HbA1c-5.3 eAG-105 [MASKED] 09:12AM BLOOD Triglyc-71 HDL-67 CHOL/HD-3.2 LDLcalc-132* [MASKED] 09:12AM BLOOD HCG-<5 [MASKED] 04:08PM BLOOD CRP-0.6 Troponins: [MASKED] 09:12AM BLOOD cTropnT-<0.01 [MASKED] 04:08PM BLOOD cTropnT-<0.01 [MASKED] 12:25PM BLOOD cTropnT-<0.01 Discharge Labs: [MASKED] 07:41AM BLOOD WBC-5.5 RBC-4.68 Hgb-14.5 Hct-43.2 MCV-92 MCH-31.0 MCHC-33.6 RDW-12.3 RDWSD-41.7 Plt [MASKED] [MASKED] 07:41AM BLOOD Glucose-100 UreaN-11 Creat-0.9 Na-141 K-4.1 Cl-104 HCO3-25 AnGap-12 [MASKED] CTA CORONARY ARTERIES Calcium score: 0 Questionable CAD-RADS 2- Mild stenosis ([MASKED]) of the left circumflex, raising concern for mild non-obstructive CAD. [MASKED] Cardiovascular Transthoracic Echo Report CONCLUSION: The left atrial volume index is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is [MASKED] mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Overall left ventricular systolic function is hyperdynamic. The visually estimated left ventricular ejection fraction is 75%. There is no resting left ventricular outflow tract gradient. Tissue Doppler suggests a normal left ventricular filling pressure (PCWP less than 12mmHg). Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. There is no pericardial effusion. IMPRESSION: Normal left ventricular wall thickness and biventricular cavity sizes and regional/ global systolic function. FINDINGS: LEFT ATRIUM (LA)/PULMONARY VEINS: Normal LA volume index. RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC): Normal RA size. No atrial septal defect by 2D/color Doppler. Normal IVC diameter with normal inspiratory collapse==>RA pressure [MASKED] mmHg. LEFT VENTRICLE (LV): Normal wall thicknesses. Normal cavity size. Normal regional/global systolic function. The visually estimated left ventricular ejection fraction is 75%. Hyperdynamic ejection fraction. No resting outflow tract gradient. Tissue Doppler suggests normal PCWP. RIGHT VENTRICLE (RV): Normal cavity size. Normal free wall motion. AORTA: Normal sinus diameter for gender. Normal ascending diameter for gender. Normal arch diameter. AORTIC VALVE (AV): Normal/thin (3) leaflets. No stenosis. No regurgitation. MITRAL VALVE (MV): Normal leaflets. No systolic prolapse. Trivial regurgitation. PULMONIC VALVE (PV): Normal leaflets. Physiologic regurgitation. TRICUSPID VALVE (TV): Normal leaflets. Physiologic regurgitation. Indeterminate pulmonary artery systolic pressure. PERICARDIUM: No effusion. [MASKED] Imaging CHEST (PA & LAT) FINDINGS: Costophrenic angles are sharp. Cardiomediastinal silhouette is normal in contour and size. No focal consolidation or pneumothorax. Osseous structures are intact. IMPRESSION: No acute cardiopulmonary process. [MASKED] Cardiovascular STRESS EXERCISE RESULTS RESTING DATA EKG: SR, NSSTTWS HEART RATE: 61 BLOOD PRESSURE: 162/72 PROTOCOL [MASKED] - TREADMILL STAGE TIME SPEED ELEVATION HEART BLOOD RPP (MIN) (MPH) (%) RATE PRESSURE 1 [MASKED] 1.7 10 107 178/74 [MASKED] 2 [MASKED] 2.5 12 123 178/80 [MASKED] 3.4 14 144 182/76 [MASKED] 4.2 16 169 196/80 [MASKED] TOTAL EXERCISE TIME: 12 % MAX HRT RATE ACHIEVED: 99 INTERPRETATION: This [MASKED] year old woman was referred to the lab for evaluation of chest discomfort and dizziness. The patient exercised for 12 minutes of [MASKED] protocol to a workload of [MASKED] METS and stopped for fatigue. This represents a good functional capacity for her age. The patient presented with [MASKED] left sided chest discomfort which has been present constantly for the past week. This discomfort remained unchanged throughout the exercise and recovery periods. Baseline EKG shows biphasic T waves in III, AVF, V3-5. At peak exercise, there was 0.5- epression in these same leads. The T waves normalized in early recovery and returned to baseline morphology by 10 minutes post exercise. IMPRESSION: Non-specific ST segment changes in the setting of atypical chest discomfort. Brief Hospital Course: [MASKED] female presents with atypical chest pain, but with new anterior T wave inversions, negative troponins. # Atypical Chest Pain: EKG with nonspecific T wave abnormalities. Troponin negative x3. Stress test with nonspecific ST segment changes with no alteration in atypical chest discomfort. Coronary CTA [MASKED] reveals calcium score of 0, mild stenosis ([MASKED]) of the left circumflex, raising concern for mild non-obstructive CAD that is unlikely to be contributing to her pain. Lipid panel [MASKED]: TC 213, Tg 71, HDL 67, LDL 132. HgA1c: 5.3. Persistent right-sided chest pain unlikely to be of cardiac origin. No tachycardia, dyspnea, or hypoxemia to suggest PE. No tenderness of jaw to suggest arteritis. - Recommend primary prevention with ASA 81mg daily and atorvastatin - Follow-up with PCP [MASKED] # Anxiety: Realized anxiety about health status - Multiple conversations offering support and reassurance - Social work consult Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Chest Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [MASKED] to evaluate the cause of your chest pain. Cardiac blood tests and EKGs confirmed you were not having a heart attack. An echocardiogram showed normal heart structure and function. You had a coronary CT scan. The preliminary read showed no significant stenosis and minimal coronary calcium deposits. Please make the following changes to your pre-hospitalization medicine list: - Start ASA 81 mg daily - Start atorvastatin 20 mg daily Your PCP may choose to stop these medications if it is felt that you are low risk. If you have any urgent questions that are related to your recovery from your medical issues 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! Your [MASKED] Cardiac Care Team Followup Instructions: [MASKED]	[]	[]	[ "R0789: Other chest pain", "F064: Anxiety disorder due to known physiological condition", "R9431: Abnormal electrocardiogram [ECG] [EKG]" ]
10,094,476	21,993,712	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Latex / Forteo / clindamycin / Neosporin / adhesive tape / Diflucan / Bactrim DS / Plaquenil / Augmentin / alendronate sodium / Dilaudid / vancomycin / Keflex / topiramate / Lyrica / Cat gut suture Attending: ___. Chief Complaint: Knee pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ hx Waldenstrom's macroglobulinemia and bilateral knee replacements cb septic arthritis receiving monthly IVIg therapy pw excruciating R knee pain. The patient has had weakness, fatigue, and bone pain worse below the knees for the last several months, ever since recovering from likely viral URI in ___. with 4 months of R knee pain that extends up the thigh and down the leg brought on by walking. She has had 4 months of chronic R knee pain that extends up the thigh and down the leg while walking. The pain is sharp and stabbing. The night prior to admission at 5pm, she developed sudden onset of this pain with ___ severity while at home. No trauma, fall, or direct blow to knee. She was in excruciating pain and felt unable to move her R leg due to pain. She took Tylenol and aleve to relieve the pain, which have helped moderately with the pain. She also has some tingling in her R foot; however, she has had intermittent paresthesias for months. The pain lasted through the night and the morning, including during her appointment with her hematologist. She has been using crutches to ambulate. Of note, she has had prior episodes of excruciating R knee pain that have resolved with oxycodone and NSAIDs. Her pain has improved to ___ after receiving oxycodone in ED. Patient endorses some chills in the past few months. Denies fevers, nausea, vomiting, shortness of breath, chest pain, palpitations, diarrhea/constipation. In the ED, initial vital signs were notable for: Temp 98.3, HR 72, BP 123/78, O2 sat 96% Ra. Exam notable for: Cardiac: faint decrescendo diastolic murmur at ___ reported aortic regurgitation. MSK: R knee pain on passive ROM. Whole leg painful to palpation. Bl knee caps feel warm to the touch. Studies performed include: R lower extremity ultrasound: no DVT R pelvis/hip XR: stable appearance of bilateral femoral hardware. No evidence of fracture or dislocation. Moderate degenerative change at the hip joints bilaterally. R knee XR: No evidence of hardware complication, fracture, or dislocation. Patient was given: 5mg PO oxycodone immediate release, 1000mg PO Tylenol Review of Systems: ================== Complete ROS obtained and is otherwise negative. Past Medical History: - ___'s macroglobulinemia - Osteoporosis - Hypothyroidism - Peripheral neuropathy - Hypogammaglobulinemia - OA - Lumbar radiculopathy - Hyperplastic colon polyps - Iron deficiency - Migraine - Depression - Eating disorder - GERD - Fibromyalgia - Hemorrhoids - Rosacea PAST SURGICAL HISTORY: - Bilateral breast reduction - ___ - Right ankle torn ligament repair - ___ - Laparoscopic Fundoplication - ___ - Incisional hernia repair - ___ - 2 RT hand trigger finger surgeries and tenosynovectomy of wrist - ___ - LT hand CTR and 2 LT hand trigger finger releases - ___ - ORIF of RT distal radius fracture - ___ - Removal of lipoma in the arm, RT ring trigger finger release, and removal of 2 loose screws in RT wrist - ___ - DeQuervain's release and removal of ganglion - ___ - Bilateral total knee arthroplasties: first in ___, cb infection bilaterally s/p polyethylene exchange in ___. In ___, bilateral knees septic again s/p hardware removal and antibiotic spacer placement. ___ bilateral knee revisions. - s/p Tenolysis of right FCR tendon, revision right carpal tunnel release, right index finger MCP joint release, reconstruction of right index finger flexor digitorum profundus tendon with gracilis allograft ___ - Status post ORIF previous left proximal hip fracture - Cataracts, ___ - Blephoroplasty, ___ Social History: ___ Family History: Mother with metastatic lung cancer. Father died tragically in plane crash. Physical Exam: ADMISSION EXAM: ============== VITALS: T 97.3, BP 121/74, HR 56, RR 18, O2Sat 96 Ra GENERAL: Alert and interactive. Anxious, but in no acute distress. HEENT: PERRL, EOMI. MMM. Oropharynx is clear. NECK: Supple CARDIAC: RRR. Diastolic murmur at ___ reported aortic regurgitation. LUNGS: Clear to auscultation bilaterally ABDOMEN: Soft, nontender, nondistended. MSK: Bilateral knees without warmth, erythema, or effusion. No pain on distraction with passive ROM knee and hip joints. EXTREMITIES: Warm and well-perfused. No clubbing, cyanosis, or edema. Pulses DP 2+ bilaterally. Patient unable to flex R index PIP. NEUROLOGIC: A&Ox3. CN II-XII intact. Full strength UE and ___ bilaterally. Normal sensation, although complains of intermittent tingling. DISCHARGE EXAM: ============== VITALS: T 97.3, BP 121/74, HR 56, RR 18, O2Sat 96 Ra GENERAL: Alert and interactive. Anxious, but in no acute distress. HEENT: PERRL, EOMI. MMM. Oropharynx is clear. NECK: Supple CARDIAC: RRR. Diastolic murmur at ___ reported aortic regurgitation. LUNGS: Clear to auscultation bilaterally ABDOMEN: Soft, nontender, nondistended. MSK: Bilateral knees without warmth, erythema, or effusion. No pain with passive ROM knee and hip joints. No anterior/posterior drawer sign. EXTREMITIES: Warm and well-perfused. No clubbing, cyanosis, or edema. Pulses DP 2+ bilaterally. Patient unable to flex R index PIP. NEUROLOGIC: A&Ox3. CN II-XII intact. Full strength UE and ___ bilaterally. Normal sensation, although complains of intermittent tingling. Pertinent Results: ADMISSION LABS: ============= ___ 01:44AM BLOOD WBC-5.7 RBC-3.91 Hgb-12.0 Hct-35.7 MCV-91 MCH-30.7 MCHC-33.6 RDW-13.3 RDWSD-44.3 Plt ___ ___ 01:44AM BLOOD Glucose-101* UreaN-29* Creat-0.8 Na-141 K-4.1 Cl-101 HCO3-27 AnGap-13 ___ 01:45AM BLOOD cTropnT-<0.01 ___ 01:44AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.1 ___ 01:44AM BLOOD TSH-9.9* ___ 01:44AM BLOOD T3-80 Free T4-1.1 ___ 01:44AM BLOOD CRP-3.0 DISCHARGE LABS: ============== None REPORTS/STUDIES: =============== ___ RIGHT LOWER EXTREMITY ULTRASOUND There is normal compressibility, flow, and augmentation of the right common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. ___ HIP/PELVIS XRAY The patient is status post ORIF of a left femoral neck fracture, without evidence of screw migration or loosening in comparison to ___. The positioning of a partially imaged intramedullary femoral stem appears in unchanged position to ___. No evidence of adjacent fracture or loosening. There is moderate joint space narrowing and bony spurring at the hip joints, bilaterally. There is disc space narrowing and osteophytosis in the visualized lumbar spine. No acute fracture or dislocation. Chronic deformities of the right superior and inferior pubic rami are again noted. No worrisome lytic or sclerotic lesion. ___ RIGHT KNEE XRAY The patient is status post total right knee arthroplasty. There is no evidence of hardware migration or periprosthetic fracture. Appearance of the knee joint appears stable from ___. There is mild osteopenia about the knee joint. No worrisome lytic or sclerotic lesions. No significant soft tissue swelling. Brief Hospital Course: ___ with PMHx significant for Waldenstrom's macroglobulinemia receiving monthly IV Ig therapy, osteoporosis c/b several fractures, bilateral TKA complicated by remote history of septic arthritis, lumber disc disease with chronic bilateral knee and lower leg pain who presented with acute worsening of right knee pain. # Acute on Chronic Knee pain Patient has complicated orthopedic and osteoporotic fracture history. History of bilateral TKA complicated by infection bilaterally in ___ and ___, now s/p revisions in ___. She has had chronic bilateral leg pain described as "bone pain" for months, also with intermittent paresthesias of feet. Xray of pelvis/hip obtained in emergency room with stable appearance of femoral hardware but moderate DJD changes at hip joints. Xray of right knee w/o evidence of hardware complication, fracture, or dislocation. No warmth or swelling/effusion. Patient has remained afebrile without leukocytosis, making infection unlikely likely. No evidence to suggest crystal arthropathy. Of note, patient had PET scanning ___ w/o osseous lesions and Bone Scan ___ with DJD in her knees. Notably, in previous episodes of pain exacerbation, she has responded to NSAIDs. Her pain is likely chronic, secondary to DJD, OA, lumbar radiculopathy and history of multiple knee surgeries with hardware. Also has a history of fibromyalgia. No concern for acute musculoskeletal process, with XR showing no fracture or implant loosening. No DVT of right lower extremity. Do not suspect meniscal tear or ligament strain. Patient was given tylenol and NSAIDS with moderate improvement. ___ was consulted who recommended that she was safe to be discharged home and could have outpatient ___. # Fatigue. Reports fatigue since URI last ___. Nonspecific symptoms. Labs on admission including CBC and electrolytes are normal. Differential considered included hypothyrodisim, fibromyalgia, MDD/anxiety, related to her Waldenstrom's macroglobulenemia. TSH noted to be 9.9. Free t4 was 1.1, t3 was 80. Levothyroxine was increased to 75 mcg daily after discussion with PCP. #Hypothyroidism. Was found to have elevated TSH and low-normal FT4 and T3. In coordination with her PCP, was increased to 75 mcg levothyroxine for discharge. She will need follow up labs in 6 weeks. # Waldenstrom's macroglobulinemia: On monthly IV Ig. Has routine Heme/Onc follow up and allergy f/u. #Depression/Anxiety: Patient reported feeling significant anxiety and stress at home due to several issues including poor contact with her children/grandchildren, she lives alone and has had history of trauma (i.e. former abusive husband, father died tragically). Continued home SSRI, SNRI, ativan. SW consult offered to patient but she deferred. TRANSITIONAL ISSUES: ================= [] Will increase her levothyroxine from 50mcg to 75mcg iso TSH elevated to 9.9. She will need outpatient labs in 6 weeks. [] Neuropathy: She will have follow up with her neurologist Dr. ___ on ___. [] For pain: Recommended patient take acetaminophen, naproxen, and warm compresses as needed for symptoms. [] Patient expressed significant isolation as she is estranged from her children and grandchildren. [] Pt was provided script for outpatient ___ ___ sessions) assess how she is responding to ___ and if she needs more sessions with them Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Denosumab (Prolia) 60 mg SC ONCE 2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 3. Levothyroxine Sodium 50 mcg PO DAILY 4. DULoxetine 60 mg PO DAILY 5. LORazepam 4 mg PO QHS 6. Montelukast 10 mg PO QHS 7. Sertraline 200 mg PO QHS 8. Sumatriptan Succinate 6 mg SC ONCE:PRN migraines 9. Citracal + D Maximum (calcium citrate-vitamin D3) unknown oral unknown 10. ___ (cranberry extract) unknown oral unknown 11. docusate calcium unknown oral unknown 12. Lactaid (lactase) 3,000 unit oral DAILY 13. Multivitamins 1 TAB PO DAILY 14. Polyethylene Glycol 17 g PO DAILY 15. Ranitidine 150 mg PO QHS 16. Acetaminophen-Caff-Butalbital 1 TAB PO PRN SEVERE MIGRAINE 17. Artificial Tears ___ DROP BOTH EYES PRN DRY EYE 18. dexlansoprazole 60 mg oral QAM Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Moderate 2. Naproxen 500 mg PO Q12H:PRN Pain - Moderate 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Acetaminophen-Caff-Butalbital 1 TAB PO PRN SEVERE MIGRAINE 5. Artificial Tears ___ DROP BOTH EYES PRN DRY EYE 6. Citracal + D Maximum (calcium citrate-vitamin D3) unknown oral BID 7. ___ (cranberry extract) 1 U oral DAILY unknown dosage 8. Denosumab (Prolia) 60 mg SC ONCE 9. dexlansoprazole 60 mg oral QAM 10. docusate calcium unknown oral DAILY 11. DULoxetine 60 mg PO DAILY 12. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 13. Lactaid (lactase) 3,000 unit oral DAILY 14. LORazepam 4 mg PO QHS 15. Montelukast 10 mg PO QHS 16. Multivitamins 1 TAB PO DAILY 17. Polyethylene Glycol 17 g PO DAILY 18. Ranitidine 150 mg PO QHS 19. Sertraline 200 mg PO QHS 20. Sumatriptan Succinate 6 mg SC ONCE:PRN migraines Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Acute on Chronic Knee Pain Secondary Diagnosis: Hypothyroidism, Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital with knee pain. You had X-rays of your knee and hips and an ultrasound of your leg which did not show anything concerning to explain your pain. There was no evidence of fracture to your hips or knee and no issues with your hardware. There was no blood clot in the leg. Your thyroid tests showed they thyroid levels were low. What to do next? - We will prescribe you a higher dose levothyroxine of 75mcg. You should take this medicine once a day. Please have follow up thyroid labs taken in 6 weeks. - Please call your primary care doctor's office ___ morning. Your primary care doctor is aware that you should follow up with her in 1 week. - Please take your medicines as prescribed and follow up with your primary care doctor and orthopedic doctor. We wish you the best, Your ___ Care Team Followup Instructions: ___	[ "M25561", "G8929", "M170", "M160", "Z96653", "E039", "M797", "M898X6", "M5116", "R5383", "R531", "C880", "M19141", "M810", "Z87310", "G629", "D801", "G43909", "F329", "F5000", "F419", "K219", "N858" ]	Allergies: Latex / Forteo / clindamycin / Neosporin / adhesive tape / Diflucan / Bactrim DS / Plaquenil / Augmentin / alendronate sodium / Dilaudid / vancomycin / Keflex / topiramate / Lyrica / Cat gut suture Chief Complaint: Knee pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] hx Waldenstrom's macroglobulinemia and bilateral knee replacements cb septic arthritis receiving monthly IVIg therapy pw excruciating R knee pain. The patient has had weakness, fatigue, and bone pain worse below the knees for the last several months, ever since recovering from likely viral URI in [MASKED]. with 4 months of R knee pain that extends up the thigh and down the leg brought on by walking. She has had 4 months of chronic R knee pain that extends up the thigh and down the leg while walking. The pain is sharp and stabbing. The night prior to admission at 5pm, she developed sudden onset of this pain with [MASKED] severity while at home. No trauma, fall, or direct blow to knee. She was in excruciating pain and felt unable to move her R leg due to pain. She took Tylenol and aleve to relieve the pain, which have helped moderately with the pain. She also has some tingling in her R foot; however, she has had intermittent paresthesias for months. The pain lasted through the night and the morning, including during her appointment with her hematologist. She has been using crutches to ambulate. Of note, she has had prior episodes of excruciating R knee pain that have resolved with oxycodone and NSAIDs. Her pain has improved to [MASKED] after receiving oxycodone in ED. Patient endorses some chills in the past few months. Denies fevers, nausea, vomiting, shortness of breath, chest pain, palpitations, diarrhea/constipation. In the ED, initial vital signs were notable for: Temp 98.3, HR 72, BP 123/78, O2 sat 96% Ra. Exam notable for: Cardiac: faint decrescendo diastolic murmur at [MASKED] reported aortic regurgitation. MSK: R knee pain on passive ROM. Whole leg painful to palpation. Bl knee caps feel warm to the touch. Studies performed include: R lower extremity ultrasound: no DVT R pelvis/hip XR: stable appearance of bilateral femoral hardware. No evidence of fracture or dislocation. Moderate degenerative change at the hip joints bilaterally. R knee XR: No evidence of hardware complication, fracture, or dislocation. Patient was given: 5mg PO oxycodone immediate release, 1000mg PO Tylenol Review of Systems: ================== Complete ROS obtained and is otherwise negative. Past Medical History: - [MASKED]'s macroglobulinemia - Osteoporosis - Hypothyroidism - Peripheral neuropathy - Hypogammaglobulinemia - OA - Lumbar radiculopathy - Hyperplastic colon polyps - Iron deficiency - Migraine - Depression - Eating disorder - GERD - Fibromyalgia - Hemorrhoids - Rosacea PAST SURGICAL HISTORY: - Bilateral breast reduction - [MASKED] - Right ankle torn ligament repair - [MASKED] - Laparoscopic Fundoplication - [MASKED] - Incisional hernia repair - [MASKED] - 2 RT hand trigger finger surgeries and tenosynovectomy of wrist - [MASKED] - LT hand CTR and 2 LT hand trigger finger releases - [MASKED] - ORIF of RT distal radius fracture - [MASKED] - Removal of lipoma in the arm, RT ring trigger finger release, and removal of 2 loose screws in RT wrist - [MASKED] - DeQuervain's release and removal of ganglion - [MASKED] - Bilateral total knee arthroplasties: first in [MASKED], cb infection bilaterally s/p polyethylene exchange in [MASKED]. In [MASKED], bilateral knees septic again s/p hardware removal and antibiotic spacer placement. [MASKED] bilateral knee revisions. - s/p Tenolysis of right FCR tendon, revision right carpal tunnel release, right index finger MCP joint release, reconstruction of right index finger flexor digitorum profundus tendon with gracilis allograft [MASKED] - Status post ORIF previous left proximal hip fracture - Cataracts, [MASKED] - Blephoroplasty, [MASKED] Social History: [MASKED] Family History: Mother with metastatic lung cancer. Father died tragically in plane crash. Physical Exam: ADMISSION EXAM: ============== VITALS: T 97.3, BP 121/74, HR 56, RR 18, O2Sat 96 Ra GENERAL: Alert and interactive. Anxious, but in no acute distress. HEENT: PERRL, EOMI. MMM. Oropharynx is clear. NECK: Supple CARDIAC: RRR. Diastolic murmur at [MASKED] reported aortic regurgitation. LUNGS: Clear to auscultation bilaterally ABDOMEN: Soft, nontender, nondistended. MSK: Bilateral knees without warmth, erythema, or effusion. No pain on distraction with passive ROM knee and hip joints. EXTREMITIES: Warm and well-perfused. No clubbing, cyanosis, or edema. Pulses DP 2+ bilaterally. Patient unable to flex R index PIP. NEUROLOGIC: A&Ox3. CN II-XII intact. Full strength UE and [MASKED] bilaterally. Normal sensation, although complains of intermittent tingling. DISCHARGE EXAM: ============== VITALS: T 97.3, BP 121/74, HR 56, RR 18, O2Sat 96 Ra GENERAL: Alert and interactive. Anxious, but in no acute distress. HEENT: PERRL, EOMI. MMM. Oropharynx is clear. NECK: Supple CARDIAC: RRR. Diastolic murmur at [MASKED] reported aortic regurgitation. LUNGS: Clear to auscultation bilaterally ABDOMEN: Soft, nontender, nondistended. MSK: Bilateral knees without warmth, erythema, or effusion. No pain with passive ROM knee and hip joints. No anterior/posterior drawer sign. EXTREMITIES: Warm and well-perfused. No clubbing, cyanosis, or edema. Pulses DP 2+ bilaterally. Patient unable to flex R index PIP. NEUROLOGIC: A&Ox3. CN II-XII intact. Full strength UE and [MASKED] bilaterally. Normal sensation, although complains of intermittent tingling. Pertinent Results: ADMISSION LABS: ============= [MASKED] 01:44AM BLOOD WBC-5.7 RBC-3.91 Hgb-12.0 Hct-35.7 MCV-91 MCH-30.7 MCHC-33.6 RDW-13.3 RDWSD-44.3 Plt [MASKED] [MASKED] 01:44AM BLOOD Glucose-101* UreaN-29* Creat-0.8 Na-141 K-4.1 Cl-101 HCO3-27 AnGap-13 [MASKED] 01:45AM BLOOD cTropnT-<0.01 [MASKED] 01:44AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.1 [MASKED] 01:44AM BLOOD TSH-9.9* [MASKED] 01:44AM BLOOD T3-80 Free T4-1.1 [MASKED] 01:44AM BLOOD CRP-3.0 DISCHARGE LABS: ============== None REPORTS/STUDIES: =============== [MASKED] RIGHT LOWER EXTREMITY ULTRASOUND There is normal compressibility, flow, and augmentation of the right common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa ([MASKED]) cyst. [MASKED] HIP/PELVIS XRAY The patient is status post ORIF of a left femoral neck fracture, without evidence of screw migration or loosening in comparison to [MASKED]. The positioning of a partially imaged intramedullary femoral stem appears in unchanged position to [MASKED]. No evidence of adjacent fracture or loosening. There is moderate joint space narrowing and bony spurring at the hip joints, bilaterally. There is disc space narrowing and osteophytosis in the visualized lumbar spine. No acute fracture or dislocation. Chronic deformities of the right superior and inferior pubic rami are again noted. No worrisome lytic or sclerotic lesion. [MASKED] RIGHT KNEE XRAY The patient is status post total right knee arthroplasty. There is no evidence of hardware migration or periprosthetic fracture. Appearance of the knee joint appears stable from [MASKED]. There is mild osteopenia about the knee joint. No worrisome lytic or sclerotic lesions. No significant soft tissue swelling. Brief Hospital Course: [MASKED] with PMHx significant for Waldenstrom's macroglobulinemia receiving monthly IV Ig therapy, osteoporosis c/b several fractures, bilateral TKA complicated by remote history of septic arthritis, lumber disc disease with chronic bilateral knee and lower leg pain who presented with acute worsening of right knee pain. # Acute on Chronic Knee pain Patient has complicated orthopedic and osteoporotic fracture history. History of bilateral TKA complicated by infection bilaterally in [MASKED] and [MASKED], now s/p revisions in [MASKED]. She has had chronic bilateral leg pain described as "bone pain" for months, also with intermittent paresthesias of feet. Xray of pelvis/hip obtained in emergency room with stable appearance of femoral hardware but moderate DJD changes at hip joints. Xray of right knee w/o evidence of hardware complication, fracture, or dislocation. No warmth or swelling/effusion. Patient has remained afebrile without leukocytosis, making infection unlikely likely. No evidence to suggest crystal arthropathy. Of note, patient had PET scanning [MASKED] w/o osseous lesions and Bone Scan [MASKED] with DJD in her knees. Notably, in previous episodes of pain exacerbation, she has responded to NSAIDs. Her pain is likely chronic, secondary to DJD, OA, lumbar radiculopathy and history of multiple knee surgeries with hardware. Also has a history of fibromyalgia. No concern for acute musculoskeletal process, with XR showing no fracture or implant loosening. No DVT of right lower extremity. Do not suspect meniscal tear or ligament strain. Patient was given tylenol and NSAIDS with moderate improvement. [MASKED] was consulted who recommended that she was safe to be discharged home and could have outpatient [MASKED]. # Fatigue. Reports fatigue since URI last [MASKED]. Nonspecific symptoms. Labs on admission including CBC and electrolytes are normal. Differential considered included hypothyrodisim, fibromyalgia, MDD/anxiety, related to her Waldenstrom's macroglobulenemia. TSH noted to be 9.9. Free t4 was 1.1, t3 was 80. Levothyroxine was increased to 75 mcg daily after discussion with PCP. #Hypothyroidism. Was found to have elevated TSH and low-normal FT4 and T3. In coordination with her PCP, was increased to 75 mcg levothyroxine for discharge. She will need follow up labs in 6 weeks. # Waldenstrom's macroglobulinemia: On monthly IV Ig. Has routine Heme/Onc follow up and allergy f/u. #Depression/Anxiety: Patient reported feeling significant anxiety and stress at home due to several issues including poor contact with her children/grandchildren, she lives alone and has had history of trauma (i.e. former abusive husband, father died tragically). Continued home SSRI, SNRI, ativan. SW consult offered to patient but she deferred. TRANSITIONAL ISSUES: ================= [] Will increase her levothyroxine from 50mcg to 75mcg iso TSH elevated to 9.9. She will need outpatient labs in 6 weeks. [] Neuropathy: She will have follow up with her neurologist Dr. [MASKED] on [MASKED]. [] For pain: Recommended patient take acetaminophen, naproxen, and warm compresses as needed for symptoms. [] Patient expressed significant isolation as she is estranged from her children and grandchildren. [] Pt was provided script for outpatient [MASKED] [MASKED] sessions) assess how she is responding to [MASKED] and if she needs more sessions with them Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Denosumab (Prolia) 60 mg SC ONCE 2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 3. Levothyroxine Sodium 50 mcg PO DAILY 4. DULoxetine 60 mg PO DAILY 5. LORazepam 4 mg PO QHS 6. Montelukast 10 mg PO QHS 7. Sertraline 200 mg PO QHS 8. Sumatriptan Succinate 6 mg SC ONCE:PRN migraines 9. Citracal + D Maximum (calcium citrate-vitamin D3) unknown oral unknown 10. [MASKED] (cranberry extract) unknown oral unknown 11. docusate calcium unknown oral unknown 12. Lactaid (lactase) 3,000 unit oral DAILY 13. Multivitamins 1 TAB PO DAILY 14. Polyethylene Glycol 17 g PO DAILY 15. Ranitidine 150 mg PO QHS 16. Acetaminophen-Caff-Butalbital 1 TAB PO PRN SEVERE MIGRAINE 17. Artificial Tears [MASKED] DROP BOTH EYES PRN DRY EYE 18. dexlansoprazole 60 mg oral QAM Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Moderate 2. Naproxen 500 mg PO Q12H:PRN Pain - Moderate 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Acetaminophen-Caff-Butalbital 1 TAB PO PRN SEVERE MIGRAINE 5. Artificial Tears [MASKED] DROP BOTH EYES PRN DRY EYE 6. Citracal + D Maximum (calcium citrate-vitamin D3) unknown oral BID 7. [MASKED] (cranberry extract) 1 U oral DAILY unknown dosage 8. Denosumab (Prolia) 60 mg SC ONCE 9. dexlansoprazole 60 mg oral QAM 10. docusate calcium unknown oral DAILY 11. DULoxetine 60 mg PO DAILY 12. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 13. Lactaid (lactase) 3,000 unit oral DAILY 14. LORazepam 4 mg PO QHS 15. Montelukast 10 mg PO QHS 16. Multivitamins 1 TAB PO DAILY 17. Polyethylene Glycol 17 g PO DAILY 18. Ranitidine 150 mg PO QHS 19. Sertraline 200 mg PO QHS 20. Sumatriptan Succinate 6 mg SC ONCE:PRN migraines Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Acute on Chronic Knee Pain Secondary Diagnosis: Hypothyroidism, Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the hospital with knee pain. You had X-rays of your knee and hips and an ultrasound of your leg which did not show anything concerning to explain your pain. There was no evidence of fracture to your hips or knee and no issues with your hardware. There was no blood clot in the leg. Your thyroid tests showed they thyroid levels were low. What to do next? - We will prescribe you a higher dose levothyroxine of 75mcg. You should take this medicine once a day. Please have follow up thyroid labs taken in 6 weeks. - Please call your primary care doctor's office [MASKED] morning. Your primary care doctor is aware that you should follow up with her in 1 week. - Please take your medicines as prescribed and follow up with your primary care doctor and orthopedic doctor. We wish you the best, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "G8929", "E039", "F329", "F419", "K219" ]	[ "M25561: Pain in right knee", "G8929: Other chronic pain", "M170: Bilateral primary osteoarthritis of knee", "M160: Bilateral primary osteoarthritis of hip", "Z96653: Presence of artificial knee joint, bilateral", "E039: Hypothyroidism, unspecified", "M797: Fibromyalgia", "M898X6: Other specified disorders of bone, lower leg", "M5116: Intervertebral disc disorders with radiculopathy, lumbar region", "R5383: Other fatigue", "R531: Weakness", "C880: Waldenström macroglobulinemia", "M19141: Post-traumatic osteoarthritis, right hand", "M810: Age-related osteoporosis without current pathological fracture", "Z87310: Personal history of (healed) osteoporosis fracture", "G629: Polyneuropathy, unspecified", "D801: Nonfamilial hypogammaglobulinemia", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "F329: Major depressive disorder, single episode, unspecified", "F5000: Anorexia nervosa, unspecified", "F419: Anxiety disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "N858: Other specified noninflammatory disorders of uterus" ]
10,094,582	29,660,954	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: codeine Attending: ___ Chief Complaint: Seizures Major Surgical or Invasive Procedure: None History of Present Illness: ___ (DOB ___ is a ___ year old woman with history of epilepsy and nonepileptic seizures followed at ___, anxiety, depression, PTSD, who presents with prolonged seizure. History was initially limited and obtained via report. She was in a group therapy session today when she had a seizure and fell to the ground. EMS was called and on arrival she was having generalized shaking movements, and so they administered Ativan 2mg IM x2 doses while en route. At ___, she continued to have shaking movements, and she was given additional 2mg of Ativan IV. Movements did not cease, and were associated with tachycardia, but the remainder of her vital signs remained normal including her oxygen saturation. Neurology was consulted and she was also given a load of keppra IV 2000mg. While keppra was infusing, the movements stopped. She awoke and was able to state her name and date of birth slowly, but could not provide additional history. For the remainder of the encounter and examination she had multiple further episodes of shaking movements, lasting up to 30 seconds each time, followed by return back to the awake but slowed state. There was high suspicion for nonepileptic seizures based on her clinical event (as described below in the examination) and past history, as well as lack of responsiveness to Ativan, Upon repeat visit with patient later, she was back to her baseline and able to provide additional history. She had just started a new intensive psychiatric day program yesterday and had the second session today. She states that the session which focused on grief became extremely intense and anxiety provoking for her, and last remembers sitting in the chair facing the other participants. She does not recall any of the events as described above. She states adamantly that she will not be returning to this program again. Her past neurologic history was found via ___ records and reviewed. She is followed by Drs. ___ and ___. Apparently her seizures began in ___ with a cluster of 22 events in 24 hours. She was evaluated at a local hospital, started on tegretol, and admitted to ___ for LTM, which revealed "3 seizure-like events captured notable for right sided and full body shaking with difficulty speaking that did not show any evidence of electrographic correlate" however was maintained on AED. She continued to have events, and was readmitted for LTM again in ___. This time she did have three events which did have an EEG correlate, all arising from sleep, characterized by tonic extension followed by flexion of arms and generalized shaking. EEG showed irregular ___ Hz frontally predominant spike and wave complexes prior to event, then rhythmic theta at ___ Hz starting in F3/F4/Fz, then generalizing in one second. She had, in addition, several events during wakefulness consisting of behavioral arrest, feeling unwell with racing heartbeat and tachycardia to 120-130s, which did not have EEG correlate. She had been maintained on keppra at a dose of 2500mg BID; decision was made in the past year to cross-taper this with lamictal to better improve her mood. She increased lamictal over the summer to 200mg BID, and has since been decreasing her keppra by 500mg BID increments every 4 weeks, now at 1500mg BID. She denies any missed doses. Her last seizure was over a year ago and last a few minutes; she has never had a single event this prolonged. Neurology ROS is negative for headache, visual symptoms, 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. Past Medical History: Epilepsy PNES PTSD Depression SI with multiple hospitalizations in past, followed by ___ psychiatrist Dr. ___ Possible borderline personality disorder Social History: ___ Family History: non-contributory Physical Exam: ===ADMISSION EXAM=== Gen: eyes closed, not responsive, intermittent 30 second - 1 min episodes consisting of LUE tonic extension with tremulous movements, RUE tonic flexion and hand fixed in claw posture, BLE tonic internal rotation. Between episodes, she was awake, slow to respond. HEENT: few lacerations in forehead/temporal region, hard C-collar in place Resp: breathing comfortably on room air CV: tachycardic Abd: soft, nontender, nondistended Ext: warm, well perfused Neurologic: - MS: unresponsive with eyes closed during episodes. Between episodes, she is awake without any inter-ictal somnolence. Regards and tracks examiner. Slow to respond but able to state own name and age, unable to state location or date. Follows simple commands slowly (raises her arms) but unable to comply with most of neurology examination. Appears frightened. - CN: PERRL 3->2mm, tracks in all fields of gaze, face appears symmetric. - Sensorimotor: withdraws all extremities to noxious stimuli. - Reflexes: 1+ throughout, toes mute. ===DISCHARGE EXAM=== General: Awake, cooperative, NAD. HEENT: lacerations noted in forehead/temporal region, no scleral icterus noted, MMM, no lesions noted in oropharynx Resp: breathing comfortably on room air CV: regular rate and rhythm, no m/g/r Abd: soft, nontender, nondistended Ext: warm, well perfused Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. -Cranial Nerves: II, III, IV, VI: PERRL 3->2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: No deficits to light touch throughout. No extinction to DSS. -DTRs: 1+ throughout, symmetric. Plantar response was mute bilaterally. -Coordination: No dysmetria on FNF bilaterally. Pertinent Results: ===ADMISSION LABS=== ___ 01:23PM BLOOD WBC-8.0 RBC-4.22 Hgb-12.1 Hct-37.3 MCV-88 MCH-28.7 MCHC-32.4 RDW-13.1 RDWSD-42.2 Plt ___ ___ 01:23PM BLOOD Neuts-67.7 ___ Monos-6.8 Eos-1.4 Baso-0.5 Im ___ AbsNeut-5.41 AbsLymp-1.84 AbsMono-0.54 AbsEos-0.11 AbsBaso-0.04 ___ 01:23PM BLOOD ___ PTT-30.4 ___ ___ 01:23PM BLOOD Glucose-128* UreaN-13 Creat-0.8 Na-136 K-4.3 Cl-97 HCO3-21* AnGap-22* ___ 01:23PM BLOOD ALT-12 AST-14 AlkPhos-92 TotBili-<0.2 ___ 01:23PM BLOOD Albumin-4.6 Calcium-9.5 Phos-3.3 Mg-1.9 ___ 01:23PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 03:22PM BLOOD Lactate-1.5 ___ 03:35PM URINE Color-Straw Appear-Clear Sp ___ ___ 03:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ===DIAGNOSTIC STUDIES=== ___ CT HEAD 1. No acute intracranial abnormality. Brief Hospital Course: Ms. ___ was admitted to the Neurology service after multiple episodes of shaking movements that started during a psychotherapy session. EEG showed normal background with beta frequency, likely due to the Ativan she received in the field and the ED. Infectious work up was negative. Most likely cause of her spells was thought to be psychogenic, non-epileptic seizures. By the following morning, she was back to her baseline, with mild residual headache. No changes to her medications were made at this time. She has Neurology follow up with Dr. ___ Dr. ___ at ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LevETIRAcetam 1500 mg PO BID 2. LamoTRIgine 200 mg PO BID 3. Amitriptyline 25 mg PO QHS 4. Strattera (atomoxetine) 25 mg oral BID 5. Citalopram 20 mg PO DAILY 6. TraZODone 150 mg PO QHS 7. CloNIDine 0.1 mg PO QHS 8. ClonazePAM 1 mg PO TID Discharge Disposition: Home Discharge Diagnosis: Non-epileptic seizures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted after having multiple shaking episodes. You were admitted to the hospital and received medications to treat seizures. You were monitored on EEG which did not show seizure activity. Your home medications were not changed. You are advised to take all of your medications exactly as directed and do not miss doses. In addition, we advise you to avoid driving or operating heavy machinery for at least 6 months following these events. Please follow up with your Neurologist as scheduled. It was a pleasure taking care of you. Sincerely, ___ Neurology Followup Instructions: ___	[ "R569", "G40909", "F419", "F329", "F4310" ]	Allergies: codeine Chief Complaint: Seizures Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] (DOB [MASKED] is a [MASKED] year old woman with history of epilepsy and nonepileptic seizures followed at [MASKED], anxiety, depression, PTSD, who presents with prolonged seizure. History was initially limited and obtained via report. She was in a group therapy session today when she had a seizure and fell to the ground. EMS was called and on arrival she was having generalized shaking movements, and so they administered Ativan 2mg IM x2 doses while en route. At [MASKED], she continued to have shaking movements, and she was given additional 2mg of Ativan IV. Movements did not cease, and were associated with tachycardia, but the remainder of her vital signs remained normal including her oxygen saturation. Neurology was consulted and she was also given a load of keppra IV 2000mg. While keppra was infusing, the movements stopped. She awoke and was able to state her name and date of birth slowly, but could not provide additional history. For the remainder of the encounter and examination she had multiple further episodes of shaking movements, lasting up to 30 seconds each time, followed by return back to the awake but slowed state. There was high suspicion for nonepileptic seizures based on her clinical event (as described below in the examination) and past history, as well as lack of responsiveness to Ativan, Upon repeat visit with patient later, she was back to her baseline and able to provide additional history. She had just started a new intensive psychiatric day program yesterday and had the second session today. She states that the session which focused on grief became extremely intense and anxiety provoking for her, and last remembers sitting in the chair facing the other participants. She does not recall any of the events as described above. She states adamantly that she will not be returning to this program again. Her past neurologic history was found via [MASKED] records and reviewed. She is followed by Drs. [MASKED] and [MASKED]. Apparently her seizures began in [MASKED] with a cluster of 22 events in 24 hours. She was evaluated at a local hospital, started on tegretol, and admitted to [MASKED] for LTM, which revealed "3 seizure-like events captured notable for right sided and full body shaking with difficulty speaking that did not show any evidence of electrographic correlate" however was maintained on AED. She continued to have events, and was readmitted for LTM again in [MASKED]. This time she did have three events which did have an EEG correlate, all arising from sleep, characterized by tonic extension followed by flexion of arms and generalized shaking. EEG showed irregular [MASKED] Hz frontally predominant spike and wave complexes prior to event, then rhythmic theta at [MASKED] Hz starting in F3/F4/Fz, then generalizing in one second. She had, in addition, several events during wakefulness consisting of behavioral arrest, feeling unwell with racing heartbeat and tachycardia to 120-130s, which did not have EEG correlate. She had been maintained on keppra at a dose of 2500mg BID; decision was made in the past year to cross-taper this with lamictal to better improve her mood. She increased lamictal over the summer to 200mg BID, and has since been decreasing her keppra by 500mg BID increments every 4 weeks, now at 1500mg BID. She denies any missed doses. Her last seizure was over a year ago and last a few minutes; she has never had a single event this prolonged. Neurology ROS is negative for headache, visual symptoms, 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. Past Medical History: Epilepsy PNES PTSD Depression SI with multiple hospitalizations in past, followed by [MASKED] psychiatrist Dr. [MASKED] Possible borderline personality disorder Social History: [MASKED] Family History: non-contributory Physical Exam: ===ADMISSION EXAM=== Gen: eyes closed, not responsive, intermittent 30 second - 1 min episodes consisting of LUE tonic extension with tremulous movements, RUE tonic flexion and hand fixed in claw posture, BLE tonic internal rotation. Between episodes, she was awake, slow to respond. HEENT: few lacerations in forehead/temporal region, hard C-collar in place Resp: breathing comfortably on room air CV: tachycardic Abd: soft, nontender, nondistended Ext: warm, well perfused Neurologic: - MS: unresponsive with eyes closed during episodes. Between episodes, she is awake without any inter-ictal somnolence. Regards and tracks examiner. Slow to respond but able to state own name and age, unable to state location or date. Follows simple commands slowly (raises her arms) but unable to comply with most of neurology examination. Appears frightened. - CN: PERRL 3->2mm, tracks in all fields of gaze, face appears symmetric. - Sensorimotor: withdraws all extremities to noxious stimuli. - Reflexes: 1+ throughout, toes mute. ===DISCHARGE EXAM=== General: Awake, cooperative, NAD. HEENT: lacerations noted in forehead/temporal region, no scleral icterus noted, MMM, no lesions noted in oropharynx Resp: breathing comfortably on room air CV: regular rate and rhythm, no m/g/r Abd: soft, nontender, nondistended Ext: warm, well perfused 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. Speech was not dysarthric. Able to follow both midline and appendicular commands. -Cranial Nerves: II, III, IV, VI: PERRL 3->2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. 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 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 throughout. No extinction to DSS. -DTRs: 1+ throughout, symmetric. Plantar response was mute bilaterally. -Coordination: No dysmetria on FNF bilaterally. Pertinent Results: ===ADMISSION LABS=== [MASKED] 01:23PM BLOOD WBC-8.0 RBC-4.22 Hgb-12.1 Hct-37.3 MCV-88 MCH-28.7 MCHC-32.4 RDW-13.1 RDWSD-42.2 Plt [MASKED] [MASKED] 01:23PM BLOOD Neuts-67.7 [MASKED] Monos-6.8 Eos-1.4 Baso-0.5 Im [MASKED] AbsNeut-5.41 AbsLymp-1.84 AbsMono-0.54 AbsEos-0.11 AbsBaso-0.04 [MASKED] 01:23PM BLOOD [MASKED] PTT-30.4 [MASKED] [MASKED] 01:23PM BLOOD Glucose-128* UreaN-13 Creat-0.8 Na-136 K-4.3 Cl-97 HCO3-21* AnGap-22* [MASKED] 01:23PM BLOOD ALT-12 AST-14 AlkPhos-92 TotBili-<0.2 [MASKED] 01:23PM BLOOD Albumin-4.6 Calcium-9.5 Phos-3.3 Mg-1.9 [MASKED] 01:23PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 03:22PM BLOOD Lactate-1.5 [MASKED] 03:35PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 03:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ===DIAGNOSTIC STUDIES=== [MASKED] CT HEAD 1. No acute intracranial abnormality. Brief Hospital Course: Ms. [MASKED] was admitted to the Neurology service after multiple episodes of shaking movements that started during a psychotherapy session. EEG showed normal background with beta frequency, likely due to the Ativan she received in the field and the ED. Infectious work up was negative. Most likely cause of her spells was thought to be psychogenic, non-epileptic seizures. By the following morning, she was back to her baseline, with mild residual headache. No changes to her medications were made at this time. She has Neurology follow up with Dr. [MASKED] Dr. [MASKED] at [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LevETIRAcetam 1500 mg PO BID 2. LamoTRIgine 200 mg PO BID 3. Amitriptyline 25 mg PO QHS 4. Strattera (atomoxetine) 25 mg oral BID 5. Citalopram 20 mg PO DAILY 6. TraZODone 150 mg PO QHS 7. CloNIDine 0.1 mg PO QHS 8. ClonazePAM 1 mg PO TID Discharge Disposition: Home Discharge Diagnosis: Non-epileptic seizures 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 after having multiple shaking episodes. You were admitted to the hospital and received medications to treat seizures. You were monitored on EEG which did not show seizure activity. Your home medications were not changed. You are advised to take all of your medications exactly as directed and do not miss doses. In addition, we advise you to avoid driving or operating heavy machinery for at least 6 months following these events. Please follow up with your Neurologist as scheduled. It was a pleasure taking care of you. Sincerely, [MASKED] Neurology Followup Instructions: [MASKED]	[]	[ "F419", "F329" ]	[ "R569: Unspecified convulsions", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F4310: Post-traumatic stress disorder, unspecified" ]
10,094,706	20,352,089	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PSYCHIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Direct Admission for ECT in the setting of worsening depression Major Surgical or Invasive Procedure: ECT History of Present Illness: Mr. ___ is a ___ year old man with history of autism spectrum disorder, depression, anxiety, and a likely gambling disorder who presented to the ___ ED to be directly admitted to Deac 4 for ECT. He has a history of multiple prior suicide attempts, including trying to drown himself in a toilet while in the ___, drinking detergent, and taking sleeping pills. At the beginning of this year, he had an argument with his girlfriend about his non-compliance with his psychiatric medication regimen. They separated, which led to a period of worsening depression with suicidal ideation that culminated in a presentation to the ___ ED on ___. He stayed in the ED for 2 days, over which time his mood improved and he was ultimately discharged home with close follow-up with his outpatient psychiatrist. About 1 week after being discharged from this hospital, he went to ___ to stay with a friend. Around the same time, he stopped taking his psychiatric medications (duloxetine, Adderall). Since then, he has had worsening symptoms of depression. His depression has marked by his feeling "pretty bad" and "depressed" to the point of feeling "desperate." He has had significant sleep difficulty, noting that he either sleeps either for a couple of hours or for a whole day. He reports anergia and fatigue, amotivation, and anhedonia (reduced/more transient pleasure obtained from playing video games or watching cartoons). He has also had suicidal thoughts, with plans consisting of "falling," "drowning," or "interfering with a ___ so he would get shot while simultaneously protecting animals. He says thoughts of his death give him "comfort." He returned from ___ about 2 weeks ago, after which he decided to pursue ECT because he felt he needed help beyond what medications could do. He saw Dr. ___ on ___, after which he decided to pursue ECT. He is hopeful that it will help him, but he is anxious about the procedure and worries that it might only partially work or not work at all. He denies any history of symptoms of mania, including reduced need for sleep with increased goal-directed activity, elevated mood, pressured speech, or grandiosity. He also denies any symptoms of psychosis, including auditory/visual hallucinations. PAST PSYCHIATRIC HISTORY: - Hospitalizations: hospitalized at ___ for suicidal ideation after being seen in ___ ED ___ years ago - Current treaters and treatment: Dr. ___ and ___ at ___ (___) - Medication and ECT trials: fluoxetine, bupropion, lithium, trazodone, lorazepam - Self-injury: reports many suicide attempts since the age of ___ such as drinking detergent, overdosing on medication, and attempt at drowning self in toilet (aborted by army comrades) - Harm to others: denies - Access to weapons: denies Past Medical History: - history of pneumonia and ear infections as a child - hx migraines Social History: ___ Family History: Patient's mother has depression with multiple hospitalizations, patient reports he was told she also has schizophrenia Physical Exam: BP: 151/102, HR: 87, T: 97, RR: 15, SpO2: 99% on RA General: in no acute distress Head/Neck: atraumatic, no thyromegaly, no lymphadenopathy Lungs: CTAB Heart: RRR with no m/r/g Abdomen: + BS, soft, NT, ND Extremities: no edema Skin: no rashes or lesions Neurological: tone and strength: appropriate bulk and tone with strength 5 throughout UEs and ___, no pronator drift sensation: intact and symmetric to light touch bilaterally reflexes: 2+ and symmetric in biceps, triceps, brachioradialis, Patellar, and Achilles tendons bilaterally; toes down-going. cranial nerves: II-XII intact and symmetric bilaterally with difficulty with smooth pursuit, no nystagmus abnormal movements: no tremor gait: steady, no ataxia Romberg: negative Cognition: Wakefulness/alertness: awake and alert throughout interview Attention: after initial pause, does MOYB without difficulty; after initial pause, does serial 8s without difficulty Orientation: A&O to person, place, and time/date Executive function: no deficiency on go-no go (finger challenge) Memory: ___ registration, ___ delayed recall Fund of knowledge: knows current president ___ and presidential candidates ___ Calculations: "35... no, 23" nickels in $1.15 Abstraction: apples/oranges "both round, fruit", watches/rules "both have numbers" Proverb: grass is always greener on the other side means "everything you don't have always looks better" Speech: halting, monotone, with a depressed prosody Language: fluent ___ with no paraphasic errors Mental Status: Appearance: Young, disheveled Caucasian man who is wearing a red Hakuna Matata shirt and blue Pokeman sweat pants. He has an underbite and looks somewhat Behavior: cooperative with interview though he makes somewhat reduced eye contact Mood and Affect: "pretty bad, depressed" with a restricted affect that is congruent to mood Thought process/associations: linear, question-directed Thought Content: endorses passive SI, denies current suicide plan, denies perceptual disturbances, denies paranoia, no evidence for delusional thought Judgment and Insight: fair Pertinent Results: ___ 10:40PM GLUCOSE-150 UREA N-12 CREAT-1.1 SODIUM-142 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-25 ANION GAP-20 ___ 10:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 10:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 10:40PM WBC-8.7 RBC-4.95 HGB-14.9 HCT-42.3 MCV-86 MCH-30.1 MCHC-35.2 RDW-12.5 RDWSD-37.4 ___ 10:40PM NEUTS-62.6 ___ MONOS-5.6 EOS-1.4 BASOS-0.5 IM ___ AbsNeut-5.48 AbsLymp-2.56 AbsMono-0.49 AbsEos-0.12 AbsBaso-0.04 ___ 10:40PM PLT COUNT-240 ___ 10:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 10:40PM URINE RBC-3* WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 Brief Hospital Course: GLOBAL ASSESSMENT ___ w/ depression, autistic spectrum, who was admitted for elective ECT. Pt immediately wanted d/c upon arrival to unit, stating that it was too old, uncomfortable, and reminded him of previous admissions were he did not feel well. Pt agreed to try 1 ECT tx but became too anxious on that date and refused and demanded d/c. My impression is that pt has ongoing chronic risk for self-harm, but he was not admitted w/ acute risk and despite not liking the unit and getting anxious, he remained in good behavioral control and safe. His lack of flexibility is likely ___ autistic spectrum and the milieu of the unit was very unsettling for him, and I agree he might do better w/ outpt ECT from home. PSYCHIATRIC #DEPRESSION Pt has c/o ongoing depression w/ low mood, anhedonia, anergia, low esteem, chornic SI. HE is on SSDI from depression and has 2 prior psych admissions. Came to hospital for elective ECT but talked about it being "for criminals" and expressing regret about his decision once he came to unit. Pt was unwilling to work w/ team on watching any educational videos about ECT - although we recommend his outpt team do this w/ him if he continues to be curious about/interested in the treatment. His depression was such that he appeared dsyphoric on the unit but safe. He wore pj's w/ cartoon characters during his admission and had some limited self-care, but nothing that rose to a dangerous level. He was safe on the unit and future oriented. Pt also was able to mobilize around unit, go to groups and interact w/ peers. #AUTISTIC SPECTRUM ___ was very concrete and inflexible. He asked if he could be awake during ECT, for example, and when team educated him about the process he continued to say, "I want the full experience" - explaining that he wanted to forego anesthesia despite our instruction that this would not be possible. He also became very upset on morning of scheduled ECT that he did not have a specific time for treatment and perseverated on needing times and details. Pt also had some trouble w/ social reciprocity during the admission. PSYCHOSOCIAL #GROUPS/MILIEU - Did attend coping skills and participated - stating that he missed his cat and wanted to go home. He was seen in the milieu often and had no behavioral problems during admission. #FAMILY MEETING - Pt's mother came when he asked for d/c and she agreed he was safe. We provided psychoeducation for both pt and mother. She had no safety concerns and I informed her of the risks that would warrant calling 911/going to nearest ED w/ ___ such as suicidal thoughts/unsafe behaviors. She said she is glad he is coming home today and the plan is for him to stay w/ her until he feels better. Mother also said she will call to make f/u appts for pt as they did not want to stay in hospital for this to be completed. LEGAL STATUS Admitted on CV but asserted he wanted to leave verbally to the team as he felt uncomfortable on the unit. RISK ASSESSMENT Pt has low acute risk for self-harm but ongoing chronic risk. STATIC RF -white race -young ___ -h/o suicidal thoughts - once attempted to drink bleach at ___ yo and at ___ overdosed on pills, both resulting in admissions to psych units. MODIFIABLE RF -depression - we helped pt modify this by explaining different treatment options. Although he refuses ECT, he will consider it and also ___ and ___ med changes in the future -anxiety - we helped pt process his emotions in a supportive environment. We also responded to his wish to go home by involving his family in care and supporting his wishes. -supports - had a family meeting w/ mother on date of d/c and she was supportive PROTECTIVE FX -supportive family -stable housing -income via SSDI -relationship to GF -interest in his cat -good alliance w/ outpt treaters -interest in learning more about treatment options -sobriety PROGNOSIS Guarded - given long-standing depression, chronic passive SI, and his inflexible nature. Pt does have a good relationship to mother, GF and therapist, which are all in his favor, however, and he is future oriented. If he can continue to process emotions and consider tx options, his prognosis will improve. Medications on Admission: none Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: Major depressive disorder Autism spectrum disorder Discharge Condition: General: NAD, disheveled, wearing cartoon pajama pants, appears stated age Behavior: Cooperative but irritable, fair eye contact Speech: Fluent ___, pauses before answers, slightly irritable tone, normal volume and rate Mood/Affect: 'Fine', appears blunted but does get irritable Thought content: Linear, no delusions or paranoia, focused on wanting to go home, difficult to engage on other topics Insight/Judgment: poor/poor Discharge Instructions: Discharge Instructions: You were hospitalized at ___ for depression. You were electively admitted for ECT but upon arrival to Deac 4 expressed that you changed your mind and wanted to go home. -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Please continue all medications as directed. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call ___ or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. Followup Instructions: ___	[ "F329", "R45851", "F840", "F419", "Z5329", "Z915" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Direct Admission for ECT in the setting of worsening depression Major Surgical or Invasive Procedure: ECT History of Present Illness: Mr. [MASKED] is a [MASKED] year old man with history of autism spectrum disorder, depression, anxiety, and a likely gambling disorder who presented to the [MASKED] ED to be directly admitted to Deac 4 for ECT. He has a history of multiple prior suicide attempts, including trying to drown himself in a toilet while in the [MASKED], drinking detergent, and taking sleeping pills. At the beginning of this year, he had an argument with his girlfriend about his non-compliance with his psychiatric medication regimen. They separated, which led to a period of worsening depression with suicidal ideation that culminated in a presentation to the [MASKED] ED on [MASKED]. He stayed in the ED for 2 days, over which time his mood improved and he was ultimately discharged home with close follow-up with his outpatient psychiatrist. About 1 week after being discharged from this hospital, he went to [MASKED] to stay with a friend. Around the same time, he stopped taking his psychiatric medications (duloxetine, Adderall). Since then, he has had worsening symptoms of depression. His depression has marked by his feeling "pretty bad" and "depressed" to the point of feeling "desperate." He has had significant sleep difficulty, noting that he either sleeps either for a couple of hours or for a whole day. He reports anergia and fatigue, amotivation, and anhedonia (reduced/more transient pleasure obtained from playing video games or watching cartoons). He has also had suicidal thoughts, with plans consisting of "falling," "drowning," or "interfering with a [MASKED] so he would get shot while simultaneously protecting animals. He says thoughts of his death give him "comfort." He returned from [MASKED] about 2 weeks ago, after which he decided to pursue ECT because he felt he needed help beyond what medications could do. He saw Dr. [MASKED] on [MASKED], after which he decided to pursue ECT. He is hopeful that it will help him, but he is anxious about the procedure and worries that it might only partially work or not work at all. He denies any history of symptoms of mania, including reduced need for sleep with increased goal-directed activity, elevated mood, pressured speech, or grandiosity. He also denies any symptoms of psychosis, including auditory/visual hallucinations. PAST PSYCHIATRIC HISTORY: - Hospitalizations: hospitalized at [MASKED] for suicidal ideation after being seen in [MASKED] ED [MASKED] years ago - Current treaters and treatment: Dr. [MASKED] and [MASKED] at [MASKED] ([MASKED]) - Medication and ECT trials: fluoxetine, bupropion, lithium, trazodone, lorazepam - Self-injury: reports many suicide attempts since the age of [MASKED] such as drinking detergent, overdosing on medication, and attempt at drowning self in toilet (aborted by army comrades) - Harm to others: denies - Access to weapons: denies Past Medical History: - history of pneumonia and ear infections as a child - hx migraines Social History: [MASKED] Family History: Patient's mother has depression with multiple hospitalizations, patient reports he was told she also has schizophrenia Physical Exam: BP: 151/102, HR: 87, T: 97, RR: 15, SpO2: 99% on RA General: in no acute distress Head/Neck: atraumatic, no thyromegaly, no lymphadenopathy Lungs: CTAB Heart: RRR with no m/r/g Abdomen: + BS, soft, NT, ND Extremities: no edema Skin: no rashes or lesions Neurological: tone and strength: appropriate bulk and tone with strength 5 throughout UEs and [MASKED], no pronator drift sensation: intact and symmetric to light touch bilaterally reflexes: 2+ and symmetric in biceps, triceps, brachioradialis, Patellar, and Achilles tendons bilaterally; toes down-going. cranial nerves: II-XII intact and symmetric bilaterally with difficulty with smooth pursuit, no nystagmus abnormal movements: no tremor gait: steady, no ataxia Romberg: negative Cognition: Wakefulness/alertness: awake and alert throughout interview Attention: after initial pause, does MOYB without difficulty; after initial pause, does serial 8s without difficulty Orientation: A&O to person, place, and time/date Executive function: no deficiency on go-no go (finger challenge) Memory: [MASKED] registration, [MASKED] delayed recall Fund of knowledge: knows current president [MASKED] and presidential candidates [MASKED] Calculations: "35... no, 23" nickels in $1.15 Abstraction: apples/oranges "both round, fruit", watches/rules "both have numbers" Proverb: grass is always greener on the other side means "everything you don't have always looks better" Speech: halting, monotone, with a depressed prosody Language: fluent [MASKED] with no paraphasic errors Mental Status: Appearance: Young, disheveled Caucasian man who is wearing a red Hakuna Matata shirt and blue Pokeman sweat pants. He has an underbite and looks somewhat Behavior: cooperative with interview though he makes somewhat reduced eye contact Mood and Affect: "pretty bad, depressed" with a restricted affect that is congruent to mood Thought process/associations: linear, question-directed Thought Content: endorses passive SI, denies current suicide plan, denies perceptual disturbances, denies paranoia, no evidence for delusional thought Judgment and Insight: fair Pertinent Results: [MASKED] 10:40PM GLUCOSE-150 UREA N-12 CREAT-1.1 SODIUM-142 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-25 ANION GAP-20 [MASKED] 10:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [MASKED] 10:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG [MASKED] 10:40PM WBC-8.7 RBC-4.95 HGB-14.9 HCT-42.3 MCV-86 MCH-30.1 MCHC-35.2 RDW-12.5 RDWSD-37.4 [MASKED] 10:40PM NEUTS-62.6 [MASKED] MONOS-5.6 EOS-1.4 BASOS-0.5 IM [MASKED] AbsNeut-5.48 AbsLymp-2.56 AbsMono-0.49 AbsEos-0.12 AbsBaso-0.04 [MASKED] 10:40PM PLT COUNT-240 [MASKED] 10:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [MASKED] 10:40PM URINE RBC-3* WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 Brief Hospital Course: GLOBAL ASSESSMENT [MASKED] w/ depression, autistic spectrum, who was admitted for elective ECT. Pt immediately wanted d/c upon arrival to unit, stating that it was too old, uncomfortable, and reminded him of previous admissions were he did not feel well. Pt agreed to try 1 ECT tx but became too anxious on that date and refused and demanded d/c. My impression is that pt has ongoing chronic risk for self-harm, but he was not admitted w/ acute risk and despite not liking the unit and getting anxious, he remained in good behavioral control and safe. His lack of flexibility is likely [MASKED] autistic spectrum and the milieu of the unit was very unsettling for him, and I agree he might do better w/ outpt ECT from home. PSYCHIATRIC #DEPRESSION Pt has c/o ongoing depression w/ low mood, anhedonia, anergia, low esteem, chornic SI. HE is on SSDI from depression and has 2 prior psych admissions. Came to hospital for elective ECT but talked about it being "for criminals" and expressing regret about his decision once he came to unit. Pt was unwilling to work w/ team on watching any educational videos about ECT - although we recommend his outpt team do this w/ him if he continues to be curious about/interested in the treatment. His depression was such that he appeared dsyphoric on the unit but safe. He wore pj's w/ cartoon characters during his admission and had some limited self-care, but nothing that rose to a dangerous level. He was safe on the unit and future oriented. Pt also was able to mobilize around unit, go to groups and interact w/ peers. #AUTISTIC SPECTRUM [MASKED] was very concrete and inflexible. He asked if he could be awake during ECT, for example, and when team educated him about the process he continued to say, "I want the full experience" - explaining that he wanted to forego anesthesia despite our instruction that this would not be possible. He also became very upset on morning of scheduled ECT that he did not have a specific time for treatment and perseverated on needing times and details. Pt also had some trouble w/ social reciprocity during the admission. PSYCHOSOCIAL #GROUPS/MILIEU - Did attend coping skills and participated - stating that he missed his cat and wanted to go home. He was seen in the milieu often and had no behavioral problems during admission. #FAMILY MEETING - Pt's mother came when he asked for d/c and she agreed he was safe. We provided psychoeducation for both pt and mother. She had no safety concerns and I informed her of the risks that would warrant calling 911/going to nearest ED w/ [MASKED] such as suicidal thoughts/unsafe behaviors. She said she is glad he is coming home today and the plan is for him to stay w/ her until he feels better. Mother also said she will call to make f/u appts for pt as they did not want to stay in hospital for this to be completed. LEGAL STATUS Admitted on CV but asserted he wanted to leave verbally to the team as he felt uncomfortable on the unit. RISK ASSESSMENT Pt has low acute risk for self-harm but ongoing chronic risk. STATIC RF -white race -young [MASKED] -h/o suicidal thoughts - once attempted to drink bleach at [MASKED] yo and at [MASKED] overdosed on pills, both resulting in admissions to psych units. MODIFIABLE RF -depression - we helped pt modify this by explaining different treatment options. Although he refuses ECT, he will consider it and also [MASKED] and [MASKED] med changes in the future -anxiety - we helped pt process his emotions in a supportive environment. We also responded to his wish to go home by involving his family in care and supporting his wishes. -supports - had a family meeting w/ mother on date of d/c and she was supportive PROTECTIVE FX -supportive family -stable housing -income via SSDI -relationship to GF -interest in his cat -good alliance w/ outpt treaters -interest in learning more about treatment options -sobriety PROGNOSIS Guarded - given long-standing depression, chronic passive SI, and his inflexible nature. Pt does have a good relationship to mother, GF and therapist, which are all in his favor, however, and he is future oriented. If he can continue to process emotions and consider tx options, his prognosis will improve. Medications on Admission: none Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: Major depressive disorder Autism spectrum disorder Discharge Condition: General: NAD, disheveled, wearing cartoon pajama pants, appears stated age Behavior: Cooperative but irritable, fair eye contact Speech: Fluent [MASKED], pauses before answers, slightly irritable tone, normal volume and rate Mood/Affect: 'Fine', appears blunted but does get irritable Thought content: Linear, no delusions or paranoia, focused on wanting to go home, difficult to engage on other topics Insight/Judgment: poor/poor Discharge Instructions: Discharge Instructions: You were hospitalized at [MASKED] for depression. You were electively admitted for ECT but upon arrival to Deac 4 expressed that you changed your mind and wanted to go home. -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Please continue all medications as directed. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call [MASKED] or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. Followup Instructions: [MASKED]	[]	[ "F329", "F419" ]	[ "F329: Major depressive disorder, single episode, unspecified", "R45851: Suicidal ideations", "F840: Autistic disorder", "F419: Anxiety disorder, unspecified", "Z5329: Procedure and treatment not carried out because of patient's decision for other reasons", "Z915: Personal history of self-harm" ]
10,094,811	20,600,295	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Dyspnea, weakness Major Surgical or Invasive Procedure: ___ paracentesis with 6L ascites removed on ___ History of Present Illness: ___ male PMH ESRD on HD MWF, HTN, DM, HLD, A. fib, HTN, HFrEF (LVEF 37% ___, PVD, cirrhosis presenting with profound weakness and lethargy. Patient was recently discharged from the hospital. He felt improved upon discharge, however over the last 3 days he developed progressive weakness and fatigue. He is unable to walk across his house due to fatigue. He denies any chest pain, palpitations, fever, abdominal pain, N/V, melena, dysuria, new pain or changes in chronic lower extremity wounds. He endorses chronic cough which is unchanged over the last few months. In the ED: - Initial vital signs were notable for: T 96.8 F, HR 95, BP 123/58, RR 18, SpO2 92% RA - Exam notable for: abdomen soft, mildly distended with fluid wave, nondistended, no guarding, rebound or masses; CTAB - Labs were notable for: Lactate 2.5, H/H 10.0/31.7, WBC 10.6, BUN/Cr 38/5.7, AP 207, Albumin 3.3, negative Flu A/B PCR - Studies performed include: ___ CXR PA/LAT: Low lung volumes with probable mild pulmonary vascular congestion and bibasilar atelectasis. ___ RUQ U/S: 1. Patent portal vasculature. 2. Cirrhotic liver, with sequela of portal hypertension, including moderate to large volume ascites and mild splenomegaly. - Diagnostic paracentesis was negative for SBP. - Patient was given: no medications - Consults: RT Upon arrival to the floor, patient denies SOB, chest pain, orthopnea, PND, cough, fevers, chills, N/V, diarrhea, dizziness, lightheadedness, foul-smelling drainage from L foot, or erythema from calciphylaxis sites. He endorses metallic taste in his mouth. He noticed fatigue and lethargy after being discharged home. This started on day of discharge and has progressively worsened. He also notes progressive dyspnea on exertion. He was working with ___ today who referred him to ED given his progressive weakness. He thinks he had more energy prior to discharge. Specifically, he was able to sit in the chair whereas at home he has been in bed. Of note, he was recently admitted from ___ after mechanical fall. He was found to have presumed L foot osteomyelitis. Podiatry and Vascular Surgery evaluated and recommended no intervention given previous non-healing wound after L ___ toe amputation in ___ and comorbidities. Deep wound culture grew mixed flora and MRSA. ID was consulted and recommended empiric 6-week course with Vancomycin/Ceftazidime/Flagyl for osteomyelitis. Admission was complicated by multifactorial encephalopathy, acute hypoxic respiratory failure, and new diagnosis of calciphylaxis. He was restarted on metoprolol prior to discharge. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative. Past Medical History: 1. End-stage renal disease (ESRD) secondary to diabetic nephropathy 2. Pulmonary hypertension 3. Diabetes mellitus 4. Hypertension 5. Dyslipidemia 6. Atrial flutter s/p failed ablation 7. Obstructive sleep apnea 8. HFrEF 9. PVD 10. HTN 11. left carotid stenosis - concern for TIA/stroke in setting of hypoperfusion Social History: ___ Family History: Father had diabetes and died from complications of diabetes at age ___ including ESRD. Grandfather had diabetes and died at age ___ from complications. Mother died in her ___ likely due to osteosarcoma. Has two brothers, one who has medication-controlled diabetes. Sister had gestational diabetes and diabetes that resolved after gastric bypass. Physical Exam: ADMISSION PHYSICAL EXAM: ======================= VITALS: 97.5 148 / 74 70 18 GENERAL: alert, interactive, NAD, hoarse voice HEENT: sclera anicteric, EOMI, PERRL, MMM, poor dentition, missing bottom front teeth CARDIAC: Irregularly irregular rhythm, regular rate, III/VI holosystolic murmur throughout, III/VI crescendo murmur at L ___ intercostal space, no rubs RESP: Unlabored respirations, no wheezes, rales, or rhonchi ABDOMEN: soft, non-distended, non-tender to palpation, hypoactive bowel sounds throughout, +fluid wave MSK: Radial pulses 1+ bilaterally, trace bilateral lower extremity edema SKIN: bilateral lower extremity venous stasis changes, multiple dark-colored plaques on right toes, left foot partially covered in dressing NEUROLOGIC: CN II-XII intact, moving all four extremities with purpose DISCHARGE PHYSICAL EXAM: ========================= 24 HR Data (last updated ___ @ 2305) Temp: 97.7 (Tm 97.7), BP: 122/67 (102-122/64-70), HR: 66 (62-71), RR: 18, O2 sat: 98% (95-98), O2 delivery: Ra GENERAL: alert, interactive, NAD, soft voice HEENT: MMM. CARDIAC: Irregularly irregular rhythm, regular rate, III/VI holosystolic murmur throughout, Grade III/VI crescesndo-decrescendo systolic late peaking systolic ejection murmur radiating to clavicle RESP: Unlabored respirations, no wheezes, rales, or rhonchi ABDOMEN: Soft, non-tender, nondistended abdomen improved from yesterday MSK: Radial pulses 1+ bilaterally, no lower extremity edema SKIN: bilateral lower extremity venous stasis changes, multiple dark-colored plaques on right toes, left foot partially covered in dressing Pertinent Results: ADMISSION LABS ============== ___ 09:05PM BLOOD WBC-10.6* RBC-3.08* Hgb-10.0* Hct-31.7* MCV-103* MCH-32.5* MCHC-31.5* RDW-15.6* RDWSD-58.3* Plt ___ ___ 09:05PM BLOOD Neuts-76.3* Lymphs-9.7* Monos-10.6 Eos-2.0 Baso-0.8 Im ___ AbsNeut-8.12* AbsLymp-1.03* AbsMono-1.13* AbsEos-0.21 AbsBaso-0.09* ___ 11:46PM BLOOD ___ PTT-34.1 ___ ___ 09:05PM BLOOD Glucose-187* UreaN-38* Creat-5.7* Na-146 K-5.9* Cl-96 HCO3-25 AnGap-25* ___ 09:05PM BLOOD ALT-9 AST-15 AlkPhos-207* TotBili-0.4 ___ 09:05PM BLOOD Albumin-3.3* Calcium-9.7 Phos-4.0 Mg-2.2 ___ 06:20AM BLOOD TSH-2.2 ___ 06:20AM BLOOD CRP-8.2* ___ 09:15PM BLOOD Lactate-2.5* IMAGING ======= ___ CXR: Low lung volumes with probable mild pulmonary vascular congestion and bibasilar atelectasis. ___ RUQUS: 1. Patent portal vasculature. 2. Cirrhotic liver, with sequela of portal hypertension, including moderate to large volume ascites and mild splenomegaly. US EXTREMITY LIMITED SOFT TISSUE (___) Lobulated echogenic masslike areas in bilateral subcutaneous gluteal tissues correspond to the palpable abnormalities, consistent with calcifications and sequela of fat necrosis. These likely relate to the known diagnosis of calciphylaxis. DISCHARGE LABS =============== ___ 06:30AM BLOOD WBC-8.5 RBC-3.26* Hgb-10.5* Hct-32.5* MCV-100* MCH-32.2* MCHC-32.3 RDW-15.2 RDWSD-56.0* Plt ___ ___ 06:21AM BLOOD Glucose-125* UreaN-19 Creat-4.8# Na-143 K-4.9 Cl-96 HCO3-27 AnGap-20 ___ 06:30AM BLOOD VitB12-___ male PMH HFrEF (LVEF 37% ___, ESRD on HD MWF, HTN, paroxysmal A. fib, HTN, DM, PVD, decompensated cirrhosis presenting with weakness. He was recently admitted for left foot osteomyelitis (___) and discharged home on prolonged broad-spectrum antibiotics course. He was readmitted on ___ after presenting with profound fatigue making it difficult to even get out of bed after discharge home. Fatigue suspected to be secondary to deconditioning and after re-evaluation by ___ he was recommended for discharge to rehab. This hospital course also notable for ___ guided paracentesis on ___ with 6L fluid removed. He was also started on sertraline 25 mg daily for depression on ___ after psychiatry evaluation. TRANSITIONAL ISSUES =================== [ ] Sertraline: Started at 25 mg on ___. Increase dose to 50 mg daily on ___ if well tolerated [ ] Consider referral to CBT, psychiatry, and/or palliative care as an outpatient. [ ] Follow-up with general surgery to discuss if surgical removal of calciphylaxis related masses would be possible [ ] Refractory ascites: Hepatology was consulted and recommended that most viable solution will likely be to maximize UF volume at outpatient HD and support his blood pressures with midodrine if necessary (unfortunately this could worsen his HF). If this were to fail further evaluation for TIPS could be considered but this would require a discussion with his cardiologist, he may not tolerate the increase in preload derived from TIPS. [ ] Dietary changes: continue to suggest max sodium 2 grm/day for ascites management [ ] Serial paracentesis may be useful for comfort, noting complexity of scheduling outpatient paracentesis with DOAC. Have been holding apixaban for 2 days prior to each paracentesis. He is at somewhat lower risk of infection due to the high ascites protein, but an indwelling catheter for drainage would still be a risk and likely reasonable only if his prognosis overall is rather poor and comfort-focused care is the goal. [ ] Avoid LVP on HD days given history of hypotension [ ] Has never had EGD for variceal screening [ ] Avoid calcium, iron supplementation, warfarin use, prednisone, vitamin D (all of which can worsen calciphylaxis) [ ] Needs to follow up with his OSH podiatrist for monitoring of L foot. [ ] Antibiotics: 6 week course of antibiotics for L foot osteomyelitis with vanc/ceftaz to be given and HD, and PO flagyl. ___, end date ___. ACUTE ISSUES: ============= # Weakness, fatigue Presented with progressive weakness and fatigue in the days after discharge from last admission on ___. Most likely related to deconditioning from recent hospitalization on a background of multi-organ dysfunction with ESRD, CHF, and cirrhosis as well as infection with osteomyelitis. Also suspect a component of depression (see below). Less likely medication related. Ongoing infection unlikely given decreased CRP to 8 and appropriate IV antibiotics. ___ was consulted and recommended discharge to rehab. # Calciphylaxis Skin lesions on bilateral legs and penis. Dermatology evaluated during last admission and deferred biopsy. Noted this admission to have sacral superficial ulceration with central dark coloration as well as lobulated echogenic mass like areas in bilateral subcutaneous gluteal tissues on U/S c/w calciphylaxis. He was connected to general surgery for follow-up for consideration of removal of these masses. Continued Sodium Thiosulfate 25mg IV w/ every HD until wounds improve (trial of at last 4 weeks). Per Dermatology, avoid calcium and iron supplementation, warfarin use, prednisone, vitamin D, and goal to maintain goal Ca x P product below 55 mg2/dL. Continued Oxycodone 5 mg PO q4h PRN. # Depression He reported feeling depressed and expressed thoughts of passive suicidal ideation("maybe it would be better if I weren't here, but I would never kill myself"). He does not want to be a burden on his family and feels guilt over his medical needs; however, he has a strong relationship with his wife and has 2 ___ that he wants to see more than anything. He has never been on medications for depression. Psychiatry concerned for hypoactive delirium and depression due to impaired attention and disorganized thinking. He was started on mirtazapine 7.5 mg which was increased to 15 mg but was discontinued due to increased daytime sleepiness. He was started on sertraline on ___ at 25 mg with plant to increase to 50 gm daily in one week if well tolerated. # Cirrhosis, decompensated by ascites Etiology cardiac secondary to right-sided heart failure +/- NASH. Decompensated by ascites and hepatic encephalopathy. RUQUS on ___ showed moderate to large ascites. Diagnostic tap on ___ no evidence of SBP. Hepatology was consulted and noted that more volume removal with HD could be assisted with midodrine if not already tried, and if permissible with respect to his CHF. Last LVP prior to this admission was on ___. Held apixaban ___ and ___ for ___ guided paracentesis on ___. 6L was removed and he was given 50 mg albumin after. Continued Lactulose 30 mL TID titrating to ___ BMs, Rifaximin 550 mg PO BID. Hepatology was consulted regarding his refractory ascites and noted that UF will be the most viable solution although could continue with serial paracentesis for comfort (holding apixaban for 2 days prior). See above transitional issues for further hepatology suggestions. # PVD: # Osteomyelitis, L foot: Recent admission for progressive L foot ___ digit gangrene and non-healing ___ digit amputation site probing to bone. Highly concerning for osteomyelitis, however podiatry and vascular surgery recommended no intervention given comorbidities and demonstrated poor wound healing. Deep wound cx grew mixed flora and MRSA. ID recommended empiric 6 week course of Vanc/Ceftaz/Flagyl for presumed osteomyelitis (___). Repeat CRP decreased to 8. Continued Vanc/Ceftaz/Flagyl. Blood cxs x2 NGTD. # Anemia, macrocytic: Suspect due to cirrhosis, anemia of chronic disease. Remained stable in the ___ range. CHRONIC ISSUES: =============== # Atrial fibrillation, paroxysmal: CHADS-VASc 4, high risk, 4% annual risk of thromboembolism. Anticoagulation: Apixaban 2.5 mg PO BID (held for paracentesis ___ Rate: continued home metoprolol Continued Digoxin 0.125 mg PO 3X/WEEK (___) post-HD # HFrEF Has right-sided HF and pulmonary HTN in the setting of longstanding OSA. TTE from ___ showed LVEF 37%, mod-severe TR, mod RV hypokinesis, severe pulmonary artery systolic HTN, moderate global LV systolic dysfunction. Preload: HD MWF - Afterload: Continue Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY - NHBK: Home metoprolol 12.5 mg daily. # ESRD on HD MWF: Continued sevelamer CARBONATE 1600 mg PO TID W/MEALS. Continue Nephrocaps 1 CAP PO DAILY. Liberalized the potassium restriction on diet as discussed risk of hyperkalemia and patient reported that food is one of the only things that he has to look forward to on a daily basis. # Type II DM: Hgb A1c 6.7% in ___. No longer on medications. # HLD: Continued home atorvastatin # Gout: Continued home Allopurinol ___ mg PO DAILY. # OSA: Declines CPAP at home. CORE MEASURES ============= #CODE: Full code #CONTACT: ___ wife, Phone: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 2.5 mg PO BID 2. Atorvastatin 40 mg PO QPM 3. Digoxin 0.125 mg PO 3X/WEEK (___) 4. Pantoprazole 40 mg PO Q24H 5. sevelamer CARBONATE 1600 mg PO TID W/MEALS 6. CefTAZidime 2 g IV POST HD (MO,WE) 7. CefTAZidime 3 g IV POST HD (FR) 8. Collagenase Ointment 1 Appl TP DAILY 9. Dakins ___ Strength 1 Appl TP ASDIR 10. Lactulose 30 mL PO TID 11. MetroNIDAZOLE 500 mg PO/NG Q8H 12. rifAXIMin 550 mg PO BID 13. Sodium Thiosulfate 25 g IV ONCE 14. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe 15. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 16. Zolpidem Tartrate 5 mg PO QHS:PRN Insomnia 17. paricalcitol 8 mcg oral 3X/WEEK (___) 18. ___ MD to order daily dose IV HD PROTOCOL 19. Nephrocaps 1 CAP PO DAILY 20. Allopurinol ___ mg PO DAILY 21. Metoprolol Succinate XL 12.5 mg PO DAILY Discharge Medications: 1. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN sore throat 2. Sertraline 25 mg PO DAILY 3. Allopurinol ___ mg PO DAILY 4. Apixaban 2.5 mg PO BID 5. Atorvastatin 40 mg PO QPM 6. CefTAZidime 2 g IV POST HD (MO,WE) 7. CefTAZidime 3 g IV POST HD (FR) 8. Collagenase Ointment 1 Appl TP DAILY 9. Dakins ___ Strength 1 Appl TP ASDIR 10. Digoxin 0.125 mg PO 3X/WEEK (___) 11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 12. Lactulose 30 mL PO TID 13. Metoprolol Succinate XL 12.5 mg PO DAILY 14. MetroNIDAZOLE 500 mg PO Q8H 15. Nephrocaps 1 CAP PO DAILY 16. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe 17. Pantoprazole 40 mg PO Q24H 18. paricalcitol 8 mcg oral 3X/WEEK (___) 19. rifAXIMin 550 mg PO BID 20. sevelamer CARBONATE 1600 mg PO TID W/MEALS 21. Sodium Thiosulfate 25 g IV ONCE 22. ___ MD to order daily dose IV HD PROTOCOL 23. Zolpidem Tartrate 5 mg PO QHS:PRN Insomnia Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Deconditioning SECONDARY DIAGNOSIS: L foot osteomyelitis Calciphylaxis Ascites Hypoxic respiratory failure Cirrhosis Peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a privilege taking care of you at the ___ ___. Why was I admitted to the hospital? ================================= - You were admitted because you had weakness and fatigue. What happened while I was in the hospital? ==================================== - You were was seen by the physical therapists who recommended that you go to a rehab center. - You were seen by the psychiatry team who started you on a medication called sertraline to improve your mood. - The dermatology team saw you and recommended an ultrasound of the painful skin lesions on your buttock. The ultrasound showed that these are likely related to your calciphylaxis. We have arranged follow-up with a surgeon to discuss if a surgical removal of the masses would be possible. It is important that you limit the amount of calcium and dairy you take in going forward. What should I do after leaving the hospital? ==================================== - Please take your medications as listed in discharge summary and follow up at the listed appointments. Thank you for allowing us to be involved in your care, we wish you all the best. Sincerely, Your ___ Healthcare Team Followup Instructions: ___	[ "K7460", "N186", "J9691", "R188", "I5022", "I4892", "M869", "R45851", "E440", "K7290", "I110", "I953", "L98429", "E1169", "I50810", "K7581", "E1122", "D638", "E8359", "I2720", "E785", "E1151", "R5383", "G4733", "I6522", "I480", "M109", "B9562", "D539", "I071", "R410", "G4700", "F4321", "J383", "M6281", "Z89422", "Z992", "Z7901", "Z9111" ]	Allergies: Penicillins Chief Complaint: Dyspnea, weakness Major Surgical or Invasive Procedure: [MASKED] paracentesis with 6L ascites removed on [MASKED] History of Present Illness: [MASKED] male PMH ESRD on HD MWF, HTN, DM, HLD, A. fib, HTN, HFrEF (LVEF 37% [MASKED], PVD, cirrhosis presenting with profound weakness and lethargy. Patient was recently discharged from the hospital. He felt improved upon discharge, however over the last 3 days he developed progressive weakness and fatigue. He is unable to walk across his house due to fatigue. He denies any chest pain, palpitations, fever, abdominal pain, N/V, melena, dysuria, new pain or changes in chronic lower extremity wounds. He endorses chronic cough which is unchanged over the last few months. In the ED: - Initial vital signs were notable for: T 96.8 F, HR 95, BP 123/58, RR 18, SpO2 92% RA - Exam notable for: abdomen soft, mildly distended with fluid wave, nondistended, no guarding, rebound or masses; CTAB - Labs were notable for: Lactate 2.5, H/H 10.0/31.7, WBC 10.6, BUN/Cr 38/5.7, AP 207, Albumin 3.3, negative Flu A/B PCR - Studies performed include: [MASKED] CXR PA/LAT: Low lung volumes with probable mild pulmonary vascular congestion and bibasilar atelectasis. [MASKED] RUQ U/S: 1. Patent portal vasculature. 2. Cirrhotic liver, with sequela of portal hypertension, including moderate to large volume ascites and mild splenomegaly. - Diagnostic paracentesis was negative for SBP. - Patient was given: no medications - Consults: RT Upon arrival to the floor, patient denies SOB, chest pain, orthopnea, PND, cough, fevers, chills, N/V, diarrhea, dizziness, lightheadedness, foul-smelling drainage from L foot, or erythema from calciphylaxis sites. He endorses metallic taste in his mouth. He noticed fatigue and lethargy after being discharged home. This started on day of discharge and has progressively worsened. He also notes progressive dyspnea on exertion. He was working with [MASKED] today who referred him to ED given his progressive weakness. He thinks he had more energy prior to discharge. Specifically, he was able to sit in the chair whereas at home he has been in bed. Of note, he was recently admitted from [MASKED] after mechanical fall. He was found to have presumed L foot osteomyelitis. Podiatry and Vascular Surgery evaluated and recommended no intervention given previous non-healing wound after L [MASKED] toe amputation in [MASKED] and comorbidities. Deep wound culture grew mixed flora and MRSA. ID was consulted and recommended empiric 6-week course with Vancomycin/Ceftazidime/Flagyl for osteomyelitis. Admission was complicated by multifactorial encephalopathy, acute hypoxic respiratory failure, and new diagnosis of calciphylaxis. He was restarted on metoprolol prior to discharge. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative. Past Medical History: 1. End-stage renal disease (ESRD) secondary to diabetic nephropathy 2. Pulmonary hypertension 3. Diabetes mellitus 4. Hypertension 5. Dyslipidemia 6. Atrial flutter s/p failed ablation 7. Obstructive sleep apnea 8. HFrEF 9. PVD 10. HTN 11. left carotid stenosis - concern for TIA/stroke in setting of hypoperfusion Social History: [MASKED] Family History: Father had diabetes and died from complications of diabetes at age [MASKED] including ESRD. Grandfather had diabetes and died at age [MASKED] from complications. Mother died in her [MASKED] likely due to osteosarcoma. Has two brothers, one who has medication-controlled diabetes. Sister had gestational diabetes and diabetes that resolved after gastric bypass. Physical Exam: ADMISSION PHYSICAL EXAM: ======================= VITALS: 97.5 148 / 74 70 18 GENERAL: alert, interactive, NAD, hoarse voice HEENT: sclera anicteric, EOMI, PERRL, MMM, poor dentition, missing bottom front teeth CARDIAC: Irregularly irregular rhythm, regular rate, III/VI holosystolic murmur throughout, III/VI crescendo murmur at L [MASKED] intercostal space, no rubs RESP: Unlabored respirations, no wheezes, rales, or rhonchi ABDOMEN: soft, non-distended, non-tender to palpation, hypoactive bowel sounds throughout, +fluid wave MSK: Radial pulses 1+ bilaterally, trace bilateral lower extremity edema SKIN: bilateral lower extremity venous stasis changes, multiple dark-colored plaques on right toes, left foot partially covered in dressing NEUROLOGIC: CN II-XII intact, moving all four extremities with purpose DISCHARGE PHYSICAL EXAM: ========================= 24 HR Data (last updated [MASKED] @ 2305) Temp: 97.7 (Tm 97.7), BP: 122/67 (102-122/64-70), HR: 66 (62-71), RR: 18, O2 sat: 98% (95-98), O2 delivery: Ra GENERAL: alert, interactive, NAD, soft voice HEENT: MMM. CARDIAC: Irregularly irregular rhythm, regular rate, III/VI holosystolic murmur throughout, Grade III/VI crescesndo-decrescendo systolic late peaking systolic ejection murmur radiating to clavicle RESP: Unlabored respirations, no wheezes, rales, or rhonchi ABDOMEN: Soft, non-tender, nondistended abdomen improved from yesterday MSK: Radial pulses 1+ bilaterally, no lower extremity edema SKIN: bilateral lower extremity venous stasis changes, multiple dark-colored plaques on right toes, left foot partially covered in dressing Pertinent Results: ADMISSION LABS ============== [MASKED] 09:05PM BLOOD WBC-10.6* RBC-3.08* Hgb-10.0* Hct-31.7* MCV-103* MCH-32.5* MCHC-31.5* RDW-15.6* RDWSD-58.3* Plt [MASKED] [MASKED] 09:05PM BLOOD Neuts-76.3* Lymphs-9.7* Monos-10.6 Eos-2.0 Baso-0.8 Im [MASKED] AbsNeut-8.12* AbsLymp-1.03* AbsMono-1.13* AbsEos-0.21 AbsBaso-0.09* [MASKED] 11:46PM BLOOD [MASKED] PTT-34.1 [MASKED] [MASKED] 09:05PM BLOOD Glucose-187* UreaN-38* Creat-5.7* Na-146 K-5.9* Cl-96 HCO3-25 AnGap-25* [MASKED] 09:05PM BLOOD ALT-9 AST-15 AlkPhos-207* TotBili-0.4 [MASKED] 09:05PM BLOOD Albumin-3.3* Calcium-9.7 Phos-4.0 Mg-2.2 [MASKED] 06:20AM BLOOD TSH-2.2 [MASKED] 06:20AM BLOOD CRP-8.2* [MASKED] 09:15PM BLOOD Lactate-2.5* IMAGING ======= [MASKED] CXR: Low lung volumes with probable mild pulmonary vascular congestion and bibasilar atelectasis. [MASKED] RUQUS: 1. Patent portal vasculature. 2. Cirrhotic liver, with sequela of portal hypertension, including moderate to large volume ascites and mild splenomegaly. US EXTREMITY LIMITED SOFT TISSUE ([MASKED]) Lobulated echogenic masslike areas in bilateral subcutaneous gluteal tissues correspond to the palpable abnormalities, consistent with calcifications and sequela of fat necrosis. These likely relate to the known diagnosis of calciphylaxis. DISCHARGE LABS =============== [MASKED] 06:30AM BLOOD WBC-8.5 RBC-3.26* Hgb-10.5* Hct-32.5* MCV-100* MCH-32.2* MCHC-32.3 RDW-15.2 RDWSD-56.0* Plt [MASKED] [MASKED] 06:21AM BLOOD Glucose-125* UreaN-19 Creat-4.8# Na-143 K-4.9 Cl-96 HCO3-27 AnGap-20 [MASKED] 06:30AM BLOOD VitB12-[MASKED] male PMH HFrEF (LVEF 37% [MASKED], ESRD on HD MWF, HTN, paroxysmal A. fib, HTN, DM, PVD, decompensated cirrhosis presenting with weakness. He was recently admitted for left foot osteomyelitis ([MASKED]) and discharged home on prolonged broad-spectrum antibiotics course. He was readmitted on [MASKED] after presenting with profound fatigue making it difficult to even get out of bed after discharge home. Fatigue suspected to be secondary to deconditioning and after re-evaluation by [MASKED] he was recommended for discharge to rehab. This hospital course also notable for [MASKED] guided paracentesis on [MASKED] with 6L fluid removed. He was also started on sertraline 25 mg daily for depression on [MASKED] after psychiatry evaluation. TRANSITIONAL ISSUES =================== [ ] Sertraline: Started at 25 mg on [MASKED]. Increase dose to 50 mg daily on [MASKED] if well tolerated [ ] Consider referral to CBT, psychiatry, and/or palliative care as an outpatient. [ ] Follow-up with general surgery to discuss if surgical removal of calciphylaxis related masses would be possible [ ] Refractory ascites: Hepatology was consulted and recommended that most viable solution will likely be to maximize UF volume at outpatient HD and support his blood pressures with midodrine if necessary (unfortunately this could worsen his HF). If this were to fail further evaluation for TIPS could be considered but this would require a discussion with his cardiologist, he may not tolerate the increase in preload derived from TIPS. [ ] Dietary changes: continue to suggest max sodium 2 grm/day for ascites management [ ] Serial paracentesis may be useful for comfort, noting complexity of scheduling outpatient paracentesis with DOAC. Have been holding apixaban for 2 days prior to each paracentesis. He is at somewhat lower risk of infection due to the high ascites protein, but an indwelling catheter for drainage would still be a risk and likely reasonable only if his prognosis overall is rather poor and comfort-focused care is the goal. [ ] Avoid LVP on HD days given history of hypotension [ ] Has never had EGD for variceal screening [ ] Avoid calcium, iron supplementation, warfarin use, prednisone, vitamin D (all of which can worsen calciphylaxis) [ ] Needs to follow up with his OSH podiatrist for monitoring of L foot. [ ] Antibiotics: 6 week course of antibiotics for L foot osteomyelitis with vanc/ceftaz to be given and HD, and PO flagyl. [MASKED], end date [MASKED]. ACUTE ISSUES: ============= # Weakness, fatigue Presented with progressive weakness and fatigue in the days after discharge from last admission on [MASKED]. Most likely related to deconditioning from recent hospitalization on a background of multi-organ dysfunction with ESRD, CHF, and cirrhosis as well as infection with osteomyelitis. Also suspect a component of depression (see below). Less likely medication related. Ongoing infection unlikely given decreased CRP to 8 and appropriate IV antibiotics. [MASKED] was consulted and recommended discharge to rehab. # Calciphylaxis Skin lesions on bilateral legs and penis. Dermatology evaluated during last admission and deferred biopsy. Noted this admission to have sacral superficial ulceration with central dark coloration as well as lobulated echogenic mass like areas in bilateral subcutaneous gluteal tissues on U/S c/w calciphylaxis. He was connected to general surgery for follow-up for consideration of removal of these masses. Continued Sodium Thiosulfate 25mg IV w/ every HD until wounds improve (trial of at last 4 weeks). Per Dermatology, avoid calcium and iron supplementation, warfarin use, prednisone, vitamin D, and goal to maintain goal Ca x P product below 55 mg2/dL. Continued Oxycodone 5 mg PO q4h PRN. # Depression He reported feeling depressed and expressed thoughts of passive suicidal ideation("maybe it would be better if I weren't here, but I would never kill myself"). He does not want to be a burden on his family and feels guilt over his medical needs; however, he has a strong relationship with his wife and has 2 [MASKED] that he wants to see more than anything. He has never been on medications for depression. Psychiatry concerned for hypoactive delirium and depression due to impaired attention and disorganized thinking. He was started on mirtazapine 7.5 mg which was increased to 15 mg but was discontinued due to increased daytime sleepiness. He was started on sertraline on [MASKED] at 25 mg with plant to increase to 50 gm daily in one week if well tolerated. # Cirrhosis, decompensated by ascites Etiology cardiac secondary to right-sided heart failure +/- NASH. Decompensated by ascites and hepatic encephalopathy. RUQUS on [MASKED] showed moderate to large ascites. Diagnostic tap on [MASKED] no evidence of SBP. Hepatology was consulted and noted that more volume removal with HD could be assisted with midodrine if not already tried, and if permissible with respect to his CHF. Last LVP prior to this admission was on [MASKED]. Held apixaban [MASKED] and [MASKED] for [MASKED] guided paracentesis on [MASKED]. 6L was removed and he was given 50 mg albumin after. Continued Lactulose 30 mL TID titrating to [MASKED] BMs, Rifaximin 550 mg PO BID. Hepatology was consulted regarding his refractory ascites and noted that UF will be the most viable solution although could continue with serial paracentesis for comfort (holding apixaban for 2 days prior). See above transitional issues for further hepatology suggestions. # PVD: # Osteomyelitis, L foot: Recent admission for progressive L foot [MASKED] digit gangrene and non-healing [MASKED] digit amputation site probing to bone. Highly concerning for osteomyelitis, however podiatry and vascular surgery recommended no intervention given comorbidities and demonstrated poor wound healing. Deep wound cx grew mixed flora and MRSA. ID recommended empiric 6 week course of Vanc/Ceftaz/Flagyl for presumed osteomyelitis ([MASKED]). Repeat CRP decreased to 8. Continued Vanc/Ceftaz/Flagyl. Blood cxs x2 NGTD. # Anemia, macrocytic: Suspect due to cirrhosis, anemia of chronic disease. Remained stable in the [MASKED] range. CHRONIC ISSUES: =============== # Atrial fibrillation, paroxysmal: CHADS-VASc 4, high risk, 4% annual risk of thromboembolism. Anticoagulation: Apixaban 2.5 mg PO BID (held for paracentesis [MASKED] Rate: continued home metoprolol Continued Digoxin 0.125 mg PO 3X/WEEK ([MASKED]) post-HD # HFrEF Has right-sided HF and pulmonary HTN in the setting of longstanding OSA. TTE from [MASKED] showed LVEF 37%, mod-severe TR, mod RV hypokinesis, severe pulmonary artery systolic HTN, moderate global LV systolic dysfunction. Preload: HD MWF - Afterload: Continue Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY - NHBK: Home metoprolol 12.5 mg daily. # ESRD on HD MWF: Continued sevelamer CARBONATE 1600 mg PO TID W/MEALS. Continue Nephrocaps 1 CAP PO DAILY. Liberalized the potassium restriction on diet as discussed risk of hyperkalemia and patient reported that food is one of the only things that he has to look forward to on a daily basis. # Type II DM: Hgb A1c 6.7% in [MASKED]. No longer on medications. # HLD: Continued home atorvastatin # Gout: Continued home Allopurinol [MASKED] mg PO DAILY. # OSA: Declines CPAP at home. CORE MEASURES ============= #CODE: Full code #CONTACT: [MASKED] wife, Phone: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 2.5 mg PO BID 2. Atorvastatin 40 mg PO QPM 3. Digoxin 0.125 mg PO 3X/WEEK ([MASKED]) 4. Pantoprazole 40 mg PO Q24H 5. sevelamer CARBONATE 1600 mg PO TID W/MEALS 6. CefTAZidime 2 g IV POST HD (MO,WE) 7. CefTAZidime 3 g IV POST HD (FR) 8. Collagenase Ointment 1 Appl TP DAILY 9. Dakins [MASKED] Strength 1 Appl TP ASDIR 10. Lactulose 30 mL PO TID 11. MetroNIDAZOLE 500 mg PO/NG Q8H 12. rifAXIMin 550 mg PO BID 13. Sodium Thiosulfate 25 g IV ONCE 14. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe 15. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 16. Zolpidem Tartrate 5 mg PO QHS:PRN Insomnia 17. paricalcitol 8 mcg oral 3X/WEEK ([MASKED]) 18. [MASKED] MD to order daily dose IV HD PROTOCOL 19. Nephrocaps 1 CAP PO DAILY 20. Allopurinol [MASKED] mg PO DAILY 21. Metoprolol Succinate XL 12.5 mg PO DAILY Discharge Medications: 1. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN sore throat 2. Sertraline 25 mg PO DAILY 3. Allopurinol [MASKED] mg PO DAILY 4. Apixaban 2.5 mg PO BID 5. Atorvastatin 40 mg PO QPM 6. CefTAZidime 2 g IV POST HD (MO,WE) 7. CefTAZidime 3 g IV POST HD (FR) 8. Collagenase Ointment 1 Appl TP DAILY 9. Dakins [MASKED] Strength 1 Appl TP ASDIR 10. Digoxin 0.125 mg PO 3X/WEEK ([MASKED]) 11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 12. Lactulose 30 mL PO TID 13. Metoprolol Succinate XL 12.5 mg PO DAILY 14. MetroNIDAZOLE 500 mg PO Q8H 15. Nephrocaps 1 CAP PO DAILY 16. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe 17. Pantoprazole 40 mg PO Q24H 18. paricalcitol 8 mcg oral 3X/WEEK ([MASKED]) 19. rifAXIMin 550 mg PO BID 20. sevelamer CARBONATE 1600 mg PO TID W/MEALS 21. Sodium Thiosulfate 25 g IV ONCE 22. [MASKED] MD to order daily dose IV HD PROTOCOL 23. Zolpidem Tartrate 5 mg PO QHS:PRN Insomnia Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: Deconditioning SECONDARY DIAGNOSIS: L foot osteomyelitis Calciphylaxis Ascites Hypoxic respiratory failure Cirrhosis Peripheral vascular disease 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 privilege taking care of you at the [MASKED] [MASKED]. Why was I admitted to the hospital? ================================= - You were admitted because you had weakness and fatigue. What happened while I was in the hospital? ==================================== - You were was seen by the physical therapists who recommended that you go to a rehab center. - You were seen by the psychiatry team who started you on a medication called sertraline to improve your mood. - The dermatology team saw you and recommended an ultrasound of the painful skin lesions on your buttock. The ultrasound showed that these are likely related to your calciphylaxis. We have arranged follow-up with a surgeon to discuss if a surgical removal of the masses would be possible. It is important that you limit the amount of calcium and dairy you take in going forward. What should I do after leaving the hospital? ==================================== - Please take your medications as listed in discharge summary and follow up at the listed appointments. Thank you for allowing us to be involved in your care, we wish you all the best. Sincerely, Your [MASKED] Healthcare Team Followup Instructions: [MASKED]	[]	[ "I110", "E1122", "E785", "G4733", "I480", "M109", "G4700", "Z7901" ]	[ "K7460: Unspecified cirrhosis of liver", "N186: End stage renal disease", "J9691: Respiratory failure, unspecified with hypoxia", "R188: Other ascites", "I5022: Chronic systolic (congestive) heart failure", "I4892: Unspecified atrial flutter", "M869: Osteomyelitis, unspecified", "R45851: Suicidal ideations", "E440: Moderate protein-calorie malnutrition", "K7290: Hepatic failure, unspecified without coma", "I110: Hypertensive heart disease with heart failure", "I953: Hypotension of hemodialysis", "L98429: Non-pressure chronic ulcer of back with unspecified severity", "E1169: Type 2 diabetes mellitus with other specified complication", "I50810: Right heart failure, unspecified", "K7581: Nonalcoholic steatohepatitis (NASH)", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "D638: Anemia in other chronic diseases classified elsewhere", "E8359: Other disorders of calcium metabolism", "I2720: Pulmonary hypertension, unspecified", "E785: Hyperlipidemia, unspecified", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "R5383: Other fatigue", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I6522: Occlusion and stenosis of left carotid artery", "I480: Paroxysmal atrial fibrillation", "M109: Gout, unspecified", "B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere", "D539: Nutritional anemia, unspecified", "I071: Rheumatic tricuspid insufficiency", "R410: Disorientation, unspecified", "G4700: Insomnia, unspecified", "F4321: Adjustment disorder with depressed mood", "J383: Other diseases of vocal cords", "M6281: Muscle weakness (generalized)", "Z89422: Acquired absence of other left toe(s)", "Z992: Dependence on renal dialysis", "Z7901: Long term (current) use of anticoagulants", "Z9111: Patient's noncompliance with dietary regimen" ]
10,094,811	20,619,460	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Major Surgical or Invasive Procedure: Diagnostic/therapeutic paracentesis ___ - 8L removed attach Pertinent Results: ADMISSION LABS: ============== ___ 10:30AM BLOOD WBC-9.6 RBC-3.32* Hgb-10.6* Hct-35.0* MCV-105* MCH-31.9 MCHC-30.3* RDW-15.1 RDWSD-58.3* Plt ___ ___ 10:30AM BLOOD Neuts-76.0* Lymphs-9.1* Monos-10.2 Eos-3.5 Baso-0.6 Im ___ AbsNeut-7.32* AbsLymp-0.88* AbsMono-0.98* AbsEos-0.34 AbsBaso-0.06 ___ 04:53PM BLOOD ___ PTT-27.8 ___ ___ 10:30AM BLOOD Glucose-127* UreaN-73* Creat-8.5# Na-144 K-5.8 Cl-94* HCO3-27 AnGap-23* ___ 04:39AM BLOOD ALT-8 AST-16 AlkPhos-272* TotBili-0.8 ___ 04:53PM BLOOD Calcium-9.4 Phos-6.3* Mg-2.0 ___ 04:39AM BLOOD CRP-110.1* ___ 09:51PM BLOOD Digoxin-<0.4* ___ 04:58PM BLOOD ___ pO2-34* pCO2-41 pH-7.40 calTCO2-26 Base XS-0 Comment-GREEN TOP ___ 10:33AM BLOOD Lactate-2.0 K-5.1 MICROBIOLOGY: ============= ___ 12:45PM ASCITES TNC-242* RBC-23* Polys-5* Lymphs-21* ___ Mesothe-2* Macroph-69* Other-3* ___ 12:45PM ASCITES TotPro-3.8 Albumin-1.9 __________________________________________________________ ___ 12:45 pm PERITONEAL FLUID PERITONEAL. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count, if applicable. FLUID CULTURE (Preliminary): ANAEROBIC CULTURE (Preliminary): __________________________________________________________ ___ 2:54 pm SWAB Source: Left ___ Digit Amp Site. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final ___: MIXED BACTERIAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT ___ this culture. STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. RIFAMPIN should not be used alone for therapy. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. __________________________________________________________ ___ 4:53 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 10:30 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. STUDIES: ======== FOOT AP,LAT & OBL LEFTStudy Date of ___ Status post amputation of the third digit, without evidence of osteomyelitis. CT HEAD W/O CONTRASTStudy Date of ___ 1. No acute intracranial hemorrhage. 2. Chronic periventricular white matter disease. Extensive arterial calcifications. CHEST (PORTABLE AP)Study Date of ___ Low lung volumes and AP technique accentuate the bronchovascular markings as well as the cardiac silhouette, but there may be mild to moderate pulmonary vascular congestion. Cardiomegaly. ___ PARACENTESIS DIAG/THERAP W IMAGING GUIDStudy Date of ___ 1. Technically successful ultrasound guided diagnostic and therapeutic paracentesis. 2. 8 L of fluid were removed and sent for analysis. DISCHARGE LABS: ============== ___ 06:21AM BLOOD WBC-10.5* RBC-3.30* Hgb-10.7* Hct-33.2* MCV-101* MCH-32.4* MCHC-32.2 RDW-15.9* RDWSD-58.8* Plt ___ ___ 06:58AM BLOOD ___ PTT-35.7 ___ ___ 06:21AM BLOOD Glucose-161* UreaN-32* Creat-5.8# Na-142 K-5.2 Cl-96 HCO3-22 AnGap-24 ___ 06:58AM BLOOD ALT-10 AST-14 LD(LDH)-196 AlkPhos-219* TotBili-0.5 ___ 06:21AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.___ with h/o ESRD on HD, DM, atrial fibrillation (on apixaban), CHF (EF 37 %), PVD, cirrhosis, who presented after a mechanical fall, found to have presumed L foot osteomyelitis with course c/b multifactorial encephalopathy, acute hypoxic respiratory failure, and new diagnosis of calciphylaxis. TRANSITIONAL ISSUES: ================== [] Monitor need for paracentesis. For future outpatient planned paracenteses, suggest that he hold home apixaban for 2 days prior to procedure without heparin bridge as it is nonsustainable to bridge for each of his frequent paras. [] Planned 6 week course of antibiotics for L foot osteomyelitis with vanc/ceftaz to be given and HD, and PO flagyl. ___, end date ___. [] Needs to follow up with his OSH podiatrist for monitoring of L foot. [] Calciphylaxis: Dermatology recommended - avoidance of calcium, iron supplementation, warfarin use, prednisone, vitamin D and goal to tmaintain goal Ca x P product below 55 mg2/dL. He is on paricalcitol--recommended review by outpatient nephrology team regarding if this is a medication he should continue. [] GDMT for HFrEF: He was started on metoprolol succinate 12.5 mg daily this admission. Transitional issue to consider restarting lisinopril if he is able to tolerate it. [] Ensure he establishes outpatient hepatology care. ACUTE ISSUES =============== #Osteomyelitis Patient with worsening left lower foot ___ digit gangrene and also found to have non-healing ___ digit amputation site from ___ at ___ that probes to bone. CRP elevated 110. Overall highly concerning for osteomyelitis. Podiatry and vascular surgery did not recommend any intervention, given concern for his comorbidities and demonstrated poor wound healing. ID recommended empiric 6 week course of antibiotics with vanc/ceftaz/flagyl for presumed osteomyelitis ___, end date ___. Deep wound culture obtained at bedside grew mixed flora and MRSA. He should follow up with his OSH podiatrist as an outpatient. #Acute Encephalopathy Patient initially became encephalopathic/unresponsive during dialysis from ED, after receiving morphine, which improved with narcan so likely opiate effect. Subsequently he was encephalopathic with asterixis most consistent with hepatic encephalopathy, for which he was treated with lactulose and rifaximin. He did receive paracentesis this admission on ___ but after many days of antibiotics; paracentesis did not show SBP based on cell counts. His mental status was clear by discharge. He was able to tolerate home percocet dosing with clear mental status. #Calciphylaxis Skin lesions on bilateral legs and on penis. Dermatology was consulted and felt it was consistent with calciphylaxis on exam, biopsy deferred. He was started on sodium thiosulfate with dialysis on ___. Dermatology recommended - avoidance of calcium, iron supplementation, warfarin use, prednisone, vitamin D and goal to tmaintain goal Ca x P product below 55 mg2/dL. #Acute Hypoxemic hypercarbic respiratory failure Patient required non-rebreather ___ E.D., which was weaned to NC ___ ICU. Difficulty with pulse oximeter readings may have contributed, given his underlying peripheral artery disease. He was noted to have discrepant O2 sat readings between forehead vs peripheral. Chest Xray notable for possible mild to moderate pulmonary vascular congestion, potentially ___ the setting of having truncated ED HD session. He was stable on RA on the floor. #Ascites #Cirrhosis secondary to heart failure Recent diagnosis of cardiac cirrhosis. Decompensated this admission by ascites and hepatic encephalopathy as above. Started on lactulose and rifaximin this admission. No prior EGD for variceal screening. He has not yet established outpatient hepatology care. He had increasing abdominal distension due to ascites this admission, for which he received ___ diagnostic/therapeutic paracentesis on ___ with 8L removed, no SBP on cell counts (but on abx for some time), and received 50g albumin post para and tolerated it well. Recommend avoiding LVP on HD days given his prior issues with hypotension post LVP. Of note, his home apixaban was held prior to planned paracentesis given concern for bleeding risk with reduced dose apixaban use ___ ESRD and he was bridged with heparin. He was resumed on home apixaban by discharge. For future outpatient planned paracenteses, suggest that he hold homeapixaban for 2 days prior to procedure without heparin bridge as it is nonsustainable to bridge for each of his paras. #Falls Most likely mechanical ___ the setting of significant claudication and peripheral vascular disease, low suspicion for cardiogenic etiology. ___ recommended home with rehab. #Dysphonia Patient had an episode of confusion during HD with significant screaming and shouting. Following this episode, patient reported persistent dysphonia. SLP evaluated patient yesterday and cleared him for a regular diet with thin liquids due to lack of evidence of aspiration. SLP also recommended ORL evaluation of vocal cords to evaluate for trauma following episode of shouting. ENT exam noted minimally retroflexed epiglottis with hypomobile left true vocal fold. Right true vocal fold compensation present with ~2mm glottic gap. No intervention indicated but was scheduled for ENT follow-up for monitoring. CHRONIC ISSUES =============== #Paroxysmal Afib: Continued home digoxin. Home apixaban was held for planned para as above and he was bridged with heparin, then resumed on apixaban post para. #HFrEF Patient with right sided HF, pulmonary HTN, ascites and cardiac cirrhosis. TTE w/ worsening AS (moderate ___ ___, otherwise stable moderate-severe TR with moderate RV hypokinesis, severe pulmonary artery systolic hypertension. Moderate global left ventricular systolic dysfunction w/ EF 37%. Volume status was managed with dialysis. He was restarted on low dose metoprolol this admission. Transitional issue to consider restarting lisinopril if he is able to tolerate it. ___ last admission BB and ACEi were held iso hypotension.) #DM2: last hemoglobin A1C 6.7 on ___. No longer on medications. #HLD: Continued home atorvastatin #Gout: Resumed home allopurinol. #OSA: Declines CPAP at home #CODE STATUS: Full (confirmed) #CONTACT: ___ (wife) ___ >30 minutes spent on complex discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 2.5 mg PO/NG BID 2. Allopurinol ___ mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Digoxin 0.125 mg PO 3X/WEEK (___) 5. Pantoprazole 40 mg PO Q24H 6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 7. paricalcitol 8 mcg oral 3X/WEEK (___) 8. sevelamer CARBONATE 1600 mg PO TID W/MEALS 9. Zolpidem Tartrate 5 mg PO QHS:PRN Insomnia 10. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe 11. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1 Discharge Medications: 1. CefTAZidime 2 g IV POST HD (MO,WE) 2. CefTAZidime 3 g IV POST HD (FR) 3. Collagenase Ointment 1 Appl TP DAILY RX collagenase clostridium histo. [Santyl] 250 unit/gram apply to affected area once a day Refills:0 4. Dakins ___ Strength 1 Appl TP ASDIR RX sodium hypochlorite [Dakin's Solution] 0.25 % apply as directed once a day Refills:0 5. Lactulose 30 mL PO TID RX lactulose 20 gram/30 mL 30 ml by mouth three times a day Disp #1 Bottle Refills:0 6. Metoprolol Succinate XL 12.5 mg PO DAILY RX metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth once a day Disp #15 Tablet Refills:0 7. MetroNIDAZOLE 500 mg PO/NG Q8H RX metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three times a day Disp #98 Tablet Refills:0 8. Nephrocaps 1 CAP PO DAILY RX B complex with C 20-folic acid [Mynephrocaps] 1 mg 1 capsule(s) by mouth once a day Disp #30 Capsule Refills:0 9. rifAXIMin 550 mg PO BID RX rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:*0 10. Sodium Thiosulfate 25 g IV ONCE Duration: 1 Dose 11. ___ MD to order daily dose IV HD PROTOCOL 12. Allopurinol ___ mg PO DAILY 13. Apixaban 2.5 mg PO BID 14. Atorvastatin 40 mg PO QPM 15. Digoxin 0.125 mg PO 3X/WEEK (___) 16. Influenza Vaccine Quadrivalent 0.5 mL IM NOW ___. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe 18. Pantoprazole 40 mg PO Q24H 19. paricalcitol 8 mcg oral 3X/WEEK (___) 20. sevelamer CARBONATE 1600 mg PO TID W/MEALS 21. Zolpidem Tartrate 5 mg PO QHS:PRN Insomnia 22. HELD- Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY This medication was held. Do not restart Isosorbide Mononitrate (Extended Release) until you speak with your cotor. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: L foot osteomyelitis Calciphylaxis Encephalopathy Ascites Hypoxic respiratory failure SECONDARY DIAGNOSIS: Cirrhosis Peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure to care for you at ___ ___. WHY WERE YOU ADMITTED? - You had a fall, then were found to have an infection of your foot, as well as confusion. WHAT HAPPENED ___ THE HOSPITAL? - You were started on treatment with antibiotics for your foot infection, which may involve the bone. You will get IV antibiotics with dialysis. You will also take an oral antibiotic (flagyl). - Your confusion was initially from pain medication effect, and improved with Narcan. Your confusion subsequently was from your liver cirrhosis, for which you were treated with lactulose and rifaximin. - You had painful skin lesions that were diagnosed as "calciphylaxis," which is a disease that occurs due to deposition of calcium ___ the skin and small blood vessels of people on dialysis. You were started on treatment for this (sodium thiosulfate, which you will receive at dialysis). - You had abdominal distension due to accumulation of fluid within your abdomen from cirrhosis, for which you received a paracentesis procedure to remove the fluid. WHAT SHOULD YOU DO AT HOME? - Take your medications as prescribed. - Keep your follow up appointments. We wish you the best, Your ___ team Followup Instructions: ___	[ "E1169", "J9601", "M868X7", "I132", "I5022", "E1152", "I96", "J9811", "B9562", "B9689", "N186", "G92", "T402X5A", "K7290", "I082", "E8359", "G4733", "K7469", "I2722", "K7581", "I953", "R490", "M109", "I6522", "I480", "N4889", "E1122", "E11319", "E785", "Z833", "Z9119", "Z9181", "Z992", "Z89422" ]	Allergies: Penicillins Major Surgical or Invasive Procedure: Diagnostic/therapeutic paracentesis [MASKED] - 8L removed attach Pertinent Results: ADMISSION LABS: ============== [MASKED] 10:30AM BLOOD WBC-9.6 RBC-3.32* Hgb-10.6* Hct-35.0* MCV-105* MCH-31.9 MCHC-30.3* RDW-15.1 RDWSD-58.3* Plt [MASKED] [MASKED] 10:30AM BLOOD Neuts-76.0* Lymphs-9.1* Monos-10.2 Eos-3.5 Baso-0.6 Im [MASKED] AbsNeut-7.32* AbsLymp-0.88* AbsMono-0.98* AbsEos-0.34 AbsBaso-0.06 [MASKED] 04:53PM BLOOD [MASKED] PTT-27.8 [MASKED] [MASKED] 10:30AM BLOOD Glucose-127* UreaN-73* Creat-8.5# Na-144 K-5.8 Cl-94* HCO3-27 AnGap-23* [MASKED] 04:39AM BLOOD ALT-8 AST-16 AlkPhos-272* TotBili-0.8 [MASKED] 04:53PM BLOOD Calcium-9.4 Phos-6.3* Mg-2.0 [MASKED] 04:39AM BLOOD CRP-110.1* [MASKED] 09:51PM BLOOD Digoxin-<0.4* [MASKED] 04:58PM BLOOD [MASKED] pO2-34* pCO2-41 pH-7.40 calTCO2-26 Base XS-0 Comment-GREEN TOP [MASKED] 10:33AM BLOOD Lactate-2.0 K-5.1 MICROBIOLOGY: ============= [MASKED] 12:45PM ASCITES TNC-242* RBC-23* Polys-5* Lymphs-21* [MASKED] Mesothe-2* Macroph-69* Other-3* [MASKED] 12:45PM ASCITES TotPro-3.8 Albumin-1.9 [MASKED] [MASKED] 12:45 pm PERITONEAL FLUID PERITONEAL. GRAM STAIN (Final [MASKED]: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count, if applicable. FLUID CULTURE (Preliminary): ANAEROBIC CULTURE (Preliminary): [MASKED] [MASKED] 2:54 pm SWAB Source: Left [MASKED] Digit Amp Site. GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] PAIRS AND SINGLY. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT [MASKED] this culture. STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. RIFAMPIN should not be used alone for therapy. SENSITIVITIES: MIC expressed [MASKED] MCG/ML [MASKED] STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. [MASKED] [MASKED] 4:53 pm BLOOD CULTURE FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 10:30 am BLOOD CULTURE FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. STUDIES: ======== FOOT AP,LAT & OBL LEFTStudy Date of [MASKED] Status post amputation of the third digit, without evidence of osteomyelitis. CT HEAD W/O CONTRASTStudy Date of [MASKED] 1. No acute intracranial hemorrhage. 2. Chronic periventricular white matter disease. Extensive arterial calcifications. CHEST (PORTABLE AP)Study Date of [MASKED] Low lung volumes and AP technique accentuate the bronchovascular markings as well as the cardiac silhouette, but there may be mild to moderate pulmonary vascular congestion. Cardiomegaly. [MASKED] PARACENTESIS DIAG/THERAP W IMAGING GUIDStudy Date of [MASKED] 1. Technically successful ultrasound guided diagnostic and therapeutic paracentesis. 2. 8 L of fluid were removed and sent for analysis. DISCHARGE LABS: ============== [MASKED] 06:21AM BLOOD WBC-10.5* RBC-3.30* Hgb-10.7* Hct-33.2* MCV-101* MCH-32.4* MCHC-32.2 RDW-15.9* RDWSD-58.8* Plt [MASKED] [MASKED] 06:58AM BLOOD [MASKED] PTT-35.7 [MASKED] [MASKED] 06:21AM BLOOD Glucose-161* UreaN-32* Creat-5.8# Na-142 K-5.2 Cl-96 HCO3-22 AnGap-24 [MASKED] 06:58AM BLOOD ALT-10 AST-14 LD(LDH)-196 AlkPhos-219* TotBili-0.5 [MASKED] 06:21AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.[MASKED] with h/o ESRD on HD, DM, atrial fibrillation (on apixaban), CHF (EF 37 %), PVD, cirrhosis, who presented after a mechanical fall, found to have presumed L foot osteomyelitis with course c/b multifactorial encephalopathy, acute hypoxic respiratory failure, and new diagnosis of calciphylaxis. TRANSITIONAL ISSUES: ================== [] Monitor need for paracentesis. For future outpatient planned paracenteses, suggest that he hold home apixaban for 2 days prior to procedure without heparin bridge as it is nonsustainable to bridge for each of his frequent paras. [] Planned 6 week course of antibiotics for L foot osteomyelitis with vanc/ceftaz to be given and HD, and PO flagyl. [MASKED], end date [MASKED]. [] Needs to follow up with his OSH podiatrist for monitoring of L foot. [] Calciphylaxis: Dermatology recommended - avoidance of calcium, iron supplementation, warfarin use, prednisone, vitamin D and goal to tmaintain goal Ca x P product below 55 mg2/dL. He is on paricalcitol--recommended review by outpatient nephrology team regarding if this is a medication he should continue. [] GDMT for HFrEF: He was started on metoprolol succinate 12.5 mg daily this admission. Transitional issue to consider restarting lisinopril if he is able to tolerate it. [] Ensure he establishes outpatient hepatology care. ACUTE ISSUES =============== #Osteomyelitis Patient with worsening left lower foot [MASKED] digit gangrene and also found to have non-healing [MASKED] digit amputation site from [MASKED] at [MASKED] that probes to bone. CRP elevated 110. Overall highly concerning for osteomyelitis. Podiatry and vascular surgery did not recommend any intervention, given concern for his comorbidities and demonstrated poor wound healing. ID recommended empiric 6 week course of antibiotics with vanc/ceftaz/flagyl for presumed osteomyelitis [MASKED], end date [MASKED]. Deep wound culture obtained at bedside grew mixed flora and MRSA. He should follow up with his OSH podiatrist as an outpatient. #Acute Encephalopathy Patient initially became encephalopathic/unresponsive during dialysis from ED, after receiving morphine, which improved with narcan so likely opiate effect. Subsequently he was encephalopathic with asterixis most consistent with hepatic encephalopathy, for which he was treated with lactulose and rifaximin. He did receive paracentesis this admission on [MASKED] but after many days of antibiotics; paracentesis did not show SBP based on cell counts. His mental status was clear by discharge. He was able to tolerate home percocet dosing with clear mental status. #Calciphylaxis Skin lesions on bilateral legs and on penis. Dermatology was consulted and felt it was consistent with calciphylaxis on exam, biopsy deferred. He was started on sodium thiosulfate with dialysis on [MASKED]. Dermatology recommended - avoidance of calcium, iron supplementation, warfarin use, prednisone, vitamin D and goal to tmaintain goal Ca x P product below 55 mg2/dL. #Acute Hypoxemic hypercarbic respiratory failure Patient required non-rebreather [MASKED] E.D., which was weaned to NC [MASKED] ICU. Difficulty with pulse oximeter readings may have contributed, given his underlying peripheral artery disease. He was noted to have discrepant O2 sat readings between forehead vs peripheral. Chest Xray notable for possible mild to moderate pulmonary vascular congestion, potentially [MASKED] the setting of having truncated ED HD session. He was stable on RA on the floor. #Ascites #Cirrhosis secondary to heart failure Recent diagnosis of cardiac cirrhosis. Decompensated this admission by ascites and hepatic encephalopathy as above. Started on lactulose and rifaximin this admission. No prior EGD for variceal screening. He has not yet established outpatient hepatology care. He had increasing abdominal distension due to ascites this admission, for which he received [MASKED] diagnostic/therapeutic paracentesis on [MASKED] with 8L removed, no SBP on cell counts (but on abx for some time), and received 50g albumin post para and tolerated it well. Recommend avoiding LVP on HD days given his prior issues with hypotension post LVP. Of note, his home apixaban was held prior to planned paracentesis given concern for bleeding risk with reduced dose apixaban use [MASKED] ESRD and he was bridged with heparin. He was resumed on home apixaban by discharge. For future outpatient planned paracenteses, suggest that he hold homeapixaban for 2 days prior to procedure without heparin bridge as it is nonsustainable to bridge for each of his paras. #Falls Most likely mechanical [MASKED] the setting of significant claudication and peripheral vascular disease, low suspicion for cardiogenic etiology. [MASKED] recommended home with rehab. #Dysphonia Patient had an episode of confusion during HD with significant screaming and shouting. Following this episode, patient reported persistent dysphonia. SLP evaluated patient yesterday and cleared him for a regular diet with thin liquids due to lack of evidence of aspiration. SLP also recommended ORL evaluation of vocal cords to evaluate for trauma following episode of shouting. ENT exam noted minimally retroflexed epiglottis with hypomobile left true vocal fold. Right true vocal fold compensation present with ~2mm glottic gap. No intervention indicated but was scheduled for ENT follow-up for monitoring. CHRONIC ISSUES =============== #Paroxysmal Afib: Continued home digoxin. Home apixaban was held for planned para as above and he was bridged with heparin, then resumed on apixaban post para. #HFrEF Patient with right sided HF, pulmonary HTN, ascites and cardiac cirrhosis. TTE w/ worsening AS (moderate [MASKED] [MASKED], otherwise stable moderate-severe TR with moderate RV hypokinesis, severe pulmonary artery systolic hypertension. Moderate global left ventricular systolic dysfunction w/ EF 37%. Volume status was managed with dialysis. He was restarted on low dose metoprolol this admission. Transitional issue to consider restarting lisinopril if he is able to tolerate it. [MASKED] last admission BB and ACEi were held iso hypotension.) #DM2: last hemoglobin A1C 6.7 on [MASKED]. No longer on medications. #HLD: Continued home atorvastatin #Gout: Resumed home allopurinol. #OSA: Declines CPAP at home #CODE STATUS: Full (confirmed) #CONTACT: [MASKED] (wife) [MASKED] >30 minutes spent on complex discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 2.5 mg PO/NG BID 2. Allopurinol [MASKED] mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Digoxin 0.125 mg PO 3X/WEEK ([MASKED]) 5. Pantoprazole 40 mg PO Q24H 6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 7. paricalcitol 8 mcg oral 3X/WEEK ([MASKED]) 8. sevelamer CARBONATE 1600 mg PO TID W/MEALS 9. Zolpidem Tartrate 5 mg PO QHS:PRN Insomnia 10. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe 11. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1 Discharge Medications: 1. CefTAZidime 2 g IV POST HD (MO,WE) 2. CefTAZidime 3 g IV POST HD (FR) 3. Collagenase Ointment 1 Appl TP DAILY RX collagenase clostridium histo. [Santyl] 250 unit/gram apply to affected area once a day Refills:0 4. Dakins [MASKED] Strength 1 Appl TP ASDIR RX sodium hypochlorite [Dakin's Solution] 0.25 % apply as directed once a day Refills:0 5. Lactulose 30 mL PO TID RX lactulose 20 gram/30 mL 30 ml by mouth three times a day Disp #1 Bottle Refills:0 6. Metoprolol Succinate XL 12.5 mg PO DAILY RX metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth once a day Disp #15 Tablet Refills:0 7. MetroNIDAZOLE 500 mg PO/NG Q8H RX metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three times a day Disp #98 Tablet Refills:0 8. Nephrocaps 1 CAP PO DAILY RX B complex with C 20-folic acid [Mynephrocaps] 1 mg 1 capsule(s) by mouth once a day Disp #30 Capsule Refills:0 9. rifAXIMin 550 mg PO BID RX rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:*0 10. Sodium Thiosulfate 25 g IV ONCE Duration: 1 Dose 11. [MASKED] MD to order daily dose IV HD PROTOCOL 12. Allopurinol [MASKED] mg PO DAILY 13. Apixaban 2.5 mg PO BID 14. Atorvastatin 40 mg PO QPM 15. Digoxin 0.125 mg PO 3X/WEEK ([MASKED]) 16. Influenza Vaccine Quadrivalent 0.5 mL IM NOW [MASKED]. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe 18. Pantoprazole 40 mg PO Q24H 19. paricalcitol 8 mcg oral 3X/WEEK ([MASKED]) 20. sevelamer CARBONATE 1600 mg PO TID W/MEALS 21. Zolpidem Tartrate 5 mg PO QHS:PRN Insomnia 22. HELD- Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY This medication was held. Do not restart Isosorbide Mononitrate (Extended Release) until you speak with your cotor. Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: L foot osteomyelitis Calciphylaxis Encephalopathy Ascites Hypoxic respiratory failure SECONDARY DIAGNOSIS: Cirrhosis Peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], It was a pleasure to care for you at [MASKED] [MASKED]. WHY WERE YOU ADMITTED? - You had a fall, then were found to have an infection of your foot, as well as confusion. WHAT HAPPENED [MASKED] THE HOSPITAL? - You were started on treatment with antibiotics for your foot infection, which may involve the bone. You will get IV antibiotics with dialysis. You will also take an oral antibiotic (flagyl). - Your confusion was initially from pain medication effect, and improved with Narcan. Your confusion subsequently was from your liver cirrhosis, for which you were treated with lactulose and rifaximin. - You had painful skin lesions that were diagnosed as "calciphylaxis," which is a disease that occurs due to deposition of calcium [MASKED] the skin and small blood vessels of people on dialysis. You were started on treatment for this (sodium thiosulfate, which you will receive at dialysis). - You had abdominal distension due to accumulation of fluid within your abdomen from cirrhosis, for which you received a paracentesis procedure to remove the fluid. WHAT SHOULD YOU DO AT HOME? - Take your medications as prescribed. - Keep your follow up appointments. We wish you the best, Your [MASKED] team Followup Instructions: [MASKED]	[]	[ "J9601", "G4733", "M109", "I480", "E1122", "E785" ]	[ "E1169: Type 2 diabetes mellitus with other specified complication", "J9601: Acute respiratory failure with hypoxia", "M868X7: Other osteomyelitis, ankle and foot", "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", "E1152: Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene", "I96: Gangrene, not elsewhere classified", "J9811: Atelectasis", "B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "N186: End stage renal disease", "G92: Toxic encephalopathy", "T402X5A: Adverse effect of other opioids, initial encounter", "K7290: Hepatic failure, unspecified without coma", "I082: Rheumatic disorders of both aortic and tricuspid valves", "E8359: Other disorders of calcium metabolism", "G4733: Obstructive sleep apnea (adult) (pediatric)", "K7469: Other cirrhosis of liver", "I2722: Pulmonary hypertension due to left heart disease", "K7581: Nonalcoholic steatohepatitis (NASH)", "I953: Hypotension of hemodialysis", "R490: Dysphonia", "M109: Gout, unspecified", "I6522: Occlusion and stenosis of left carotid artery", "I480: Paroxysmal atrial fibrillation", "N4889: Other specified disorders of penis", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E785: Hyperlipidemia, unspecified", "Z833: Family history of diabetes mellitus", "Z9119: Patient's noncompliance with other medical treatment and regimen", "Z9181: History of falling", "Z992: Dependence on renal dialysis", "Z89422: Acquired absence of other left toe(s)" ]
10,094,811	24,077,193	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Atrial flutter Major Surgical or Invasive Procedure: ___ Laparoscopic repositioning of peritoneal dialysis catheter. History of Present Illness: Mr. ___ is a ___ hx of DM complicated by nephropathy, neuropathy, retinopathy, HTN, HLD, gout, HFpEF, and ESRD recently initiated on HD, and with PD catheter placed in ___ who had elective repositioning of his PD catheter today, but had new onset of atrial flutter in the PACU. Per patient, he has a history of atrial fibrillation on and off over the years, but has never been told he has atrial flutter. He reports seeing a cardiologist about this a while ago, and he was told he was "fine" at the time. He takes labetalol 300 mg PO BID for hypertension, and is not on anticoagulation at home. EKG in PACU with Flutter and HRs in 40-60s. He was asymptomatic and hemodynamically stable. Upon arrival to the floor, the patient does not have any symptoms or concerns. He denies chest pain, shortness of breath, and palpitations. Review of Systems: (+) per HPI (-) otherwise Past Medical History: Diabetes x ___ yrs (on insulin, non compliant with glucose monitoring) Bell's palsy (on the right) approx ___ yrs ago Migraine headaches-remote past, last was a few yrs ago HTN Cervical disc disease Right shoulder injury s/p surgery High cholesterol Social History: ___ Family History: He notes his father had diabetes and died from complications of diabetes at age ___ including end-stage renal disease. His grandfather also had diabetes and died at age ___ also of complications from diabetes. His mother died in her ___ and most likely due to osteosarcoma. He has two brothers, one of whom has medication controlled diabetes and one of whom does not have diabetes. He has one sister who had gestational diabetes as well as diabetes that seems to have resolved after gastric bypass. He has two biological daughters, aged ___ and ___, who he believes are healthy. He has one adopted son, age ___, who he believes is healthy. Physical Exam: Admission exam: =============== Vitals- 97.8, BP 130 / 75, HR 53, RR 18, O2 98 Ra GENERAL: AOx3, NAD HEENT: Normocephalic, atraumatic. PERRL NECK: No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. No JVD. LUNGS: Clear to auscultation bilaterally, no wheezes ABDOMEN: Laparotomy sites are bandaged. EXTREMITIES: No clubbing, cyanosis, but trace edema. Venous stasis changes bilaterally SKIN: No facial rashes NEUROLOGIC: CN2-12 intact. Gait is normal Discharge exam: =============== Vitals- 98.0, 140-160/60-80, 50-70, 18, 96% RA GENERAL: AOx3, NAD HEENT: Normocephalic, atraumatic. PERRL NECK: No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. No JVD. LUNGS: Clear to auscultation bilaterally, no wheezes ABDOMEN: Laparotomy sites are bandaged. EXTREMITIES: No clubbing, cyanosis, but trace edema. Venous stasis changes bilaterally SKIN: No facial rashes NEUROLOGIC: CN2-12 intact. Gait is normal Pertinent Results: Admission labs: =============== ___ 12:29PM BLOOD WBC-8.0 RBC-3.98* Hgb-11.9# Hct-34.3 MCV-86 MCH-29.9# MCHC-34.7# RDW-15.5 RDWSD-48.8* Plt ___ ___ 12:50AM BLOOD PTT-74.9* ___ 12:20PM BLOOD Glucose-174* UreaN-44* Creat-4.9* Na-131* K-5.4* Cl-96 HCO3-23 AnGap-17 ___ 12:20PM BLOOD Calcium-8.9 Phos-6.9* Mg-1.9 Discharge labs: =============== ___ 07:00AM BLOOD WBC-6.4 RBC-4.30* Hgb-12.7* Hct-38.5* MCV-90 MCH-29.5 MCHC-33.0 RDW-15.8* RDWSD-51.7* Plt ___ ___ 07:00AM BLOOD Glucose-119* UreaN-33* Creat-4.9* Na-139 K-4.5 Cl-99 HCO3-26 AnGap-19 ___ 07:00AM BLOOD ___ PTT-86.2* ___ ___ 07:00AM BLOOD Calcium-9.0 Phos-5.1* Mg-2.0 ___ 12:29PM BLOOD CK-MB-3 cTropnT-0.03* Imaging: ======== KUB ___ Peritoneal catheter tip lies in the left lower quadrant. Brief Hospital Course: Mr. ___ is a ___ hx of DM complicated by nephropathy, neuropathy, retinopathy, HTN, HLD, gout, HFpEF, and ESRD recently initiated on HD, and with PD catheter placed in ___ who had elective repositioning of his PD catheter today, but had new onset of atrial flutter in the PACU. #Atrial flutter: Patient with 4:1 aflutter in PACU, and unclear history of past atrial fibrillation (paroxysmal atrial fibrillation documented in At___ records, no evidence of evaluation). He was asymptomatic and hemodynamically stable. He takes labetalol 300 mg BID for hypertension, which should also help for nodal blockade. He was started on a heparin drip and warfarin 5 mg x1, warfarin 2.5mg x1, with the plan to continue warfarin alone on discharge. Given the risk of bleeding and timing of outpatient follow-up, patient will be discharged on warfarin 2.5mg PO daily. After a lot of discussion, the family did not want to continue bridging with heparin. Aspirin was stopped to reduce bleeding risk. He will follow-up with At___ Cardiology in ___ weeks to discuss cardioversion vs ablation. #ESRD: Patient recently initiated on HD (M,T,Th,Fr), and will be transitioning to PD once catheter is appropriate. Admitted for PD catheter reposition, and the procedure went well. He will see the transplant surgery team in follow-up. He had HD on ___ and ___ prior to discharge. #Hyperkalemia: His K was 6.2 after leaving the PACU, with EKG showing peaked T-waves. He received calcium gluconate, insulin, and dextrose. Repeat K was normal Chronic Issues: #HFpEF: Not on diuretics at home. Received HD on ___ and ___ #DM2: Patient reports he was recently taken off insulin because his A1C was < 8. #HTN: Held home amlodipine as normotensive #HLD: Not on statin. Stopped home aspirin to reduce bleeding risk #Gout: Continued home allopurinol Transitional Issues: - STOPPED home aspirin 81 mg daily to reduce bleeding risk - STARTED warfarin 2.5 mg daily - INR to be followed as an outpatient with PCP #Code: Full #Contact: ___ (Wife, HCP) ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. sevelamer CARBONATE 1600 mg PO TID W/MEALS 5. Lisinopril 40 mg PO DAILY 6. Labetalol 300 mg PO BID Discharge Medications: 1. Warfarin 2.5 mg PO DAILY16 RX warfarin 2.5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 2. Allopurinol ___ mg PO DAILY 3. amLODIPine 10 mg PO DAILY 4. Labetalol 300 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. sevelamer CARBONATE 1600 mg PO TID W/MEALS Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - Atrial flutter - End stage renal disease on hemodialysis - Hyperkalemia Secondary diagnosis: - Heart failure with preserved ejection fraction - Diabetes mellitus type 2 - Hypertension - Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted due to a heart rhythm disorder, called atrial flutter, after a procedure for PD catheter repositioning. You were monitored overnight and had no complications. After discussion with the Cardiology team, we decided to start you on a blood thinner called Warfarin. You should follow-up with your primary care physician and the cardiologists for further management. It was a pleasure to take care of you. Sincerely, Your ___ team Followup Instructions: ___	[ "T85621A", "Y831", "Y929", "I4892", "E1122", "I132", "I5032", "N186", "Z992", "E875", "E1121", "E1140", "E11319", "E785", "M1A9XX0", "Z7901", "R51", "D631", "I272", "E669", "Z6830" ]	Allergies: Penicillins Chief Complaint: Atrial flutter Major Surgical or Invasive Procedure: [MASKED] Laparoscopic repositioning of peritoneal dialysis catheter. History of Present Illness: Mr. [MASKED] is a [MASKED] hx of DM complicated by nephropathy, neuropathy, retinopathy, HTN, HLD, gout, HFpEF, and ESRD recently initiated on HD, and with PD catheter placed in [MASKED] who had elective repositioning of his PD catheter today, but had new onset of atrial flutter in the PACU. Per patient, he has a history of atrial fibrillation on and off over the years, but has never been told he has atrial flutter. He reports seeing a cardiologist about this a while ago, and he was told he was "fine" at the time. He takes labetalol 300 mg PO BID for hypertension, and is not on anticoagulation at home. EKG in PACU with Flutter and HRs in 40-60s. He was asymptomatic and hemodynamically stable. Upon arrival to the floor, the patient does not have any symptoms or concerns. He denies chest pain, shortness of breath, and palpitations. Review of Systems: (+) per HPI (-) otherwise Past Medical History: Diabetes x [MASKED] yrs (on insulin, non compliant with glucose monitoring) Bell's palsy (on the right) approx [MASKED] yrs ago Migraine headaches-remote past, last was a few yrs ago HTN Cervical disc disease Right shoulder injury s/p surgery High cholesterol Social History: [MASKED] Family History: He notes his father had diabetes and died from complications of diabetes at age [MASKED] including end-stage renal disease. His grandfather also had diabetes and died at age [MASKED] also of complications from diabetes. His mother died in her [MASKED] and most likely due to osteosarcoma. He has two brothers, one of whom has medication controlled diabetes and one of whom does not have diabetes. He has one sister who had gestational diabetes as well as diabetes that seems to have resolved after gastric bypass. He has two biological daughters, aged [MASKED] and [MASKED], who he believes are healthy. He has one adopted son, age [MASKED], who he believes is healthy. Physical Exam: Admission exam: =============== Vitals- 97.8, BP 130 / 75, HR 53, RR 18, O2 98 Ra GENERAL: AOx3, NAD HEENT: Normocephalic, atraumatic. PERRL NECK: No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. No JVD. LUNGS: Clear to auscultation bilaterally, no wheezes ABDOMEN: Laparotomy sites are bandaged. EXTREMITIES: No clubbing, cyanosis, but trace edema. Venous stasis changes bilaterally SKIN: No facial rashes NEUROLOGIC: CN2-12 intact. Gait is normal Discharge exam: =============== Vitals- 98.0, 140-160/60-80, 50-70, 18, 96% RA GENERAL: AOx3, NAD HEENT: Normocephalic, atraumatic. PERRL NECK: No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. No JVD. LUNGS: Clear to auscultation bilaterally, no wheezes ABDOMEN: Laparotomy sites are bandaged. EXTREMITIES: No clubbing, cyanosis, but trace edema. Venous stasis changes bilaterally SKIN: No facial rashes NEUROLOGIC: CN2-12 intact. Gait is normal Pertinent Results: Admission labs: =============== [MASKED] 12:29PM BLOOD WBC-8.0 RBC-3.98* Hgb-11.9# Hct-34.3 MCV-86 MCH-29.9# MCHC-34.7# RDW-15.5 RDWSD-48.8* Plt [MASKED] [MASKED] 12:50AM BLOOD PTT-74.9* [MASKED] 12:20PM BLOOD Glucose-174* UreaN-44* Creat-4.9* Na-131* K-5.4* Cl-96 HCO3-23 AnGap-17 [MASKED] 12:20PM BLOOD Calcium-8.9 Phos-6.9* Mg-1.9 Discharge labs: =============== [MASKED] 07:00AM BLOOD WBC-6.4 RBC-4.30* Hgb-12.7* Hct-38.5* MCV-90 MCH-29.5 MCHC-33.0 RDW-15.8* RDWSD-51.7* Plt [MASKED] [MASKED] 07:00AM BLOOD Glucose-119* UreaN-33* Creat-4.9* Na-139 K-4.5 Cl-99 HCO3-26 AnGap-19 [MASKED] 07:00AM BLOOD [MASKED] PTT-86.2* [MASKED] [MASKED] 07:00AM BLOOD Calcium-9.0 Phos-5.1* Mg-2.0 [MASKED] 12:29PM BLOOD CK-MB-3 cTropnT-0.03* Imaging: ======== KUB [MASKED] Peritoneal catheter tip lies in the left lower quadrant. Brief Hospital Course: Mr. [MASKED] is a [MASKED] hx of DM complicated by nephropathy, neuropathy, retinopathy, HTN, HLD, gout, HFpEF, and ESRD recently initiated on HD, and with PD catheter placed in [MASKED] who had elective repositioning of his PD catheter today, but had new onset of atrial flutter in the PACU. #Atrial flutter: Patient with 4:1 aflutter in PACU, and unclear history of past atrial fibrillation (paroxysmal atrial fibrillation documented in At records, no evidence of evaluation). He was asymptomatic and hemodynamically stable. He takes labetalol 300 mg BID for hypertension, which should also help for nodal blockade. He was started on a heparin drip and warfarin 5 mg x1, warfarin 2.5mg x1, with the plan to continue warfarin alone on discharge. Given the risk of bleeding and timing of outpatient follow-up, patient will be discharged on warfarin 2.5mg PO daily. After a lot of discussion, the family did not want to continue bridging with heparin. Aspirin was stopped to reduce bleeding risk. He will follow-up with At Cardiology in [MASKED] weeks to discuss cardioversion vs ablation. #ESRD: Patient recently initiated on HD (M,T,Th,Fr), and will be transitioning to PD once catheter is appropriate. Admitted for PD catheter reposition, and the procedure went well. He will see the transplant surgery team in follow-up. He had HD on [MASKED] and [MASKED] prior to discharge. #Hyperkalemia: His K was 6.2 after leaving the PACU, with EKG showing peaked T-waves. He received calcium gluconate, insulin, and dextrose. Repeat K was normal Chronic Issues: #HFpEF: Not on diuretics at home. Received HD on [MASKED] and [MASKED] #DM2: Patient reports he was recently taken off insulin because his A1C was < 8. #HTN: Held home amlodipine as normotensive #HLD: Not on statin. Stopped home aspirin to reduce bleeding risk #Gout: Continued home allopurinol Transitional Issues: - STOPPED home aspirin 81 mg daily to reduce bleeding risk - STARTED warfarin 2.5 mg daily - INR to be followed as an outpatient with PCP #Code: Full #Contact: [MASKED] (Wife, HCP) [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. sevelamer CARBONATE 1600 mg PO TID W/MEALS 5. Lisinopril 40 mg PO DAILY 6. Labetalol 300 mg PO BID Discharge Medications: 1. Warfarin 2.5 mg PO DAILY16 RX warfarin 2.5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 2. Allopurinol [MASKED] mg PO DAILY 3. amLODIPine 10 mg PO DAILY 4. Labetalol 300 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. sevelamer CARBONATE 1600 mg PO TID W/MEALS Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - Atrial flutter - End stage renal disease on hemodialysis - Hyperkalemia Secondary diagnosis: - Heart failure with preserved ejection fraction - Diabetes mellitus type 2 - 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 were admitted due to a heart rhythm disorder, called atrial flutter, after a procedure for PD catheter repositioning. You were monitored overnight and had no complications. After discussion with the Cardiology team, we decided to start you on a blood thinner called Warfarin. You should follow-up with your primary care physician and the cardiologists for further management. It was a pleasure to take care of you. Sincerely, Your [MASKED] team Followup Instructions: [MASKED]	[]	[ "Y929", "E1122", "I5032", "E785", "Z7901", "E669" ]	[ "T85621A: Displacement of intraperitoneal dialysis catheter, initial encounter", "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", "Y929: Unspecified place or not applicable", "I4892: Unspecified atrial flutter", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "I5032: Chronic diastolic (congestive) heart failure", "N186: End stage renal disease", "Z992: Dependence on renal dialysis", "E875: Hyperkalemia", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E785: Hyperlipidemia, unspecified", "M1A9XX0: Chronic gout, unspecified, without tophus (tophi)", "Z7901: Long term (current) use of anticoagulants", "R51: Headache", "D631: Anemia in chronic kidney disease", "I272: Other secondary pulmonary hypertension", "E669: Obesity, unspecified", "Z6830: Body mass index [BMI]30.0-30.9, adult" ]
10,094,811	28,336,192	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a ___ with PMH ESRD on HD, HTN, DM c/b retinopathy, HLD, AF not on AC, pHTN, OSA on CPAP, CHF, PVD sent in from HD d/t inability to access LUE AVF with c/f AVF clot. The patient's last HD was ___, where clotting was noted in his HD tubing. He has generalized malaise, most prominent complaint is abdominal swelling and nausea with dry heaves without abdominal pain. He notes he has had diarrhea over last month as well. Additionally, on ROS, he notes his dyspnea on exertion is worse than his baseline and he endorses a dry cough. No fevers, chest pain, heart palpitations. At baseline he is oliguric, he has no dysuria or frequency/change in urine quality. He also endorses worsening BLE claudication pain. He is without sick contacts. Only recent travel to ___ (___). Notably, he was admitted at ___ where had cardiac cath not showing significant CAD as well as a therapeutic paracentesis removing 7L. He is due for BI Hepatology appt tomorrow. ED EXAM ___: irregular. JVP elevated at 30deg PULM: crackles diffusely/at bases (lying down) ABD: soft, NT, very distended with +fluid wave EXTR: WWP, 2+ pitting edema, ___ changes. AVF without bruit/thrill. MDM: #Malfunctioning AVF In the ED, initial vitals were: 96.37, 52, 127/76, 20, 94% on RA Exam notable for: elevated JVP, diffuse crackles at lung bases, positive fluid wave with notably distended abdomen, 2+pitting edema in ___. AVF without bruit/thrill Labs notable for: K 5.7, Cr 10.2, Gap 21, Ca 8.1, Phos 10.8, Alk phos 229. H&H 10.1/31.6, Trop .17, ___ 12.4, PTT 28.8, INR 1.1 Imaging was notable for: CXR Mild basilar atelectasis is seen. There is no focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. No pulmonary edema is seen. Evidence of DISH is seen along the thoracic spine. Patient was given: Lorazepam 1mg, For HyperK: Calcium gluconate 2gm, Insulin 10 units, dextrose. Isosorbide mononitrate 30mg, labetalol 200mg, clonidine 0.2mg, Allopurinol, ___, Lisinopril 40mg, Torsemide 100mg, Metoprolol Tartrate 25mg, Digoxin 0.125mg Consults: ___ for fistulagram (scheduled), transplant surgery Past Medical History: Diabetes x ___ yrs (on insulin, non compliant with glucose monitoring) Bell's palsy (on the right) approx ___ yrs ago Migraine headaches-remote past, last was a few yrs ago HTN Cervical disc disease Right shoulder injury s/p surgery High cholesterol Social History: ___ Family History: He notes his father had diabetes and died from complications of diabetes at age ___ including end-stage renal disease. His grandfather also had diabetes and died at age ___ also of complications from diabetes. His mother died in her ___ and most likely due to osteosarcoma. He has two brothers, one of whom has medication controlled diabetes and one of whom does not have diabetes. He has one sister who had gestational diabetes as well as diabetes that seems to have resolved after gastric bypass. He has two biological daughters, aged ___ and ___, who he believes are healthy. He has one adopted son, age ___, who he believes is healthy. Physical Exam: ADMISSION PHYSICAL VS: 97.6, 67, 103/47, 18, 97% 2L GENERAL: fatigued, NAD HEENT: NCAT, PERRL, MMM NECK: JVD elevated at 11cm CARDIAC: irregularly irregular, no murmurs appreciated LUNGS: clear to auscultation bilaterally ABDOMEN: distended with striae and +fluid wave EXTREMITIES: chronic venous-stasis changes in ___, 2+ edema NEUROLOGIC: CN II-XII grossly intact. Sensation grossly intact SKIN: Chronic venous stasis changes in BLE Discharge Physical GENERAL: Fatigued appearing male in NAD HEENT: PERRLA, EOMI, sclerae incicteric, MMM. CARDIAC: Irregularly irregular, no murmurs appreciated LUNGS: Clear to auscultation bilaterally ABDOMEN: Soft, non-tender, mildly distended. EXTREMITIES: chronic venous-stasis changes in ___, non pitting peripheral edema NEUROLOGIC: R CN VII deficit. Otherwise A&O x3. Strength in tact in all 4 extremities. SKIN: Chronic venous stasis changes in BLE Pertinent Results: ADMISSION LABS ___ 07:35AM BLOOD WBC-8.2 RBC-3.07* Hgb-10.1* Hct-31.6* MCV-103* MCH-32.9* MCHC-32.0 RDW-15.4 RDWSD-56.8* Plt ___ ___ 07:35AM BLOOD Neuts-78.1* Lymphs-6.7* Monos-11.5 Eos-2.5 Baso-0.6 Im ___ AbsNeut-6.37* AbsLymp-0.55* AbsMono-0.94* AbsEos-0.20 AbsBaso-0.05 ___ 09:30AM BLOOD ___ PTT-28.8 ___ ___ 07:35AM BLOOD Glucose-160* UreaN-99* Creat-10.2* Na-144 K-5.7* Cl-100 HCO3-23 AnGap-21* ___ 07:35AM BLOOD ALT-11 AST-11 LD(LDH)-208 AlkPhos-229* TotBili-0.6 ___ 07:35AM BLOOD CK-MB-8 proBNP->70000 ___ 07:35AM BLOOD Albumin-3.6 Calcium-8.1* Phos-10.8* Mg-2.1 ___ 09:29PM BLOOD ___ pO2-72* pCO2-30* pH-7.22* calTCO2-13* Base XS--14 Comment-GREEN TOP ___ 09:29PM BLOOD Lactate-4.5* ___ 11:11PM BLOOD Lactate-4.8* MICRO Blood Culture ___ - Pending IMAGING/Testing/Other ___ Carotid series complete results available at ___ ___ Paracentesis: IMPRESSION: 1. Technically successful ultrasound guided therapeutic paracentesis. 2. 3 L of fluid were removed. Art extr ___ FINDINGS: Noncompressible right brachial artery, and left-sided fistula thus at upper extremity blood pressure cannot be determined. On the right-side, triphasic Doppler waveforms were seen at the right common femoral, monophasic superficial femoral, popliteal, posterior tibial, and dorsalis pedis arteries. The right ABI was indeterminate due to noncompressible distal vessels. Toe pressure was 64 mm Hg, TBI could not be calculated due to noncompressible right brachial artery. Pulse volume recordings demonstrate moderately abnormal waveforms in the thigh, calf, ankle, severely abnormal at the metatarsal and digit. On the left-side, triphasic Doppler waveforms were seen at the left femoral, popliteal arteries, and monophasic posterior tibial, and dorsalis pedis arteries. The left ABI was indeterminate due to noncompressible distal vessels. Toe pressure was 76 mm Hg, within indeterminate TBI due to noncompressible right brachial artery. Pulse volume recordings demonstrate mild to moderately abnormal waveform in the thigh, moderately abnormal at the calf and ankle, severely abnormal at the metatarsal and moderately abnormal at the digit. IMPRESSION: Limited interpretation of study as unable to determine upper extremity blood pressure. Doppler pulse volume recordings suggest bilateral obstructive arterial disease, most significant distally. CXR ___ No pneumonia or acute cardiopulmonary process. MR ___ ___. Study is degraded by motion. 2. No acute intracranial abnormality, no definite evidence of acute infarct. 3. Global volume loss and probable microangiopathic changes as described. CT ___ and Neck ___ CT ___: There is scattered focal hypodensities in the cerebellar cortex (2:6), left frontal cortex (2:20), right frontal cortex (2:24) and right parietal cortex (2:20), that may represent areas of small prior ischemic infarcts. No evidence of acute infarction, edema, hemorrhage or mass. The ventricles and sulci are prominent, likely related to involutional change. There is no gross evidence of acute fracture. Partial opacification of the ethmoid air cells and mucosal thickening of the left maxillary sinus. There are mucous retention cysts in the right maxillary sinus. The middle air cavities are unremarkable. The visualized portion of the orbits are unremarkable. CTA neck: Streak artifact limits evaluation of bilateral vertebral artery origin. Traditional 3 vessel takeoff. Mild calcification at the level of the aortic arch. Moderate to severe calcification at the level of the carotid bifurcation. Per NASCET criteria, there is approximately 50% occlusion at the right and left bifurcations. Beaded nonocclusive narrowing of bilateral cervical ICAs are noted, concerning for fibromuscular dysplasia. Otherwise, CT angiography of the neck shows carotid and vertebral arteries without occlusion or dissection. CTA ___: Extensive nonocclusive calcification at the level of the carotid siphons and moderate calcification of the left vertebral artery, V4 segment. CT angiography of the ___ shows normal appearance of the arteries of the anterior and posterior circulation without occlusion or aneurysm greater than 3 mm in size. Major dural venous sinuses are patent. OTHER: On limited imaging of the lungs, probable left upper lobe granuloma (see 4:2). There is 1 centimeter mediastinal lymph node (4:14). Additional scattered subcentimeter nonspecific lymph nodes are noted throughout the mediastinum and neck bilaterally. The thyroid is grossly unremarkable. Multilevel degenerative changes with moderate canal narrowing at the level of the C4-C5, at the level of the previous ACDF. CT PERFUSION images are non-diagnostic. TTE ___ The left atrial volume index is mildly increased. The right atrium is markedly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is >15mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is moderate global left ventricular hypokinesis. Quantitative biplane left ventricular ejection fraction is 37 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18 mmHg). There is echocardiographic evidence for diastolic dysfunction (grade indeterminate). Moderately dilated right ventricular cavity with moderate global free wall hypokinesis. Tricuspid annular plane systolic excursion (TAPSE) is depressed. Intrinsic right ventricular systolic function is likely lower due to the severity of tricuspid regurgitation. The aortic sinus diameter is normal for gender with mildly dilated ascending aorta. The aortic arch diameter is normal with a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets are severely thickened. There is moderate aortic valve stenosis (valve area 1.0-1.5 cm2). There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is an eccentric jet of mild [1+] mitral regurgitation. Due to the Coanda effect, the severity of mitral regurgitation could be UNDERestimated. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is moderate to severe [3+] tricuspid regurgitation. There is SEVERE pulmonary artery systolic hypertension. In the setting of at least moderate to severe tricuspid regurgitation, the pulmonary artery systolic pressure may be UNDERestimated. There is a small pericardial effusion. Ascites is seen. IMPRESSION: Moderate aortic stenosis. Moderate-severe tricuspid regurgitation with moderate right ventricular hypokinesis. Severe pulmonary artery systolic hypertension. Moderate global left ventricular systolic dysfunction. Mildly dilatd ascending aorta. Compared with the prior TTE (images reviewed) of ___ , the aortic stenosis is now moderate (higher velocity across aortic valve is likely a combination of worsening aortic stenosis and increased flow across the valve from fistula patency). The estimated PA pressure is lower on the current study, though this is difficult to interpret in the setting of worsening tricuspid regurgitation. CT Abd/Pelvis w/o Contrast ___. Moderate volume ascites without findings to suggest hemoperitoneum. No abdominal wall or retroperitoneal hematoma. 2. Mild diffuse anasarca suggestive of volume overload. 3. Mild cardiomegaly. 4. Symmetric soft tissue calcifications within the region of the gluteal folds/ischiorectal fossae are nonspecific. 5. Numerous pulmonary nodules measuring up to 3 mm. Consider follow-up as per ___ guidelines below. RECOMMENDATION(S): For incidentally detected multiple solid pulmonary nodules smaller than 6mm, no CT follow-up is recommended in a low-risk patient, and an optional CT follow-up in 12 months is recommended in a high-risk patient. CXR ___ No acute cardiopulmonary process. RUQUS ___. Cirrhotic liver morphology, moderate volume ascites. 2. Patent portal system with bidirectional flow. Brief Hospital Course: Mr. ___ is a ___ year old man with ESRD, OSA non-adherent to CPAP, peripheral vascular disease and recently diagnosed cardiac ascites in the setting of longstanding pulmonary hypertension/RV dysfunction who was admitted ___ for a clotted AVF and subsequently developed hypotension on the medical floor after LVP. The patient was stabilized quickly in the MICU, however, he then had acute onset right facial droop and dysarthria/aphasia x 2 prompting code-stroke (CTA negative, MRI negative) which resolved within 15 minutes now with normal mental status. He was transferred to cardiology for further management of his volume overload and CHF where his volume status was treated with paracentesis as well as hemodialysis. He was discharged on apixaban. TRANSITIONAL ISSUES: [] Patient with significant pulmonary HTN leading to Right sided failure, consider optimial management, especially strategies for prevention of hospitalizations. [] Patient on many antihypertensives that were held in setting of hypotension, consider if necessary and optimize therapy [] Recently started on apixaban. Please follow up for if this is necessary and if patient is tolerating well without bleeding [] please check hemoglobin within 1 week to ensure not bleeding on apixaban [] Patient will need detailed outpatient workup for heart failure and consolidation of medication regimen; please consider cardiac catheterization at some point in the future [] Patient with PVD and multiple wounds, ABIs difficult given fistula. Please consider MR time of flight studies and continued vascular follow up [] please attend to wounds on right thigh and left foot [] Patient with carotid stenosis, so continue to follow up for symptoms [] Avoid prolonged hypotension which may result in watershed infarcts. [] Patient ultrasound with cirrhotic liver morphology, moderate volume ascites, and portal system with bidirectional flow. Need evaluation of if this is cardiac etiology vs simultaneous liver pathology [] continue to assess need for paracenteses [] If patient does not tolerate Apixaban due to excessive bleeding, then he should be switched back to ASA [] assess need for CPAP [] please check A1c and treat for diabetes, pt did not receive insulin while inpatient [] A follow up appointment has been set up in two weeks with Dr. ___ with vascular surgery [] Patient intermittently complaining of narrowed stool, evaluation and age appropriate cancer screening is advised (consider possible colonoscopy if indicated) ACUTE ISSUES: #RH Failure #HFrEF #Cardiac cirrhosis Patient with right sided HF, pulmonary HTN, elevated proBNP, ascites and cirrhotic appearance of liver on CT and US with preserved synthetic function. TTE w/ worsening AS (now moderate), otherwise stable moderate-severe TR with moderate RV hypokinesis, severe pulmonary artery systolic hypertension. Moderate global left ventricular systolic dysfunction w/ EF 37%. Volume status was managed with hemodialysis. Afterload agents were discontinued besides imdur given hypotension. #Symptomatic Carotid Stenosis Noted right facial droop on ___. s/p code stroke ___ at 10:22AM but did not received TPA as likely hypoperfusion in setting of left carotid stenosis and low pressures. Given underlying atrial fibrillation, unclear if patient had embolic phenomenon. Apixaban started for atrial fibrillation and for secondary stroke prevention. Started apixaban 2.5 BID and discontinued ASA. Continued atorvostatin. CTA neck with 50% occlusion at the level of the bifurcations despite inconclusive carotid US results so patient likely with carotid atherosclerosis. #Paroxysmal Afib Not on anticoagulation due recurrent bleeding in the past. His home beta blockers were held in the setting of hypotension. He was continued on digoxin and started on apixaban as above. #Clotted AV Fistula #ESRD on HD #Hyperkalemia - Resolved Pt with left brachiocephalic AV fistula placed ___. Presented to ED with clotted fistula now s/p ___ intervention. Continued HD until dry per renal recommendations Was able to be taken off of midodrine with stable BPs. Continued sevelamer CARBONATE 1600 mg PO TID W/MEALS #Hypotension Acute onset hypotension after paracenteses, initially confounded with 3u Hgb drop, however felt to be ___ fluid shifts iso poor vascular tone. Home hypertensives held in that setting. Resolved with midodrine which was weaned. #Toxic Metabolic Encephalopathy Potentially grade 1 hepatic encephalopathy given evidence of cirrhotic liver on abdominal ultrasound and CT abdomen. Also could have been in setting of procedural sedation after AV declotting. Encephalopathy resolved soon after transfer to the MICU. Did well on floor off lactulose #Left Toe Amputation #PVD S/p left toe amputation recently at ___. Site appears warm with some drainage. Evaluated by podiatry who recommend ABI during inpatient stay. ABI was non-interpretable so will need repeat. Will need vascular follow-up CHRONIC ISSUES: #Pulmonary HTN WHO group 2 pulmonary venous hypertension. Followed in pulmonary hypertension clinic, last evaluated ___ and missed recent appointment. RHC ___ with RAp 19, PAWp 28, v-waves to 38 on recent catheterization (___) and elevated left and right heart filling pressures. Patient is managed as an outpatient. #DM2 #Diabetic retinopathy Last A1c was 8.6% in ___. #HLD - continued home atorvastatin #Gout - continued home allopurinol #OSA - unclear if on CPAP at home Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. CloNIDine 0.2 mg PO BID 4. Digoxin 0.125 mg PO 3X/WEEK (___) 5. Lisinopril 40 mg PO DAILY 6. sevelamer CARBONATE 1600 mg PO TID W/MEALS 7. Torsemide 100 mg PO DAILY 8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 9. Labetalol 200 mg PO BID 10. Metoprolol Succinate XL 50 mg PO BID 11. paricalcitol 8 mcg oral 3X/WEEK Discharge Medications: 1. Apixaban 2.5 mg PO/NG BID 2. Pantoprazole 40 mg PO Q24H 3. Allopurinol ___ mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Digoxin 0.125 mg PO 3X/WEEK (___) 6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 7. paricalcitol 8 mcg oral 3X/WEEK 8. sevelamer CARBONATE 1600 mg PO TID W/MEALS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Clotted AV Fistula Hypotension RV failure, HFrEF Symptomatic Carotid Stenosis Secondary: paroxysmal atrial fibrillation ESRD on HD Toxic Metabolic Encephalopathy Left Toe Amputation/PVD Pulmonary HTN Type II DM HLD Gout OSA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___! Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because of a clotted AV fistula - You also had extra fluid on your body - You were also found to have low blood pressures - You also had a facial droop WHAT HAPPENED IN THE HOSPITAL? ============================== - You were medically managed for low blood pressure - You were started on a blood thinner - You were given dialysis and a paracentesis WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and attend all of your appointments listed below. Followup Instructions: ___	[ "T82868A", "I5023", "N186", "G92", "I63412", "I132", "R188", "R579", "E872", "R4701", "Y832", "K761", "I361", "E11319", "I50811", "E875", "E1151", "I2722", "E1122", "Y838", "R29810", "R29705", "Z992", "G4733", "Z880", "E785", "I480", "Z7901", "M1A9XX0", "Z89422", "Z833", "Z841", "Z807" ]	Allergies: Penicillins Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a [MASKED] with PMH ESRD on HD, HTN, DM c/b retinopathy, HLD, AF not on AC, pHTN, OSA on CPAP, CHF, PVD sent in from HD d/t inability to access LUE AVF with c/f AVF clot. The patient's last HD was [MASKED], where clotting was noted in his HD tubing. He has generalized malaise, most prominent complaint is abdominal swelling and nausea with dry heaves without abdominal pain. He notes he has had diarrhea over last month as well. Additionally, on ROS, he notes his dyspnea on exertion is worse than his baseline and he endorses a dry cough. No fevers, chest pain, heart palpitations. At baseline he is oliguric, he has no dysuria or frequency/change in urine quality. He also endorses worsening BLE claudication pain. He is without sick contacts. Only recent travel to [MASKED] ([MASKED]). Notably, he was admitted at [MASKED] where had cardiac cath not showing significant CAD as well as a therapeutic paracentesis removing 7L. He is due for BI Hepatology appt tomorrow. ED EXAM [MASKED]: irregular. JVP elevated at 30deg PULM: crackles diffusely/at bases (lying down) ABD: soft, NT, very distended with +fluid wave EXTR: WWP, 2+ pitting edema, [MASKED] changes. AVF without bruit/thrill. MDM: #Malfunctioning AVF In the ED, initial vitals were: 96.37, 52, 127/76, 20, 94% on RA Exam notable for: elevated JVP, diffuse crackles at lung bases, positive fluid wave with notably distended abdomen, 2+pitting edema in [MASKED]. AVF without bruit/thrill Labs notable for: K 5.7, Cr 10.2, Gap 21, Ca 8.1, Phos 10.8, Alk phos 229. H&H 10.1/31.6, Trop .17, [MASKED] 12.4, PTT 28.8, INR 1.1 Imaging was notable for: CXR Mild basilar atelectasis is seen. There is no focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. No pulmonary edema is seen. Evidence of DISH is seen along the thoracic spine. Patient was given: Lorazepam 1mg, For HyperK: Calcium gluconate 2gm, Insulin 10 units, dextrose. Isosorbide mononitrate 30mg, labetalol 200mg, clonidine 0.2mg, Allopurinol, [MASKED], Lisinopril 40mg, Torsemide 100mg, Metoprolol Tartrate 25mg, Digoxin 0.125mg Consults: [MASKED] for fistulagram (scheduled), transplant surgery Past Medical History: Diabetes x [MASKED] yrs (on insulin, non compliant with glucose monitoring) Bell's palsy (on the right) approx [MASKED] yrs ago Migraine headaches-remote past, last was a few yrs ago HTN Cervical disc disease Right shoulder injury s/p surgery High cholesterol Social History: [MASKED] Family History: He notes his father had diabetes and died from complications of diabetes at age [MASKED] including end-stage renal disease. His grandfather also had diabetes and died at age [MASKED] also of complications from diabetes. His mother died in her [MASKED] and most likely due to osteosarcoma. He has two brothers, one of whom has medication controlled diabetes and one of whom does not have diabetes. He has one sister who had gestational diabetes as well as diabetes that seems to have resolved after gastric bypass. He has two biological daughters, aged [MASKED] and [MASKED], who he believes are healthy. He has one adopted son, age [MASKED], who he believes is healthy. Physical Exam: ADMISSION PHYSICAL VS: 97.6, 67, 103/47, 18, 97% 2L GENERAL: fatigued, NAD HEENT: NCAT, PERRL, MMM NECK: JVD elevated at 11cm CARDIAC: irregularly irregular, no murmurs appreciated LUNGS: clear to auscultation bilaterally ABDOMEN: distended with striae and +fluid wave EXTREMITIES: chronic venous-stasis changes in [MASKED], 2+ edema NEUROLOGIC: CN II-XII grossly intact. Sensation grossly intact SKIN: Chronic venous stasis changes in BLE Discharge Physical GENERAL: Fatigued appearing male in NAD HEENT: PERRLA, EOMI, sclerae incicteric, MMM. CARDIAC: Irregularly irregular, no murmurs appreciated LUNGS: Clear to auscultation bilaterally ABDOMEN: Soft, non-tender, mildly distended. EXTREMITIES: chronic venous-stasis changes in [MASKED], non pitting peripheral edema NEUROLOGIC: R CN VII deficit. Otherwise A&O x3. Strength in tact in all 4 extremities. SKIN: Chronic venous stasis changes in BLE Pertinent Results: ADMISSION LABS [MASKED] 07:35AM BLOOD WBC-8.2 RBC-3.07* Hgb-10.1* Hct-31.6* MCV-103* MCH-32.9* MCHC-32.0 RDW-15.4 RDWSD-56.8* Plt [MASKED] [MASKED] 07:35AM BLOOD Neuts-78.1* Lymphs-6.7* Monos-11.5 Eos-2.5 Baso-0.6 Im [MASKED] AbsNeut-6.37* AbsLymp-0.55* AbsMono-0.94* AbsEos-0.20 AbsBaso-0.05 [MASKED] 09:30AM BLOOD [MASKED] PTT-28.8 [MASKED] [MASKED] 07:35AM BLOOD Glucose-160* UreaN-99* Creat-10.2* Na-144 K-5.7* Cl-100 HCO3-23 AnGap-21* [MASKED] 07:35AM BLOOD ALT-11 AST-11 LD(LDH)-208 AlkPhos-229* TotBili-0.6 [MASKED] 07:35AM BLOOD CK-MB-8 proBNP->70000 [MASKED] 07:35AM BLOOD Albumin-3.6 Calcium-8.1* Phos-10.8* Mg-2.1 [MASKED] 09:29PM BLOOD [MASKED] pO2-72* pCO2-30* pH-7.22* calTCO2-13* Base XS--14 Comment-GREEN TOP [MASKED] 09:29PM BLOOD Lactate-4.5* [MASKED] 11:11PM BLOOD Lactate-4.8* MICRO Blood Culture [MASKED] - Pending IMAGING/Testing/Other [MASKED] Carotid series complete results available at [MASKED] [MASKED] Paracentesis: IMPRESSION: 1. Technically successful ultrasound guided therapeutic paracentesis. 2. 3 L of fluid were removed. Art extr [MASKED] FINDINGS: Noncompressible right brachial artery, and left-sided fistula thus at upper extremity blood pressure cannot be determined. On the right-side, triphasic Doppler waveforms were seen at the right common femoral, monophasic superficial femoral, popliteal, posterior tibial, and dorsalis pedis arteries. The right ABI was indeterminate due to noncompressible distal vessels. Toe pressure was 64 mm Hg, TBI could not be calculated due to noncompressible right brachial artery. Pulse volume recordings demonstrate moderately abnormal waveforms in the thigh, calf, ankle, severely abnormal at the metatarsal and digit. On the left-side, triphasic Doppler waveforms were seen at the left femoral, popliteal arteries, and monophasic posterior tibial, and dorsalis pedis arteries. The left ABI was indeterminate due to noncompressible distal vessels. Toe pressure was 76 mm Hg, within indeterminate TBI due to noncompressible right brachial artery. Pulse volume recordings demonstrate mild to moderately abnormal waveform in the thigh, moderately abnormal at the calf and ankle, severely abnormal at the metatarsal and moderately abnormal at the digit. IMPRESSION: Limited interpretation of study as unable to determine upper extremity blood pressure. Doppler pulse volume recordings suggest bilateral obstructive arterial disease, most significant distally. CXR [MASKED] No pneumonia or acute cardiopulmonary process. MR [MASKED] [MASKED]. Study is degraded by motion. 2. No acute intracranial abnormality, no definite evidence of acute infarct. 3. Global volume loss and probable microangiopathic changes as described. CT [MASKED] and Neck [MASKED] CT [MASKED]: There is scattered focal hypodensities in the cerebellar cortex (2:6), left frontal cortex (2:20), right frontal cortex (2:24) and right parietal cortex (2:20), that may represent areas of small prior ischemic infarcts. No evidence of acute infarction, edema, hemorrhage or mass. The ventricles and sulci are prominent, likely related to involutional change. There is no gross evidence of acute fracture. Partial opacification of the ethmoid air cells and mucosal thickening of the left maxillary sinus. There are mucous retention cysts in the right maxillary sinus. The middle air cavities are unremarkable. The visualized portion of the orbits are unremarkable. CTA neck: Streak artifact limits evaluation of bilateral vertebral artery origin. Traditional 3 vessel takeoff. Mild calcification at the level of the aortic arch. Moderate to severe calcification at the level of the carotid bifurcation. Per NASCET criteria, there is approximately 50% occlusion at the right and left bifurcations. Beaded nonocclusive narrowing of bilateral cervical ICAs are noted, concerning for fibromuscular dysplasia. Otherwise, CT angiography of the neck shows carotid and vertebral arteries without occlusion or dissection. CTA [MASKED]: Extensive nonocclusive calcification at the level of the carotid siphons and moderate calcification of the left vertebral artery, V4 segment. CT angiography of the [MASKED] shows normal appearance of the arteries of the anterior and posterior circulation without occlusion or aneurysm greater than 3 mm in size. Major dural venous sinuses are patent. OTHER: On limited imaging of the lungs, probable left upper lobe granuloma (see 4:2). There is 1 centimeter mediastinal lymph node (4:14). Additional scattered subcentimeter nonspecific lymph nodes are noted throughout the mediastinum and neck bilaterally. The thyroid is grossly unremarkable. Multilevel degenerative changes with moderate canal narrowing at the level of the C4-C5, at the level of the previous ACDF. CT PERFUSION images are non-diagnostic. TTE [MASKED] The left atrial volume index is mildly increased. The right atrium is markedly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is >15mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is moderate global left ventricular hypokinesis. Quantitative biplane left ventricular ejection fraction is 37 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18 mmHg). There is echocardiographic evidence for diastolic dysfunction (grade indeterminate). Moderately dilated right ventricular cavity with moderate global free wall hypokinesis. Tricuspid annular plane systolic excursion (TAPSE) is depressed. Intrinsic right ventricular systolic function is likely lower due to the severity of tricuspid regurgitation. The aortic sinus diameter is normal for gender with mildly dilated ascending aorta. The aortic arch diameter is normal with a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets are severely thickened. There is moderate aortic valve stenosis (valve area 1.0-1.5 cm2). There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is an eccentric jet of mild [1+] mitral regurgitation. Due to the Coanda effect, the severity of mitral regurgitation could be UNDERestimated. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is moderate to severe [3+] tricuspid regurgitation. There is SEVERE pulmonary artery systolic hypertension. In the setting of at least moderate to severe tricuspid regurgitation, the pulmonary artery systolic pressure may be UNDERestimated. There is a small pericardial effusion. Ascites is seen. IMPRESSION: Moderate aortic stenosis. Moderate-severe tricuspid regurgitation with moderate right ventricular hypokinesis. Severe pulmonary artery systolic hypertension. Moderate global left ventricular systolic dysfunction. Mildly dilatd ascending aorta. Compared with the prior TTE (images reviewed) of [MASKED] , the aortic stenosis is now moderate (higher velocity across aortic valve is likely a combination of worsening aortic stenosis and increased flow across the valve from fistula patency). The estimated PA pressure is lower on the current study, though this is difficult to interpret in the setting of worsening tricuspid regurgitation. CT Abd/Pelvis w/o Contrast [MASKED]. Moderate volume ascites without findings to suggest hemoperitoneum. No abdominal wall or retroperitoneal hematoma. 2. Mild diffuse anasarca suggestive of volume overload. 3. Mild cardiomegaly. 4. Symmetric soft tissue calcifications within the region of the gluteal folds/ischiorectal fossae are nonspecific. 5. Numerous pulmonary nodules measuring up to 3 mm. Consider follow-up as per [MASKED] guidelines below. RECOMMENDATION(S): For incidentally detected multiple solid pulmonary nodules smaller than 6mm, no CT follow-up is recommended in a low-risk patient, and an optional CT follow-up in 12 months is recommended in a high-risk patient. CXR [MASKED] No acute cardiopulmonary process. RUQUS [MASKED]. Cirrhotic liver morphology, moderate volume ascites. 2. Patent portal system with bidirectional flow. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old man with ESRD, OSA non-adherent to CPAP, peripheral vascular disease and recently diagnosed cardiac ascites in the setting of longstanding pulmonary hypertension/RV dysfunction who was admitted [MASKED] for a clotted AVF and subsequently developed hypotension on the medical floor after LVP. The patient was stabilized quickly in the MICU, however, he then had acute onset right facial droop and dysarthria/aphasia x 2 prompting code-stroke (CTA negative, MRI negative) which resolved within 15 minutes now with normal mental status. He was transferred to cardiology for further management of his volume overload and CHF where his volume status was treated with paracentesis as well as hemodialysis. He was discharged on apixaban. TRANSITIONAL ISSUES: [] Patient with significant pulmonary HTN leading to Right sided failure, consider optimial management, especially strategies for prevention of hospitalizations. [] Patient on many antihypertensives that were held in setting of hypotension, consider if necessary and optimize therapy [] Recently started on apixaban. Please follow up for if this is necessary and if patient is tolerating well without bleeding [] please check hemoglobin within 1 week to ensure not bleeding on apixaban [] Patient will need detailed outpatient workup for heart failure and consolidation of medication regimen; please consider cardiac catheterization at some point in the future [] Patient with PVD and multiple wounds, ABIs difficult given fistula. Please consider MR time of flight studies and continued vascular follow up [] please attend to wounds on right thigh and left foot [] Patient with carotid stenosis, so continue to follow up for symptoms [] Avoid prolonged hypotension which may result in watershed infarcts. [] Patient ultrasound with cirrhotic liver morphology, moderate volume ascites, and portal system with bidirectional flow. Need evaluation of if this is cardiac etiology vs simultaneous liver pathology [] continue to assess need for paracenteses [] If patient does not tolerate Apixaban due to excessive bleeding, then he should be switched back to ASA [] assess need for CPAP [] please check A1c and treat for diabetes, pt did not receive insulin while inpatient [] A follow up appointment has been set up in two weeks with Dr. [MASKED] with vascular surgery [] Patient intermittently complaining of narrowed stool, evaluation and age appropriate cancer screening is advised (consider possible colonoscopy if indicated) ACUTE ISSUES: #RH Failure #HFrEF #Cardiac cirrhosis Patient with right sided HF, pulmonary HTN, elevated proBNP, ascites and cirrhotic appearance of liver on CT and US with preserved synthetic function. TTE w/ worsening AS (now moderate), otherwise stable moderate-severe TR with moderate RV hypokinesis, severe pulmonary artery systolic hypertension. Moderate global left ventricular systolic dysfunction w/ EF 37%. Volume status was managed with hemodialysis. Afterload agents were discontinued besides imdur given hypotension. #Symptomatic Carotid Stenosis Noted right facial droop on [MASKED]. s/p code stroke [MASKED] at 10:22AM but did not received TPA as likely hypoperfusion in setting of left carotid stenosis and low pressures. Given underlying atrial fibrillation, unclear if patient had embolic phenomenon. Apixaban started for atrial fibrillation and for secondary stroke prevention. Started apixaban 2.5 BID and discontinued ASA. Continued atorvostatin. CTA neck with 50% occlusion at the level of the bifurcations despite inconclusive carotid US results so patient likely with carotid atherosclerosis. #Paroxysmal Afib Not on anticoagulation due recurrent bleeding in the past. His home beta blockers were held in the setting of hypotension. He was continued on digoxin and started on apixaban as above. #Clotted AV Fistula #ESRD on HD #Hyperkalemia - Resolved Pt with left brachiocephalic AV fistula placed [MASKED]. Presented to ED with clotted fistula now s/p [MASKED] intervention. Continued HD until dry per renal recommendations Was able to be taken off of midodrine with stable BPs. Continued sevelamer CARBONATE 1600 mg PO TID W/MEALS #Hypotension Acute onset hypotension after paracenteses, initially confounded with 3u Hgb drop, however felt to be [MASKED] fluid shifts iso poor vascular tone. Home hypertensives held in that setting. Resolved with midodrine which was weaned. #Toxic Metabolic Encephalopathy Potentially grade 1 hepatic encephalopathy given evidence of cirrhotic liver on abdominal ultrasound and CT abdomen. Also could have been in setting of procedural sedation after AV declotting. Encephalopathy resolved soon after transfer to the MICU. Did well on floor off lactulose #Left Toe Amputation #PVD S/p left toe amputation recently at [MASKED]. Site appears warm with some drainage. Evaluated by podiatry who recommend ABI during inpatient stay. ABI was non-interpretable so will need repeat. Will need vascular follow-up CHRONIC ISSUES: #Pulmonary HTN WHO group 2 pulmonary venous hypertension. Followed in pulmonary hypertension clinic, last evaluated [MASKED] and missed recent appointment. RHC [MASKED] with RAp 19, PAWp 28, v-waves to 38 on recent catheterization ([MASKED]) and elevated left and right heart filling pressures. Patient is managed as an outpatient. #DM2 #Diabetic retinopathy Last A1c was 8.6% in [MASKED]. #HLD - continued home atorvastatin #Gout - continued home allopurinol #OSA - unclear if on CPAP at home Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. CloNIDine 0.2 mg PO BID 4. Digoxin 0.125 mg PO 3X/WEEK ([MASKED]) 5. Lisinopril 40 mg PO DAILY 6. sevelamer CARBONATE 1600 mg PO TID W/MEALS 7. Torsemide 100 mg PO DAILY 8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 9. Labetalol 200 mg PO BID 10. Metoprolol Succinate XL 50 mg PO BID 11. paricalcitol 8 mcg oral 3X/WEEK Discharge Medications: 1. Apixaban 2.5 mg PO/NG BID 2. Pantoprazole 40 mg PO Q24H 3. Allopurinol [MASKED] mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Digoxin 0.125 mg PO 3X/WEEK ([MASKED]) 6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 7. paricalcitol 8 mcg oral 3X/WEEK 8. sevelamer CARBONATE 1600 mg PO TID W/MEALS Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary: Clotted AV Fistula Hypotension RV failure, HFrEF Symptomatic Carotid Stenosis Secondary: paroxysmal atrial fibrillation ESRD on HD Toxic Metabolic Encephalopathy Left Toe Amputation/PVD Pulmonary HTN Type II DM HLD Gout OSA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]! Thank you for allowing us to be involved in your care, we wish you all the best! Your [MASKED] Healthcare Team WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because of a clotted AV fistula - You also had extra fluid on your body - You were also found to have low blood pressures - You also had a facial droop WHAT HAPPENED IN THE HOSPITAL? ============================== - You were medically managed for low blood pressure - You were started on a blood thinner - You were given dialysis and a paracentesis WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and attend all of your appointments listed below. Followup Instructions: [MASKED]	[]	[ "E872", "E1122", "G4733", "E785", "I480", "Z7901" ]	[ "T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter", "I5023: Acute on chronic systolic (congestive) heart failure", "N186: End stage renal disease", "G92: Toxic encephalopathy", "I63412: Cerebral infarction due to embolism of left middle cerebral artery", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "R188: Other ascites", "R579: Shock, unspecified", "E872: Acidosis", "R4701: Aphasia", "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", "K761: Chronic passive congestion of liver", "I361: Nonrheumatic tricuspid (valve) insufficiency", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "I50811: Acute right heart failure", "E875: Hyperkalemia", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "I2722: Pulmonary hypertension due to left heart disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "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", "R29810: Facial weakness", "R29705: NIHSS score 5", "Z992: Dependence on renal dialysis", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z880: Allergy status to penicillin", "E785: Hyperlipidemia, unspecified", "I480: Paroxysmal atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "M1A9XX0: Chronic gout, unspecified, without tophus (tophi)", "Z89422: Acquired absence of other left toe(s)", "Z833: Family history of diabetes mellitus", "Z841: Family history of disorders of kidney and ureter", "Z807: Family history of other malignant neoplasms of lymphoid, hematopoietic and related tissues" ]
10,094,811	29,711,874	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Chief complaint: dizziness, nausea Major Surgical or Invasive Procedure: Tunneled dialysis catheter placement (___) Hemodialysis History of Present Illness: In brief, this patient is a ___ with a history of CKD ___ DM),DM (complicated by nephropathy, neuropathy, retinopathy), HTN, HLD, and gout who presents with ___, fluid overload, and dizziness/nausea. He describes worsening lower extremity edema and dyspnea on exertion since ___. Additionally endorses 10 pound weight loss, fatigue, and reduced appetite. Denies any chest pain, orthopnea, or PND. Notably, patient presented six weeks ago with URI symptoms and was prescribed azithromycin. Again, two weeks ago, he presented with URI symptoms and was found to have sinusitis and confirmed influenza and was prescribed oseltamavir and azithromycin. He presented to the hospital because he woke up on ___ with dizziness (lightheadedness, not room-spinning), nausea but no vomiting, feeling as if his R ear is blocked, and R ear "whooshing" sound. Additionally yesterday he began to complain of a headache at the top of his head, denies photophobia and states this is not like his typical migraines. He presented to ___ and ___ was transferred to ___. In the ED, his vitals were significant for HTN to 178/91. His labs were significant for a troponin of 0.11, BUN/Cr of 100/5.9, and anemia to a hgb of 9.6. pro-BNP was 27000 and CXR showed mild pulmonary vascular congestion and mild cardiomegaly. U/A showed small blood, 300 of protein, 1 RBC and 4 WBC. CT head showed no acute intracranial abnormality. He got 4mg Zofran, 10mg reglan, and 650 mg. This AM, pt continues to complain of dizziness and reduced hearing on the R side as well as nausea. Denies vomiting. Endorses recent loose diarrhea which he connects to azithromycin prescription. Otherwise ROS as above. Past Medical History: Diabetes x ___ yrs (on insulin, non compliant with glucose monitoring) Bell's palsy (on the right) approx ___ yrs ago Migraine headaches-remote past, last was a few yrs ago HTN Cervical disc disease Right shoulder injury s/p surgery High cholesterol Social History: ___ Family History: He notes his father had diabetes and died from complications of diabetes at age ___ including end-stage renal disease. His grandfather also had diabetes and died at age ___ also of complications from diabetes. His mother died in her ___ and most likely due to osteosarcoma. He has two brothers, one of whom has medication controlled diabetes and one of whom does not have diabetes. He has one sister who had gestational diabetes as well as diabetes that seems to have resolved after gastric bypass. He has two biological daughters, aged ___ and ___, who he believes are healthy. He has one adopted son, age ___, who he believes is healthy. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS - 97.5 161/84 64 16 98RA GENERAL - No acute distress, lying in bed HEENT - PERRLA, sclera anicteric. Mucus membranes moist. Oropharynx clear. JVP up to mandible with pt at 30 degrees. CARDIAC - Regular rate and rhythm, no murmurs, rubs, or gallops appreciated. LUNGS - Clear to auscultation bilaterally. ABDOMEN - Tender to palpation in lower quadrants, "sharp" pain. Soft, no guarding, rigidity, or distention. EXTREMITIES - 2+ pitting edema to shin. +Hyperkeratosis on bilateral shins, erythema. ___ pulses 1+ bilaterally. SKIN - As above. NEUROLOGIC - CN2-12 intact with exception of 8: pt could not detect finger rub on R ear. ___ strength in hand grip bilaterally, no pronator drift, hip flexion bilaterally, ankle flexion/extension bilaterally. FNF testing intact bilaterally, ankle-to-shin intact bilaterally, RAM intact in both hands. No dysarthria detected, gait exam deferred. DISCHARGE PHYSICAL EXAM: VITALS - 97.5 148-167/84 ___ 18 97RA GENERAL - No acute distress, sitting in chair. HEENT - PERRLA, sclera anicteric. Mucus membranes moist. Oropharynx clear. CARDIAC - Regular rate and rhythm, ___ systolic murmur best heard at RUSB. LUNGS - Clear to auscultation bilaterally. ABDOMEN - Mildly tender to palpation in lower quadrants. Soft, no guarding, rigidity, or distention. EXTREMITIES - Improved minimal erythema focally in 0.5cmx1cm region on L medial ___ MTP joint. ROM intact, sensation intact distally. No open skin lesions. 2+ pitting edema to shin. +Hyperkeratosis on bilateral shins, erythema. Tenderness to palpation diffusely on calves. ___ pulses 1+ bilaterally. SKIN - As above. NEUROLOGIC - PERRLA, face symmetric, tongue midline, moves all four extremities. Pertinent Results: ADMISSION LABS: ___ 04:40PM GLUCOSE-149* UREA N-100* CREAT-5.9* SODIUM-145 POTASSIUM-4.8 CHLORIDE-111* TOTAL CO2-16* ANION GAP-23* ___ 04:40PM estGFR-Using this ___ 04:40PM ALT(SGPT)-12 AST(SGOT)-11 ALK PHOS-123 TOT BILI-0.3 ___ 04:40PM cTropnT-0.11* ___ 04:40PM CK-MB-6 ___ ___ 04:40PM ALBUMIN-3.3* IRON-41* ___ 04:40PM calTIBC-247* FERRITIN-116 TRF-190* ___ 04:40PM URINE HOURS-RANDOM ___ 04:40PM URINE UHOLD-HOLD ___ 04:40PM WBC-6.5 RBC-3.48* HGB-9.6* HCT-30.4* MCV-87 MCH-27.6 MCHC-31.6* RDW-14.7 RDWSD-46.6* ___ 04:40PM NEUTS-78.9* LYMPHS-11.5* MONOS-7.1 EOS-1.7 BASOS-0.3 IM ___ AbsNeut-5.09 AbsLymp-0.74* AbsMono-0.46 AbsEos-0.11 AbsBaso-0.02 ___ 04:40PM PLT COUNT-191 ___ 04:40PM ___ PTT-30.1 ___ ___ 04:40PM URINE COLOR-Straw APPEAR-Hazy SP ___ ___ 04:40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-300 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 04:40PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE EPI-0 ___ 04:40PM URINE AMORPH-RARE ___ 04:40PM URINE MUCOUS-RARE DISCHARGE LABS: ___ 06:48AM BLOOD WBC-5.7 RBC-3.20* Hgb-8.6* Hct-27.9* MCV-87 MCH-26.9 MCHC-30.8* RDW-14.9 RDWSD-47.3* Plt ___ ___ 06:48AM BLOOD Glucose-101* UreaN-41* Creat-4.5* Na-144 K-4.3 Cl-108 HCO3-22 AnGap-18 ___ 06:48AM BLOOD Calcium-8.2* Phos-5.1* Mg-1.9 MICROBIOLOGY: None PATHOLOGY: None IMAGING: ___ CXR IMPRESSION: Mild pulmonary vascular congestion and mild cardiomegaly. Mild bibasilar atelectasis ___ ___ IMPRESSION: No acute intracranial abnormality. ___ Renal ultrasound: IMPRESSION: 1. Proteinaceous or hemorrhagic cyst in the upper pole of the left kidney measuring 2.8 x 1.7 cm (AP X TV). 2. No evidence of hydronephrosis. ___ MRI Head without contrast: IMPRESSION: 1. No acute intracranial abnormality on noncontrast brain MRI without evidence of hemorrhage, mass, or mass effect. 2. No evidence of dural venous sinus thrombosis. ___ Transthoracic Echo: Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with mild basal inferior hypokinesis. The remaining segments contract normally. Quantitative (3D) LVEF = 47%. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction. Dilated right ventricle with mild systolic dysfunction. Mild mitral regurgitation. Moderate functional tricuspid regurgitation. Elevated LVEDP and severe pulmonary hypertension. ___ Tunneled HD line placement IMPRESSION: Successful placement of a 23cm tip-to-cuff length tunneled dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Brief Hospital Course: SUMMARY: ___ with a history of CKD ___ DM),DM (complicated by nephropathy, neuropathy, retinopathy), HTN, HLD, and gout who presents with ___, fluid overload, and dizziness/nausea. ACTIVE ISSUES: #Fluid overload and ___ on CKD: Presented with dyspnea on exertion and peripheral edema with BUN/Cr of 100/5.9, peak Cr of 6.7. Thought to be due to worsening diabetic/hypertensive nephropathy with possible prerenal component given hyaline casts on urine sediment. Patient was diuresed gently with 80mg IV Lasix given concern for prerenal etiology. He got a tunneled catheter placed for dialysis and received three sessions of dialysis, with a discharge BUN/Cr of 41/4.5 and a plan for outpatient hemodialysis starting on ___. PPD was placed in house, which was negative. #Dizziness #Nausea #Tinnitus and #Hearing loss: Sudden onset, most consistent with labyrinthitis, however, difficult to exclude uremia as a cause of mononeuropathy and nausea. Following dialysis, patient's symptoms continued, increasing the likelihood of a primary inner ear process. He was treated with meclizine. His dizziness improved after receiving steroids for his gout (see below), but unfortunately he experienced no significant improvement in his nausea and tinnitus despite multiple anti-emetics. #Gout: initially home allopurinol, then had a flare in the hospital and was started on prednisone 30mg, with any outpatient taper. #Diarrhea: Chronic for weeks after azithromycin for sinusitis, then acutely worsened in hospital. Negative c diff. Stool studies pending. Responded to loperamide. CHRONIC ISSUES: #Diabetes: home 70/30 was restarted at discharge TRANSITIONAL ISSUES New medications: 1. Docusate Sodium 100 mg PO BID 2. Polyethylene Glycol 17 g PO DAILY:PRN constipation 3. PredniSONE 20 mg PO DAILY Duration: 2 Doses This is dose # 1 of 3 tapered doses 4. PredniSONE 10 mg PO DAILY Duration: 2 Doses This is dose # 2 of 3 tapered doses 5. PredniSONE 5 mg PO DAILY Duration: 2 Doses This is dose # 3 of 3 tapered doses 6. Sevelamer CARBONATE 1600 mg PO TID W/MEALS 7. Sodium Bicarbonate 1300 mg PO BID Transitional Issues: #HTN: Patient was notably hypertensive during his hospitalization, and his lisinopril was held initially in the setting of ___. This was restarted prior to discharge. -f/u BP at next PCP ___ #HFrEF: TTE shows mild regional left ventricular systolic dysfunction, dilated right ventricle with mild systolic dysfunction, severe pulmonary hypertension. -Consider outpatient ischemic work-up. #Hyperlipidemia: Has history of hyperlipidemia, but self discontinued statin because he was concerned it was contributing to his muscle cramps which are likely do to CKD. -Consider restarting statin. #Pulmonary hypertension: Found to be severe on TTE. -Consider pulmonary outpatient follow-up. -Reinforce use of CPAP for OSA. #Gout: Started on prednisone 30mg for acute L great toe gout. -Prednisone taper: 20mg x2 days ___ and ___, 10mg x2 days ___ and ___, or 5mg ___ and ___. #Dizziness/nausea: Unclear etiology. Possibly related to labrynthitis vs uremic neuropathy. -Consider ENT workup with not improved Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. Allopurinol ___ mg PO DAILY 3. Labetalol 300 mg PO BID 4. amLODIPine 10 mg PO DAILY 5. Furosemide 80 mg PO BID 6. Aspirin 81 mg PO DAILY 7. Calcitriol 0.25 mcg PO TID 8. 70/30 70 Units Breakfast 70/30 70 Units Dinner Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 2. Metoclopramide 5 mg PO BID:PRN Nausea RX metoclopramide HCl 5 mg 1 tablet(s) by mouth twice a day Disp #14 Tablet Refills:0 3. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX polyethylene glycol 3350 17 gram/dose 17 grams by mouth Daily Refills:0 4. PredniSONE 20 mg PO DAILY Duration: 2 Doses This is dose # 1 of 3 tapered doses RX prednisone 5 mg 4 tablet(s) by mouth daily Disp #10 Tablet Refills:0 5. PredniSONE 10 mg PO DAILY Duration: 2 Doses This is dose # 2 of 3 tapered doses 6. PredniSONE 5 mg PO DAILY Duration: 2 Doses This is dose # 3 of 3 tapered doses 7. sevelamer CARBONATE 1600 mg PO TID W/MEALS RX sevelamer carbonate [Renvela] 800 mg 2 tablet(s) by mouth TID with meals Disp #180 Tablet Refills:0 8. Sodium Bicarbonate 1300 mg PO BID RX sodium bicarbonate 650 mg 2 tablet(s) by mouth twice a day Disp #120 Tablet Refills:*0 9. 70/30 70 Units Breakfast 70/30 70 Units Dinner 10. Allopurinol ___ mg PO DAILY 11. amLODIPine 10 mg PO DAILY 12. Aspirin 81 mg PO DAILY 13. Labetalol 300 mg PO BID 14. Lisinopril 40 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Acute kidney injury, uremia SECONDARY DIAGNOSES: Pulmonary hypertension, diabetes mellitus, gout, hyperlipidemia, hypertension, obstructive sleep apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were seen for worsening kidney function, dizziness, and nausea. We believe your kidney function was caused by diabetes and hypertension, as well as not eating very much. We placed a dialysis catheter and started hemodialysis. You were also very dizzy and nauseous, which we believe is due to inflammation of your inner ear. We tried many different medicines to treat your symptoms. For your headache, we looked at a CT and an MRI of your head, which were both normal. You also had a gout flare, which we treated with steroids. We also looked at an ultrasound of your heart (an echocardiogram), which showed us some dysfunction and high pressures in your pulmonary vessels. You should talk to your primary care doctor about possibly seeing a pulmonologist. You are being discharged with several new medications. In particular, you are being discharged with a small supply of metoclopramide (Reglan). Please do not exceed the prescribed dosage, as this can cause your heart to beat abnormally. It was our pleasure taking care of you! We wish you the very best. --Your care team at ___ Followup Instructions: ___	[ "N179", "I132", "I5020", "N186", "E872", "I429", "E1121", "E1122", "E8339", "I272", "H8301", "E1140", "E11319", "E785", "M109", "G4733", "R197", "Z794", "R748", "D631", "R51", "E669", "Z6833", "E8351", "E11649" ]	Allergies: Penicillins Chief Complaint: Chief complaint: dizziness, nausea Major Surgical or Invasive Procedure: Tunneled dialysis catheter placement ([MASKED]) Hemodialysis History of Present Illness: In brief, this patient is a [MASKED] with a history of CKD [MASKED] DM),DM (complicated by nephropathy, neuropathy, retinopathy), HTN, HLD, and gout who presents with [MASKED], fluid overload, and dizziness/nausea. He describes worsening lower extremity edema and dyspnea on exertion since [MASKED]. Additionally endorses 10 pound weight loss, fatigue, and reduced appetite. Denies any chest pain, orthopnea, or PND. Notably, patient presented six weeks ago with URI symptoms and was prescribed azithromycin. Again, two weeks ago, he presented with URI symptoms and was found to have sinusitis and confirmed influenza and was prescribed oseltamavir and azithromycin. He presented to the hospital because he woke up on [MASKED] with dizziness (lightheadedness, not room-spinning), nausea but no vomiting, feeling as if his R ear is blocked, and R ear "whooshing" sound. Additionally yesterday he began to complain of a headache at the top of his head, denies photophobia and states this is not like his typical migraines. He presented to [MASKED] and [MASKED] was transferred to [MASKED]. In the ED, his vitals were significant for HTN to 178/91. His labs were significant for a troponin of 0.11, BUN/Cr of 100/5.9, and anemia to a hgb of 9.6. pro-BNP was 27000 and CXR showed mild pulmonary vascular congestion and mild cardiomegaly. U/A showed small blood, 300 of protein, 1 RBC and 4 WBC. CT head showed no acute intracranial abnormality. He got 4mg Zofran, 10mg reglan, and 650 mg. This AM, pt continues to complain of dizziness and reduced hearing on the R side as well as nausea. Denies vomiting. Endorses recent loose diarrhea which he connects to azithromycin prescription. Otherwise ROS as above. Past Medical History: Diabetes x [MASKED] yrs (on insulin, non compliant with glucose monitoring) Bell's palsy (on the right) approx [MASKED] yrs ago Migraine headaches-remote past, last was a few yrs ago HTN Cervical disc disease Right shoulder injury s/p surgery High cholesterol Social History: [MASKED] Family History: He notes his father had diabetes and died from complications of diabetes at age [MASKED] including end-stage renal disease. His grandfather also had diabetes and died at age [MASKED] also of complications from diabetes. His mother died in her [MASKED] and most likely due to osteosarcoma. He has two brothers, one of whom has medication controlled diabetes and one of whom does not have diabetes. He has one sister who had gestational diabetes as well as diabetes that seems to have resolved after gastric bypass. He has two biological daughters, aged [MASKED] and [MASKED], who he believes are healthy. He has one adopted son, age [MASKED], who he believes is healthy. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS - 97.5 161/84 64 16 98RA GENERAL - No acute distress, lying in bed HEENT - PERRLA, sclera anicteric. Mucus membranes moist. Oropharynx clear. JVP up to mandible with pt at 30 degrees. CARDIAC - Regular rate and rhythm, no murmurs, rubs, or gallops appreciated. LUNGS - Clear to auscultation bilaterally. ABDOMEN - Tender to palpation in lower quadrants, "sharp" pain. Soft, no guarding, rigidity, or distention. EXTREMITIES - 2+ pitting edema to shin. +Hyperkeratosis on bilateral shins, erythema. [MASKED] pulses 1+ bilaterally. SKIN - As above. NEUROLOGIC - CN2-12 intact with exception of 8: pt could not detect finger rub on R ear. [MASKED] strength in hand grip bilaterally, no pronator drift, hip flexion bilaterally, ankle flexion/extension bilaterally. FNF testing intact bilaterally, ankle-to-shin intact bilaterally, RAM intact in both hands. No dysarthria detected, gait exam deferred. DISCHARGE PHYSICAL EXAM: VITALS - 97.5 148-167/84 [MASKED] 18 97RA GENERAL - No acute distress, sitting in chair. HEENT - PERRLA, sclera anicteric. Mucus membranes moist. Oropharynx clear. CARDIAC - Regular rate and rhythm, [MASKED] systolic murmur best heard at RUSB. LUNGS - Clear to auscultation bilaterally. ABDOMEN - Mildly tender to palpation in lower quadrants. Soft, no guarding, rigidity, or distention. EXTREMITIES - Improved minimal erythema focally in 0.5cmx1cm region on L medial [MASKED] MTP joint. ROM intact, sensation intact distally. No open skin lesions. 2+ pitting edema to shin. +Hyperkeratosis on bilateral shins, erythema. Tenderness to palpation diffusely on calves. [MASKED] pulses 1+ bilaterally. SKIN - As above. NEUROLOGIC - PERRLA, face symmetric, tongue midline, moves all four extremities. Pertinent Results: ADMISSION LABS: [MASKED] 04:40PM GLUCOSE-149* UREA N-100* CREAT-5.9* SODIUM-145 POTASSIUM-4.8 CHLORIDE-111* TOTAL CO2-16* ANION GAP-23* [MASKED] 04:40PM estGFR-Using this [MASKED] 04:40PM ALT(SGPT)-12 AST(SGOT)-11 ALK PHOS-123 TOT BILI-0.3 [MASKED] 04:40PM cTropnT-0.11* [MASKED] 04:40PM CK-MB-6 [MASKED] [MASKED] 04:40PM ALBUMIN-3.3* IRON-41* [MASKED] 04:40PM calTIBC-247* FERRITIN-116 TRF-190* [MASKED] 04:40PM URINE HOURS-RANDOM [MASKED] 04:40PM URINE UHOLD-HOLD [MASKED] 04:40PM WBC-6.5 RBC-3.48* HGB-9.6* HCT-30.4* MCV-87 MCH-27.6 MCHC-31.6* RDW-14.7 RDWSD-46.6* [MASKED] 04:40PM NEUTS-78.9* LYMPHS-11.5* MONOS-7.1 EOS-1.7 BASOS-0.3 IM [MASKED] AbsNeut-5.09 AbsLymp-0.74* AbsMono-0.46 AbsEos-0.11 AbsBaso-0.02 [MASKED] 04:40PM PLT COUNT-191 [MASKED] 04:40PM [MASKED] PTT-30.1 [MASKED] [MASKED] 04:40PM URINE COLOR-Straw APPEAR-Hazy SP [MASKED] [MASKED] 04:40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-300 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [MASKED] 04:40PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE EPI-0 [MASKED] 04:40PM URINE AMORPH-RARE [MASKED] 04:40PM URINE MUCOUS-RARE DISCHARGE LABS: [MASKED] 06:48AM BLOOD WBC-5.7 RBC-3.20* Hgb-8.6* Hct-27.9* MCV-87 MCH-26.9 MCHC-30.8* RDW-14.9 RDWSD-47.3* Plt [MASKED] [MASKED] 06:48AM BLOOD Glucose-101* UreaN-41* Creat-4.5* Na-144 K-4.3 Cl-108 HCO3-22 AnGap-18 [MASKED] 06:48AM BLOOD Calcium-8.2* Phos-5.1* Mg-1.9 MICROBIOLOGY: None PATHOLOGY: None IMAGING: [MASKED] CXR IMPRESSION: Mild pulmonary vascular congestion and mild cardiomegaly. Mild bibasilar atelectasis [MASKED] [MASKED] IMPRESSION: No acute intracranial abnormality. [MASKED] Renal ultrasound: IMPRESSION: 1. Proteinaceous or hemorrhagic cyst in the upper pole of the left kidney measuring 2.8 x 1.7 cm (AP X TV). 2. No evidence of hydronephrosis. [MASKED] MRI Head without contrast: IMPRESSION: 1. No acute intracranial abnormality on noncontrast brain MRI without evidence of hemorrhage, mass, or mass effect. 2. No evidence of dural venous sinus thrombosis. [MASKED] Transthoracic Echo: Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with mild basal inferior hypokinesis. The remaining segments contract normally. Quantitative (3D) LVEF = 47%. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction. Dilated right ventricle with mild systolic dysfunction. Mild mitral regurgitation. Moderate functional tricuspid regurgitation. Elevated LVEDP and severe pulmonary hypertension. [MASKED] Tunneled HD line placement IMPRESSION: Successful placement of a 23cm tip-to-cuff length tunneled dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Brief Hospital Course: SUMMARY: [MASKED] with a history of CKD [MASKED] DM),DM (complicated by nephropathy, neuropathy, retinopathy), HTN, HLD, and gout who presents with [MASKED], fluid overload, and dizziness/nausea. ACTIVE ISSUES: #Fluid overload and [MASKED] on CKD: Presented with dyspnea on exertion and peripheral edema with BUN/Cr of 100/5.9, peak Cr of 6.7. Thought to be due to worsening diabetic/hypertensive nephropathy with possible prerenal component given hyaline casts on urine sediment. Patient was diuresed gently with 80mg IV Lasix given concern for prerenal etiology. He got a tunneled catheter placed for dialysis and received three sessions of dialysis, with a discharge BUN/Cr of 41/4.5 and a plan for outpatient hemodialysis starting on [MASKED]. PPD was placed in house, which was negative. #Dizziness #Nausea #Tinnitus and #Hearing loss: Sudden onset, most consistent with labyrinthitis, however, difficult to exclude uremia as a cause of mononeuropathy and nausea. Following dialysis, patient's symptoms continued, increasing the likelihood of a primary inner ear process. He was treated with meclizine. His dizziness improved after receiving steroids for his gout (see below), but unfortunately he experienced no significant improvement in his nausea and tinnitus despite multiple anti-emetics. #Gout: initially home allopurinol, then had a flare in the hospital and was started on prednisone 30mg, with any outpatient taper. #Diarrhea: Chronic for weeks after azithromycin for sinusitis, then acutely worsened in hospital. Negative c diff. Stool studies pending. Responded to loperamide. CHRONIC ISSUES: #Diabetes: home 70/30 was restarted at discharge TRANSITIONAL ISSUES New medications: 1. Docusate Sodium 100 mg PO BID 2. Polyethylene Glycol 17 g PO DAILY:PRN constipation 3. PredniSONE 20 mg PO DAILY Duration: 2 Doses This is dose # 1 of 3 tapered doses 4. PredniSONE 10 mg PO DAILY Duration: 2 Doses This is dose # 2 of 3 tapered doses 5. PredniSONE 5 mg PO DAILY Duration: 2 Doses This is dose # 3 of 3 tapered doses 6. Sevelamer CARBONATE 1600 mg PO TID W/MEALS 7. Sodium Bicarbonate 1300 mg PO BID Transitional Issues: #HTN: Patient was notably hypertensive during his hospitalization, and his lisinopril was held initially in the setting of [MASKED]. This was restarted prior to discharge. -f/u BP at next PCP [MASKED] #HFrEF: TTE shows mild regional left ventricular systolic dysfunction, dilated right ventricle with mild systolic dysfunction, severe pulmonary hypertension. -Consider outpatient ischemic work-up. #Hyperlipidemia: Has history of hyperlipidemia, but self discontinued statin because he was concerned it was contributing to his muscle cramps which are likely do to CKD. -Consider restarting statin. #Pulmonary hypertension: Found to be severe on TTE. -Consider pulmonary outpatient follow-up. -Reinforce use of CPAP for OSA. #Gout: Started on prednisone 30mg for acute L great toe gout. -Prednisone taper: 20mg x2 days [MASKED] and [MASKED], 10mg x2 days [MASKED] and [MASKED], or 5mg [MASKED] and [MASKED]. #Dizziness/nausea: Unclear etiology. Possibly related to labrynthitis vs uremic neuropathy. -Consider ENT workup with not improved Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. Allopurinol [MASKED] mg PO DAILY 3. Labetalol 300 mg PO BID 4. amLODIPine 10 mg PO DAILY 5. Furosemide 80 mg PO BID 6. Aspirin 81 mg PO DAILY 7. Calcitriol 0.25 mcg PO TID 8. 70/30 70 Units Breakfast 70/30 70 Units Dinner Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 2. Metoclopramide 5 mg PO BID:PRN Nausea RX metoclopramide HCl 5 mg 1 tablet(s) by mouth twice a day Disp #14 Tablet Refills:0 3. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX polyethylene glycol 3350 17 gram/dose 17 grams by mouth Daily Refills:0 4. PredniSONE 20 mg PO DAILY Duration: 2 Doses This is dose # 1 of 3 tapered doses RX prednisone 5 mg 4 tablet(s) by mouth daily Disp #10 Tablet Refills:0 5. PredniSONE 10 mg PO DAILY Duration: 2 Doses This is dose # 2 of 3 tapered doses 6. PredniSONE 5 mg PO DAILY Duration: 2 Doses This is dose # 3 of 3 tapered doses 7. sevelamer CARBONATE 1600 mg PO TID W/MEALS RX sevelamer carbonate [Renvela] 800 mg 2 tablet(s) by mouth TID with meals Disp #180 Tablet Refills:0 8. Sodium Bicarbonate 1300 mg PO BID RX sodium bicarbonate 650 mg 2 tablet(s) by mouth twice a day Disp #120 Tablet Refills:*0 9. 70/30 70 Units Breakfast 70/30 70 Units Dinner 10. Allopurinol [MASKED] mg PO DAILY 11. amLODIPine 10 mg PO DAILY 12. Aspirin 81 mg PO DAILY 13. Labetalol 300 mg PO BID 14. Lisinopril 40 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Acute kidney injury, uremia SECONDARY DIAGNOSES: Pulmonary hypertension, diabetes mellitus, gout, hyperlipidemia, hypertension, obstructive sleep apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were seen for worsening kidney function, dizziness, and nausea. We believe your kidney function was caused by diabetes and hypertension, as well as not eating very much. We placed a dialysis catheter and started hemodialysis. You were also very dizzy and nauseous, which we believe is due to inflammation of your inner ear. We tried many different medicines to treat your symptoms. For your headache, we looked at a CT and an MRI of your head, which were both normal. You also had a gout flare, which we treated with steroids. We also looked at an ultrasound of your heart (an echocardiogram), which showed us some dysfunction and high pressures in your pulmonary vessels. You should talk to your primary care doctor about possibly seeing a pulmonologist. You are being discharged with several new medications. In particular, you are being discharged with a small supply of metoclopramide (Reglan). Please do not exceed the prescribed dosage, as this can cause your heart to beat abnormally. It was our pleasure taking care of you! We wish you the very best. --Your care team at [MASKED] Followup Instructions: [MASKED]	[]	[ "N179", "E872", "E1122", "E785", "M109", "G4733", "Z794", "E669" ]	[ "N179: Acute kidney failure, unspecified", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "I5020: Unspecified systolic (congestive) heart failure", "N186: End stage renal disease", "E872: Acidosis", "I429: Cardiomyopathy, unspecified", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E8339: Other disorders of phosphorus metabolism", "I272: Other secondary pulmonary hypertension", "H8301: Labyrinthitis, right ear", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E785: Hyperlipidemia, unspecified", "M109: Gout, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "R197: Diarrhea, unspecified", "Z794: Long term (current) use of insulin", "R748: Abnormal levels of other serum enzymes", "D631: Anemia in chronic kidney disease", "R51: Headache", "E669: Obesity, unspecified", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "E8351: Hypocalcemia", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma" ]
10,095,155	21,035,517	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left leg pain due to L open distal tibia fracture s/p GSW Major Surgical or Invasive Procedure: L open distal tibia fracture (fibula intact) s/p L tibia I&D, ex-fix ___, ___ History of Present Illness: ___ male with no significant past medical history who was transferred from an outside hospital for further management of a left open distal tib-fib fracture status post gunshot wound the last night. He reports he was walking home from a friend's house when he was shot. After realizing he was shot and he ambulated to ___ which was about 30 minutes away. At ___ his tetanus was updated and he was given Ancef 1 g. He reports no pulsatile bleeding on scene. Currently he denies any numbness or tingling into his left foot. Past Medical History: None Social History: ___ Family History: NC Physical Exam: General: Well-appearing, breathing comfortably CV: Pink and well perfused MSK: Left Lower Extremity: In ankle ex-fix with sanguinous drainage from ex-fix pines. No tenderness to palpation or active/passive ROM Sensation intact to light touch in Saph/Sural/SP/DP/T nerve distributions Motor intact for ___, FHL, TA, ___ Toes warm & well perfused Pertinent Results: ___ 06:52AM BLOOD WBC-8.2 RBC-3.24* Hgb-10.5* Hct-29.2* MCV-90 MCH-32.4* MCHC-36.0 RDW-11.9 RDWSD-38.4 Plt ___ ___ 06:52AM BLOOD Glucose-97 UreaN-8 Creat-0.7 Na-140 K-4.2 Cl-101 HCO3-26 AnGap-13 Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have open left tibia fracture after GSW and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for I&D and ex-fix placement, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home with services was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is non weight bearing in the left lower extremity in the ankle ex-fix, and will be discharged on Aspirin 325 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 1000 mg PO Q8H 2. Aspirin 325 mg PO DAILY RX aspirin 325 mg 1 tablet(s) by mouth once a day Disp #28 Tablet Refills:0 3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 4. Cephalexin 500 mg PO Q6H RX cephalexin 500 mg 1 tablet(s) by mouth four times a day Disp #20 Tablet Refills:0 5. crutch miscellaneous DAILY RX crutch Disp #1 Each Refills:0 6. Docusate Sodium 100 mg PO BID 7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate RX hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every four (4) hours PRN Disp #40 Tablet Refills:0 8. Senna 8.6 mg PO BID 9. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Left tibia fracture status post gunshot wound Discharge Condition: AVSS NAD LLE: Incision well approximated. Dressing clean and dry. Fires FHL, ___, TA, GCS. SILT ___ n distributions. Toes WWP distally. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Nonweightbearing of the left lower extremity in ex-fix 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 325 daily for 4 weeks WOUND CARE: - Your incision is covered with a dry dressing. Please change the dressing daily. If there is no drainage, you may leave your incision open to the air. If you are continuing to have drainage, you may place a dry dressing over the incision as needed. - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. Pin Site Care Instructions for Patient and ___: For patients discharged with external fixators in place, the initial dressing may have Xeroform wrapped at the pin site with surrounding gauze. Often, the Xeroform is used in the immediate post-op phase to allow for control of the bleeding. The Xeroform can be removed ___ days after surgery. If the pin sites are clean and dry, keep them open to air. If they are still draining slightly, cover with clean dry gauze until draining stops. If they need to be cleaned, use ___ strength Hydrogen Peroxide with a Q-tip to the site. 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: Activity: Activity: Activity as tolerated Left lower extremity: Non weight bearing Keep LLE elevated on pillows while in bed, up to chair. 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. Call your surgeon's office with any questions. Pin Site Care Instructions for Patient and ___: For patients discharged with external fixators in place, the initial dressing may have Xeroform wrapped at the pin site with surrounding gauze. Often, the Xeroform is used in the immediate post-op phase to allow for control of the bleeding. The Xeroform can be removed ___ days after surgery. If the pin sites are clean and dry, keep them open to air. If they are still draining slightly, cover with clean dry gauze until draining stops. If they need to be cleaned, use ___ strength Hydrogen Peroxide with a Q-tip to the site. Followup Instructions: ___	[ "S82392B", "X959XXA", "Y92410" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Left leg pain due to L open distal tibia fracture s/p GSW Major Surgical or Invasive Procedure: L open distal tibia fracture (fibula intact) s/p L tibia I&D, ex-fix [MASKED], [MASKED] History of Present Illness: [MASKED] male with no significant past medical history who was transferred from an outside hospital for further management of a left open distal tib-fib fracture status post gunshot wound the last night. He reports he was walking home from a friend's house when he was shot. After realizing he was shot and he ambulated to [MASKED] which was about 30 minutes away. At [MASKED] his tetanus was updated and he was given Ancef 1 g. He reports no pulsatile bleeding on scene. Currently he denies any numbness or tingling into his left foot. Past Medical History: None Social History: [MASKED] Family History: NC Physical Exam: General: Well-appearing, breathing comfortably CV: Pink and well perfused MSK: Left Lower Extremity: In ankle ex-fix with sanguinous drainage from ex-fix pines. No tenderness to palpation or active/passive ROM Sensation intact to light touch in Saph/Sural/SP/DP/T nerve distributions Motor intact for [MASKED], FHL, TA, [MASKED] Toes warm & well perfused Pertinent Results: [MASKED] 06:52AM BLOOD WBC-8.2 RBC-3.24* Hgb-10.5* Hct-29.2* MCV-90 MCH-32.4* MCHC-36.0 RDW-11.9 RDWSD-38.4 Plt [MASKED] [MASKED] 06:52AM BLOOD Glucose-97 UreaN-8 Creat-0.7 Na-140 K-4.2 Cl-101 HCO3-26 AnGap-13 Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have open left tibia fracture after GSW and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [MASKED] for I&D and ex-fix placement, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to home with services was appropriate. The [MASKED] hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is non weight bearing in the left lower extremity in the ankle ex-fix, and will be discharged on Aspirin 325 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 1000 mg PO Q8H 2. Aspirin 325 mg PO DAILY RX aspirin 325 mg 1 tablet(s) by mouth once a day Disp #28 Tablet Refills:0 3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 4. Cephalexin 500 mg PO Q6H RX cephalexin 500 mg 1 tablet(s) by mouth four times a day Disp #20 Tablet Refills:0 5. crutch miscellaneous DAILY RX crutch Disp #1 Each Refills:0 6. Docusate Sodium 100 mg PO BID 7. HYDROmorphone (Dilaudid) [MASKED] mg PO Q4H:PRN Pain - Moderate RX hydromorphone [Dilaudid] 2 mg [MASKED] tablet(s) by mouth every four (4) hours PRN Disp #40 Tablet Refills:0 8. Senna 8.6 mg PO BID 9. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Left tibia fracture status post gunshot wound Discharge Condition: AVSS NAD LLE: Incision well approximated. Dressing clean and dry. Fires FHL, [MASKED], TA, GCS. SILT [MASKED] n distributions. Toes WWP distally. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Nonweightbearing of the left lower extremity in ex-fix 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 325 daily for 4 weeks WOUND CARE: - Your incision is covered with a dry dressing. Please change the dressing daily. If there is no drainage, you may leave your incision open to the air. If you are continuing to have drainage, you may place a dry dressing over the incision as needed. - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. Pin Site Care Instructions for Patient and [MASKED]: For patients discharged with external fixators in place, the initial dressing may have Xeroform wrapped at the pin site with surrounding gauze. Often, the Xeroform is used in the immediate post-op phase to allow for control of the bleeding. The Xeroform can be removed [MASKED] days after surgery. If the pin sites are clean and dry, keep them open to air. If they are still draining slightly, cover with clean dry gauze until draining stops. If they need to be cleaned, use [MASKED] strength Hydrogen Peroxide with a Q-tip to the site. 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: Activity: Activity: Activity as tolerated Left lower extremity: Non weight bearing Keep LLE elevated on pillows while in bed, up to chair. 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. Call your surgeon's office with any questions. Pin Site Care Instructions for Patient and [MASKED]: For patients discharged with external fixators in place, the initial dressing may have Xeroform wrapped at the pin site with surrounding gauze. Often, the Xeroform is used in the immediate post-op phase to allow for control of the bleeding. The Xeroform can be removed [MASKED] days after surgery. If the pin sites are clean and dry, keep them open to air. If they are still draining slightly, cover with clean dry gauze until draining stops. If they need to be cleaned, use [MASKED] strength Hydrogen Peroxide with a Q-tip to the site. Followup Instructions: [MASKED]	[]	[]	[ "S82392B: Other fracture of lower end of left tibia, initial encounter for open fracture type I or II/\tinitial encounter for open fracture NOS", "X959XXA: Assault by unspecified firearm discharge, initial encounter", "Y92410: Unspecified street and highway as the place of occurrence of the external cause" ]
10,095,323	24,908,097	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dizziness, nausea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male with PMH HTN, chronic hand pain, chronic headaches, prediabetes, who presents from home with dizziness and nausea. Reports of onset of symptoms are variable, with ED reporting last ___, patient reporting 2d PTA, outpatient notes reporting 4d PTA. Patient reported hyperacute onset of dizziness, feeling like the room is spinning around him, at first lasting a few minutes, then up to an hour, with nausea started day PTA, no vomiting, and feeling sweaty, resolving without intervention. Worse with opening his eyes (has been keeping them closed), head turn (esp to the right), position changes. Associated with R side tinnitus, which patient has had intermittently over years. No ear pain, fevers. No falls, LOC. In the ED at 12:30 ___, code stroke was called given patient's severe nystagmus. PE showed: General: unwell appearing ___ male n NAD HEENT: NC, AT. Significant nystagmus with central gaze. Right beating nystagmus, which initially appeared direction changing. Neck: no cervical lymphadenopathy Chest: CTAB CV: RRR, nrml s1/s2, no m/g/r. Abdomen: soft, ___, no HSM Ext: no edema Neuro: AOx3, ___ intact, ataxia appreciated, strength ___ in all extremities, FNF intact, HINTS (performed after CT/CTA) corrective saccade and right beating nystagmus. No dysarthria. No aphasia. Symmetric face. CTA head and neck was done. CT head: No acute intracranial hemorrhage or infarct. CTA head and neck: The major vessels of the neck, circle of ___, and their principal intracranial branches appear without flow limiting stenosis, occlusion, or formation of aneurysms larger than 3 mm. Hypoplastic left venous sinus. Final read pending reformats. Neurology recommendations: ___ man who presented as a code stroke after several episodes of room spinning vertigo over the past 3 days. There are several reassuring findings on exam: Right beating nystagmus with rightward and leftward gaze, corrective saccades to the right, no nystagmus with vertical gaze, and absence of other neurological signs. The nystagmus worsened when fixation was interrupted, another feature of peripheral vertigo. Recommendations -symptomatic treatment of vertigo per ED -treatment of lab abnormalities per ED -return to ED if new symptoms such as weakness, aphasia, etc... -dispo per ED -if symptoms persist for more than 1 week, will need PCP referral to ___ neurologist" Per conversation with ED, symptoms most consistent with vestibular neuritis. Otoscope exam was normal. Patient was not walking independently in ED, had assistance (counter to documented code stroke exam), but was initially feeling better and considered going home, but then had recurrence of symptoms. He received: ___ 17:13 IV LORazepam 1 mg ___ 22:31 PO Meclizine 25 mg ___ 22:31 PO Potassium Chloride 40 mEq ___ 22:33 PO Acetaminophen 650 mg Upon arrival to floor, patient reported the above story. He felt some relief with meclizine and Ativan. Reported almost blacking out when sat up for the CT scanner. Reported occasional R ear tinnitus (ringing, not pulsatile), usually if congested. He denied nasal congestion, sore throat, cough, dyspnea, CP, palpitations, lightheadness, abdominal pain, weakness/numbness/tingling, diarrhea, poor UOP. Reported poor PO intake today but good appetite. Has daily headaches for which he usually takes Excedrin. He has chronic hand pain related to MVC ___ years ago and occasionally takes NSAIDs for this. Past Medical History: Essential hypertension obesity Colon adenoma Social History: ___ Family History: Father Cancer - ___ (70); Heart ___ Mother ___ No Significant Medical History Physical Exam: ADMISSION EXAM VITALS: 97.6 PO 137 / 85 L Lying 57 20 95 RA GENERAL: Alert, uncomfortable EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate Neck: no cervical LAD CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is ___ GI: Abdomen soft, ___ to palpation. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, central gaze and R beating nystagmus (do not see any on the left), speech fluent, moves all limbs, sensation to light touch grossly intact throughout, strength ___ throughout, ni tact FNF, deferred ambulation PSYCH: pleasant, appropriate affect DISCHARGE EXAM 24 HR Data (last updated ___ @ 727) Temp: 97.8 (Tm 97.8), BP: 124/76 (___), HR: 58 (___), RR: 18 (___), O2 sat: 97% (___), O2 delivery: RA, Wt: 285 lb/129.28 kg GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. MMMs CV: RRR no m/r/g RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is ___ GI: Abdomen soft, ___ to palpation. EXTR: wwp no edema NEURO: Alert, interactive, face symmetric, gaze conjugate with EOMI with severe horizontal nystagmys with rightward gaze, speech fluent, motor function grossly intact/symmetric, FTN intact bilaterally PSYCH: pleasant, appropriate affect Pertinent Results: Labs ___ 04:10PM BLOOD ___ ___ Plt ___ ___ 07:15AM BLOOD ___ ___ Plt ___ ___ 04:10PM BLOOD ___ ___ ___ 04:10PM BLOOD ___ ___ ___ 07:15AM BLOOD ___ ___ ___ 05:18PM BLOOD ___ ___ 05:18PM BLOOD cTropnT-<0.01 ___ 05:18PM BLOOD ___ ___ 07:15AM BLOOD ___ ___ 05:18PM BLOOD ___ ___ ___ 05:28PM BLOOD ___ ___ CTA head/neck 1. Normal head CT. 2. Patent circle of ___ without evidence of stenosis,occlusion,or aneurysm. 3. Patent bilateral cervical carotid and vertebral arteries without evidence of stenosis, occlusion, or dissection. Brief Hospital Course: #Suspected vestibular neuritis ___ is a ___ man with HTN, chronic hand pain, chronic headaches, and prediabetes, who presented from home with dizziness and nausea, likely due to vestibular neuritis. His symptoms began several days before the admission and were rapid in onset, causing severe nausea and gait instability. He was evaluated by neurology and noted to have rightward nystagmus, most severe with rightward eye movements. HINTS exam and all clinical features felt to be consistent with peripheral cause of vertigo and most consistent with vestibular neuritis. He was started on meclizine with slight improvement. Other treatments were held per neurology recommendations given lack of evidence for efficacy. The patient was able to tolerate POs and ambulate and preferred to return home. He was counseled on safety while at home and still symptomatic, as well as red flags that should prompt immediate return to care. He was given a small amount of meclizine in case there are moments when he needs symptom control in the upcoming days, but otherwise he was encouraged to avoid ___ to allow for recovery of his vestibular system. He was provided with a referral to vestibular ___ and should ___ closely with his PCP. Referral to neurology can be considered as an outpatient. # Leukocytosis In absence of other infectious symptoms, signs, possibly stress reaction. Improving prior to discharge # HTN Held amlodipine and HCTZ initially since not eating/drinking well, but restarted at discharge since PO intake improved. # Chronic headaches Reports frequent headaches relieved by Excedrin, not thought to be migraines, unclear cause. Consider outpatient referral to headache clinic. ====================== TRANSITIONAL ISSUES: - close PCP ___ - consider neurology referral if persistent symptoms - return to ED if new neurologic features - vestibular ___ referral given to patient ====================== Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Diclofenac Sodium ___ 50 mg PO TID:PRN pain 4. Excedrin Extra Strength (___) ___ mg oral DAILY:PRN headache Discharge Medications: 1. Meclizine 25 mg PO DAILY:PRN vertigo Duration: 3 Days RX meclizine 25 mg 1 tablet(s) by mouth daily as needed Disp #3 Tablet Refills:*0 2. amLODIPine 5 mg PO DAILY 3. Diclofenac Sodium ___ 50 mg PO TID:PRN pain 4. Excedrin Extra Strength (___) ___ mg oral DAILY:PRN headache 5. Hydrochlorothiazide 25 mg PO DAILY 6.Outpatient Physical Therapy ___ rehabilitation Diagnosis: vestibular neuritis (ICD 10 H81.2) Discharge Disposition: Home Discharge Diagnosis: Suspected vestibular neuritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital because of severe dizziness, which we suspect was due to vestibular neuritis, which is an inflammation of the vestibular system, which is involved in balance. It is often caused by a virus. This condition typically ___, and we expect that your symptoms will gradually improve in the upcoming ___. We have provided a referral for vestibular physical therapy, which can help in the recovery process. We have prescribed several pills of meclizine which you can take if needed for ongoing symptoms. As we discussed, you should exercise additional precautions when you return home to remain safe from falls if your symptoms persist. You should call ___ if you develop new symptoms of blurry or double vision, difficulty with speech, weakness, numbness, difficulty walking, or worsened coordination. If your current symptoms are slow to improve or are not improving over the upcoming days, then you should contact your primary care doctor. Followup Instructions: ___	[ "R42", "R110", "D72829", "R9431", "E876", "I10", "R51", "E039", "R7303", "Z87891" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: dizziness, nausea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] male with PMH HTN, chronic hand pain, chronic headaches, prediabetes, who presents from home with dizziness and nausea. Reports of onset of symptoms are variable, with ED reporting last [MASKED], patient reporting 2d PTA, outpatient notes reporting 4d PTA. Patient reported hyperacute onset of dizziness, feeling like the room is spinning around him, at first lasting a few minutes, then up to an hour, with nausea started day PTA, no vomiting, and feeling sweaty, resolving without intervention. Worse with opening his eyes (has been keeping them closed), head turn (esp to the right), position changes. Associated with R side tinnitus, which patient has had intermittently over years. No ear pain, fevers. No falls, LOC. In the ED at 12:30 [MASKED], code stroke was called given patient's severe nystagmus. PE showed: General: unwell appearing [MASKED] male n NAD HEENT: NC, AT. Significant nystagmus with central gaze. Right beating nystagmus, which initially appeared direction changing. Neck: no cervical lymphadenopathy Chest: CTAB CV: RRR, nrml s1/s2, no m/g/r. Abdomen: soft, [MASKED], no HSM Ext: no edema Neuro: AOx3, [MASKED] intact, ataxia appreciated, strength [MASKED] in all extremities, FNF intact, HINTS (performed after CT/CTA) corrective saccade and right beating nystagmus. No dysarthria. No aphasia. Symmetric face. CTA head and neck was done. CT head: No acute intracranial hemorrhage or infarct. CTA head and neck: The major vessels of the neck, circle of [MASKED], and their principal intracranial branches appear without flow limiting stenosis, occlusion, or formation of aneurysms larger than 3 mm. Hypoplastic left venous sinus. Final read pending reformats. Neurology recommendations: [MASKED] man who presented as a code stroke after several episodes of room spinning vertigo over the past 3 days. There are several reassuring findings on exam: Right beating nystagmus with rightward and leftward gaze, corrective saccades to the right, no nystagmus with vertical gaze, and absence of other neurological signs. The nystagmus worsened when fixation was interrupted, another feature of peripheral vertigo. Recommendations -symptomatic treatment of vertigo per ED -treatment of lab abnormalities per ED -return to ED if new symptoms such as weakness, aphasia, etc... -dispo per ED -if symptoms persist for more than 1 week, will need PCP referral to [MASKED] neurologist" Per conversation with ED, symptoms most consistent with vestibular neuritis. Otoscope exam was normal. Patient was not walking independently in ED, had assistance (counter to documented code stroke exam), but was initially feeling better and considered going home, but then had recurrence of symptoms. He received: [MASKED] 17:13 IV LORazepam 1 mg [MASKED] 22:31 PO Meclizine 25 mg [MASKED] 22:31 PO Potassium Chloride 40 mEq [MASKED] 22:33 PO Acetaminophen 650 mg Upon arrival to floor, patient reported the above story. He felt some relief with meclizine and Ativan. Reported almost blacking out when sat up for the CT scanner. Reported occasional R ear tinnitus (ringing, not pulsatile), usually if congested. He denied nasal congestion, sore throat, cough, dyspnea, CP, palpitations, lightheadness, abdominal pain, weakness/numbness/tingling, diarrhea, poor UOP. Reported poor PO intake today but good appetite. Has daily headaches for which he usually takes Excedrin. He has chronic hand pain related to MVC [MASKED] years ago and occasionally takes NSAIDs for this. Past Medical History: Essential hypertension obesity Colon adenoma Social History: [MASKED] Family History: Father Cancer - [MASKED] (70); Heart [MASKED] Mother [MASKED] No Significant Medical History Physical Exam: ADMISSION EXAM VITALS: 97.6 PO 137 / 85 L Lying 57 20 95 RA GENERAL: Alert, uncomfortable EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate Neck: no cervical LAD CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is [MASKED] GI: Abdomen soft, [MASKED] to palpation. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, central gaze and R beating nystagmus (do not see any on the left), speech fluent, moves all limbs, sensation to light touch grossly intact throughout, strength [MASKED] throughout, ni tact FNF, deferred ambulation PSYCH: pleasant, appropriate affect DISCHARGE EXAM 24 HR Data (last updated [MASKED] @ 727) Temp: 97.8 (Tm 97.8), BP: 124/76 ([MASKED]), HR: 58 ([MASKED]), RR: 18 ([MASKED]), O2 sat: 97% ([MASKED]), O2 delivery: RA, Wt: 285 lb/129.28 kg GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. MMMs CV: RRR no m/r/g RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is [MASKED] GI: Abdomen soft, [MASKED] to palpation. EXTR: wwp no edema NEURO: Alert, interactive, face symmetric, gaze conjugate with EOMI with severe horizontal nystagmys with rightward gaze, speech fluent, motor function grossly intact/symmetric, FTN intact bilaterally PSYCH: pleasant, appropriate affect Pertinent Results: Labs [MASKED] 04:10PM BLOOD [MASKED] [MASKED] Plt [MASKED] [MASKED] 07:15AM BLOOD [MASKED] [MASKED] Plt [MASKED] [MASKED] 04:10PM BLOOD [MASKED] [MASKED] [MASKED] 04:10PM BLOOD [MASKED] [MASKED] [MASKED] 07:15AM BLOOD [MASKED] [MASKED] [MASKED] 05:18PM BLOOD [MASKED] [MASKED] 05:18PM BLOOD cTropnT-<0.01 [MASKED] 05:18PM BLOOD [MASKED] [MASKED] 07:15AM BLOOD [MASKED] [MASKED] 05:18PM BLOOD [MASKED] [MASKED] [MASKED] 05:28PM BLOOD [MASKED] [MASKED] CTA head/neck 1. Normal head CT. 2. Patent circle of [MASKED] without evidence of stenosis,occlusion,or aneurysm. 3. Patent bilateral cervical carotid and vertebral arteries without evidence of stenosis, occlusion, or dissection. Brief Hospital Course: #Suspected vestibular neuritis [MASKED] is a [MASKED] man with HTN, chronic hand pain, chronic headaches, and prediabetes, who presented from home with dizziness and nausea, likely due to vestibular neuritis. His symptoms began several days before the admission and were rapid in onset, causing severe nausea and gait instability. He was evaluated by neurology and noted to have rightward nystagmus, most severe with rightward eye movements. HINTS exam and all clinical features felt to be consistent with peripheral cause of vertigo and most consistent with vestibular neuritis. He was started on meclizine with slight improvement. Other treatments were held per neurology recommendations given lack of evidence for efficacy. The patient was able to tolerate POs and ambulate and preferred to return home. He was counseled on safety while at home and still symptomatic, as well as red flags that should prompt immediate return to care. He was given a small amount of meclizine in case there are moments when he needs symptom control in the upcoming days, but otherwise he was encouraged to avoid [MASKED] to allow for recovery of his vestibular system. He was provided with a referral to vestibular [MASKED] and should [MASKED] closely with his PCP. Referral to neurology can be considered as an outpatient. # Leukocytosis In absence of other infectious symptoms, signs, possibly stress reaction. Improving prior to discharge # HTN Held amlodipine and HCTZ initially since not eating/drinking well, but restarted at discharge since PO intake improved. # Chronic headaches Reports frequent headaches relieved by Excedrin, not thought to be migraines, unclear cause. Consider outpatient referral to headache clinic. ====================== TRANSITIONAL ISSUES: - close PCP [MASKED] - consider neurology referral if persistent symptoms - return to ED if new neurologic features - vestibular [MASKED] referral given to patient ====================== Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Diclofenac Sodium [MASKED] 50 mg PO TID:PRN pain 4. Excedrin Extra Strength ([MASKED]) [MASKED] mg oral DAILY:PRN headache Discharge Medications: 1. Meclizine 25 mg PO DAILY:PRN vertigo Duration: 3 Days RX meclizine 25 mg 1 tablet(s) by mouth daily as needed Disp #3 Tablet Refills:*0 2. amLODIPine 5 mg PO DAILY 3. Diclofenac Sodium [MASKED] 50 mg PO TID:PRN pain 4. Excedrin Extra Strength ([MASKED]) [MASKED] mg oral DAILY:PRN headache 5. Hydrochlorothiazide 25 mg PO DAILY 6.Outpatient Physical Therapy [MASKED] rehabilitation Diagnosis: vestibular neuritis (ICD 10 H81.2) Discharge Disposition: Home Discharge Diagnosis: Suspected vestibular neuritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital because of severe dizziness, which we suspect was due to vestibular neuritis, which is an inflammation of the vestibular system, which is involved in balance. It is often caused by a virus. This condition typically [MASKED], and we expect that your symptoms will gradually improve in the upcoming [MASKED]. We have provided a referral for vestibular physical therapy, which can help in the recovery process. We have prescribed several pills of meclizine which you can take if needed for ongoing symptoms. As we discussed, you should exercise additional precautions when you return home to remain safe from falls if your symptoms persist. You should call [MASKED] if you develop new symptoms of blurry or double vision, difficulty with speech, weakness, numbness, difficulty walking, or worsened coordination. If your current symptoms are slow to improve or are not improving over the upcoming days, then you should contact your primary care doctor. Followup Instructions: [MASKED]	[]	[ "I10", "E039", "Z87891" ]	[ "R42: Dizziness and giddiness", "R110: Nausea", "D72829: Elevated white blood cell count, unspecified", "R9431: Abnormal electrocardiogram [ECG] [EKG]", "E876: Hypokalemia", "I10: Essential (primary) hypertension", "R51: Headache", "E039: Hypothyroidism, unspecified", "R7303: Prediabetes", "Z87891: Personal history of nicotine dependence" ]
10,095,417	20,201,867	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: tramadol Attending: ___. Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a pleasant ___ w/ pancreatic cancer (mets to liver, omentum) c/b DVT, gastric outlet obstruction, and hypercalcemia, now on an ivestigational drug, who is admitted from the ED with weakness. Patient was recently admitted from ___ - ___ for hypercalcemia c/b encephalopathy. Ca improved with IVF, calcitonin, and zometa (dosed ___. Hospital course was otherwise complicated by sinus tachycardia, hypervolemia, leukocytosis, elevated TBili, back pain, and thrush. During his stay, CTA was negative for PE and was started on fluconazole for persistent thrush. He also received 5 days of prednisone for back pain. He was discharged to rehab on ___. Since discharge he has continued to feel quite weak with very poor appetite. On ___ he was very somnolent and felt even more weak in his legs than usual. He reported to his family generalized malaise. After discussion with his family and oncology team, he was referred back to the ED. He denies any new fevers or chills. No URTI symptoms. He has dry throat but no frank dysphagia or odynophagia. No CP, SOB or cough. His abdomen feels like it is getting bigger, but no abdominal pain, nausea, or vomiting. His appetite is very poor. Normal BM on day prior to admission. No dysuria. He has increasing bilateral leg swelling over the last week or two. No new rashes. His chronic back pain is currently ___. In the ED, initial VS were pain 0, T 97.5, HR 80, BP 133/89, RR 16, O2 97%RA. Initial labs notable for Na 143, K 5.1, HCO3 20, Cr 0.8. Ca 8.9, ALT 75, AST 71, ALP 373, TBili 1.8, alb 2.6, WBC 24.2 (95%N), HCT 29.1, PLT 86, trop negative x1, Lactate 5.1-->4.7. CXR showed bilateral pleural effusions. RUQ US showed innumerable metastatic hepatic lesions without biliary dilation. Patient was given IV zosyn and IVF. VS prior to admission were T 97.6, HR 69, BP 136/85, RR 21, O2 96%RA. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: Pancreatic cancer stage IV - ___ Developed intermittent indigestion treated with Tums and some increased fatigue (annual jobs on the property now take longer to complete). - ___ When seen for routine PE by PCP, reported ___ ___ week h/o of new post-prandial epigastric and LUQ/rib discomfort and fullness (different from his indigestion). Due to these symptoms, he cut back on his eating which resulted in weight loss(10lbs). Initial concern for gastritis and started on Protonix. CXR and L rib plain films were normal. - ___ CT A/P was performed which unfortunately showed a large and infiltrative pancreatic body mass extending along the lesser curvature of the stomach and along the lateral aspect of the celiac axis, encasing the gastric artery. Two ill-defined lesions were noted in the liver (central/caudate and inferior R lobe) c/f mets. Extensive abdominal lymphadenopathy was also noted. Referred to Pancreas Center and imaging reviewed by ___ who recommended MRI liver for further characterization of liver lesion (caudate more suspicious, but not accessible percutaneously). Plan was to attempt to biopsy R lobe lesion if suspicious enough on MRI. - ___ MR liver showed multiple liver and omental mets as well as a pancreatic primary - ___ Omental biopsy positive for malignant cells, HA high - ___ Signed informed consent for HALO3 - ___ Found to have DVT, ineligible for HALO3, consented for ___ ___ and randomized to edoxiban - ___ C1D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - ___ C2D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - ___ CT torso showed interval improvement in disease with interval increase in the necrotic components of the large pancreatic body mass with extensive arterial and venous involvement and decrease in size and/or interval necrosis of some of the retroperitoneal lymph nodes and omental metastases as above. - ___ C3D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - ___ C4D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 ___ - ___ - hospitalized with severe fatigue, dizziness and anemia, improved with 2U PRBCs. He also had ___ and a rash over his upper arms. Echo was normal. Hemolysis labs wnl, PE was considered but given his rapid improvement after blood transfusion was not performed. Edoxaban was briefly held but stool guiac was negative on several occasions and resumed with stable Hgb. - ___ - C5D1 gemcitabine 1000 mg/m2 NAB paclitaxel 100 mg/m2 D1,8,15 (dose reduced 20%) - ___ - C5D15 treatment held due to progressive neuropathy and severe leg edema leading to worse performance status - ___ - admitted with fever and found to have E coli bacteremia with sepsis. MRCP showed micro-hepatic abscesses and mild intrahepatic biliary ductal dilatation involving the left of the liver. He underwent ERCP and plastic CBD stent was placed prophylactically on ___ with plan for repeat ERCP in ___ weeks. He was initially treated with IV zosyn, cx remained negative and he completed 4 week course of oral ciprofloxacin after discharge. Stent was removed ___. - ___ treatment break - ___ CT torso: progression with increase in multiple hepatic lesions, peritoneal and omental disease. Stable mass. - ___: C1D1 26 hr ___ infusion 2400mg/m2 plus leucovorin 400mg/m2 with liposomal irinotecan 70mg/m2 (per ___ regimen) - ___: C2D1 ___ irinotecan - ___: C3D1 ___ irinotecan - ___: C4D1 ___ irinotecan - ___: C5D1 ___ irinotecan - ___: C6D1 ___ irinotecan - ___: C7D1 ___ irinotecan - ___: C8D1 ___ irinotecan - ___: CT torso with disease progression in hepatic mets, large pancreatic mass, abdominal carcinomatosis with ascites - ___: C1D1 Clinical trial ___ - ___ - ___: Admitted for hypercalcemia and confusion PAST MEDICAL HISTORY: - Metastatic pancreatic cancer, as above - DVT - E. coli bacteremia; hepatic microabscess/biliary obstruction; sp ERCP ___ with plastic stent removal on ___ - Gastric outlet obstruction: EGD ___ with stent placement deferred - Neuropathy Social History: ___ Family History: As per admitting MD: Mother with dementia, possibly with cancer at the end of her life. Father with hypertension and ___. Paternal cousin with some sort of cancer, unknown type. Daughter with thyroid cancer. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== T 97.6 BP 131/87 HR 73 RR 18 O2 97%RA GENERAL: Pleasant, chronically ill appearing man but in no acute distress EYES: Anicteric sclerea, PERLL, EOMI; ENT: Dry MM with white plaque over tongue, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, decreased BS halfway up lungs bilaterally with fair air movement GASTROINTESTINAL: Normal bowel sounds; moderately distended but not tense; soft, nontender without rebound or guarding MUSKULOSKELATAL: 2+ lower extremity edema bilaterally up to knees; Decreased bulk NEURO: Alert, oriented, CN III-XII intact, antigravity strength intact in all limbs. SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE PHYSICAL EXAM ======================== VS: RR 16 GENERAL: Chronically-ill appearing, emaciated gentleman in anasarca. Somnolent, in no distress. HEENT: Mild scleral icterus, PERLL, Mucous membranes dry, oropharynx clear. CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops. LUNG: Appears in no respiratory distress, clear to anterior auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Globulous but non-tense, no collateral circulation, normal bowel sounds, soft, non-tender. EXT: Warm, well perfused. 1+ bilateral lower extremity edema (R>L). No erythema or tenderness. NEURO: Somnolent, short attention span. Diffusely weak but able to move four extremities at will. SKIN: No significant rashes. Pertinent Results: ___ 07:30PM BLOOD WBC-24.2* RBC-3.13* Hgb-9.5* Hct-29.1* MCV-93 MCH-30.4 MCHC-32.6 RDW-22.8* RDWSD-71.4* Plt Ct-86* ___ 06:00AM BLOOD WBC-18.2* RBC-2.93* Hgb-9.0* Hct-27.4* MCV-94 MCH-30.7 MCHC-32.8 RDW-25.5* RDWSD-82.8* Plt Ct-77* ___ 07:30PM BLOOD Neuts-94.8* Lymphs-1.5* Monos-2.7* Eos-0.0* Baso-0.1 Im ___ AbsNeut-22.89* AbsLymp-0.36* AbsMono-0.66 AbsEos-0.01* AbsBaso-0.02 ___ 06:00AM BLOOD Neuts-91.7* Lymphs-2.1* Monos-5.3 Eos-0.0* Baso-0.1 Im ___ AbsNeut-16.70* AbsLymp-0.38* AbsMono-0.97* AbsEos-0.00* AbsBaso-0.01 ___ 04:21AM BLOOD ___ PTT-41.8* ___ ___ 06:00AM BLOOD ___ PTT-141.1* ___ ___ 07:30PM BLOOD Glucose-161* UreaN-39* Creat-0.8 Na-143 K-5.1 Cl-105 HCO3-20* AnGap-18 ___ 06:00AM BLOOD Glucose-139* UreaN-30* Creat-0.9 Na-141 K-4.3 Cl-102 HCO3-23 AnGap-16 ___ 07:30PM BLOOD ALT-75* AST-71* AlkPhos-373* TotBili-1.8* ___ 06:00AM BLOOD ALT-144* AST-162* LD(LDH)-517* AlkPhos-244* TotBili-3.7* ___ 07:30PM BLOOD Albumin-2.6* Calcium-8.9 Phos-2.7 Mg-2.1 ___ 06:00AM BLOOD Albumin-3.6 Calcium-9.6 Phos-2.7 Mg-2.0 ___ 07:50PM BLOOD Lactate-5.1* ___ 08:27AM BLOOD Lactate-4.7* Brief Hospital Course: Mr. ___ is a pleasant ___ year-old gentleman with metastatic pancreatic cancer c/b DVT, gastric outlet obstruction now on ___ presenting with weakness, volume overload and found to have impending liver failure due to diffuse malignant infiltration of the liver. Now transitioned to ___ ___ care, discharged home with hospice #Metastatic Pancreatic Adenocarcinoma: Having failed 4 lines of treatment. On MRCP was found to have progression of disease with complete replacement of liver parenchyma by tumor leading to imminent liver failure. No longer a candidate for clinical trial. After discussions with primary oncologist, patient's goal is home with hospice. #Weakness #Acute Liver failure Patient presented with apparent rapid decline from discharge. Even though it is difficult to exclude an underlying acute process there was clear evidence of liver failure per his rising bilirubin and INR with now some evidence of hypoactive encephalopathy. The cause of his liver failure is irreversible, diffuse replacement of liver parenchyma by metastatic disease which is refractory to all treatment options offered. He received supportive care. #Chronic cancer related pain: Had minimal pain until day of discharge when he developed ___ back pain. As wife preferred to avoid narcotics or acetaminophen initially, ketorolac iv was given with some improvement. He was then agreable to start liquid acetaminophen and oral concentrated morphine to good effect. #Concern for cholangitis vs. SBP Per report he appeared well and walked on ___ prior to discharge to rehab but immediately became weak upon arrival to rehab. He did not have any fevers but disi present with leukocytosis. His urine was sterile, he did not have productive cough or a consolidation in his chest imaging. His leukocytosis decreased with initiation of antibiotics favoring the hypothesis of underlying infection will complete course for cholangitis vs. SBP at home with oral amoxicillin-clavulanate. #Anasarca: Secondary to aggressive fluid resusctiation during recent episode of hypercalcemia as well as severe hypoalbuminemia in setting of malnutrition and cachexia. Improved with initial aggressive diuresis. #Malignant ascites: Secondary to peritoneal involvement by adenocarcinoma. Abdomen is globulous but non-tense. ___ partially contribute to early satiety. Patient felt his abdomen did not bother him enough to undergo paracentesis. #DVT: Chronic vs recurrent. Patient was switched back to enoxaparin given ongoing liver failure and unpredictable pharmacokinetics of DOAC in this setting. Also having coagulopathy from liver failure which tends to favor thrombosis more than bleeding. Nonetheless given nuisance of subcutaneous injections in setting of new goal of comfort enoxaparin stopped per patient preference. #Severe protein calorie malnutrition: Poor po intake >7 days, temporal wasting and severe hypoalbuminemia. Nutrition recommended TF but no longer within goals. Received food for pleasure. #Oral candidiasis: Completed course of fluconazole. Resolved. TRANSITIONAL ISSUES =================== #NEW CODE STATUS: DNAR/DNI, COMFORT MEASURES ONLY #To complete 2 more days of amoxicillin-clavulanate for cholangitis This patient's discharge plan formulation, coordination and communication took 120 minutes. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Atenolol 25 mg PO DAILY 3. Finasteride 5 mg PO QHS 4. FoLIC Acid 1 mg PO DAILY 5. Mirtazapine 30 mg PO QHS 6. Nystatin Oral Suspension 5 mL PO QID 7. Ondansetron 8 mg PO Q8H:PRN nausea 8. Pantoprazole 40 mg PO Q24H 9. Prochlorperazine 10 mg PO Q6H:PRN nausea 10. Bisacodyl 10 mg PO DAILY 11. Docusate Sodium 100 mg PO BID 12. Fluconazole 200 mg PO Q24H 13. Lidocaine 5% Patch 1 PTCH TD QPM 14. Senna 8.6 mg PO BID 15. Centrum Silver (multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1 tav oral DAILY 16. cod liver oil 1,250-135 unit oral DAILY 17. Pyridoxine 100 mg PO DAILY 18. saw ___ 1080 mg oral BID Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild part of care package 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 3 Days RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #6 Tablet Refills:0 3. Caphosol 30 mL ORAL QID:PRN dry mouth RX saliva substitute combo no.2 [Caphosol] 30mL, swish and spit/swallow four times a day Refills:0 4. Dexamethasone 4 mg PO QAM RX dexamethasone 4 mg 1 tablet(s) by mouth every morning Disp #30 Tablet Refills:0 5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY RX lansoprazole [Prevacid SoluTab] 30 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 6. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___ mg PO Q2H:PRN Pain - Severe part of care package 7. Spironolactone 25 mg PO DAILY RX spironolactone 25 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 8. Torsemide 10 mg PO BID:PRN discomfort with edema RX torsemide 10 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:*0 9. Lidocaine 5% Patch 1 PTCH TD QAM 10. Lidocaine 5% Patch 1 PTCH TD QPM 11. Mirtazapine 30 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute liver failure from tumor infiltration Chronic cancer associated pain Anasarca Malignant ascites Cholangitis Metastatic pancreatic adenocarcinoma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital with fatigue, leg swelling and liver failure. We found it was due to your cancer getting worse. After discussing it with Dr. ___ decided to go home to be comfortable. It was a pleasure to take care of you. Your ___ Team Followup Instructions: ___	[ "K7200", "E43", "C787", "C786", "K311", "C251", "E8809", "D6481", "D6959", "E8339", "Z6825", "Z923", "Z515", "Z66", "T451X5A", "Z86718", "B379", "E8342", "G893", "Z8673" ]	Allergies: tramadol Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a pleasant [MASKED] w/ pancreatic cancer (mets to liver, omentum) c/b DVT, gastric outlet obstruction, and hypercalcemia, now on an ivestigational drug, who is admitted from the ED with weakness. Patient was recently admitted from [MASKED] - [MASKED] for hypercalcemia c/b encephalopathy. Ca improved with IVF, calcitonin, and zometa (dosed [MASKED]. Hospital course was otherwise complicated by sinus tachycardia, hypervolemia, leukocytosis, elevated TBili, back pain, and thrush. During his stay, CTA was negative for PE and was started on fluconazole for persistent thrush. He also received 5 days of prednisone for back pain. He was discharged to rehab on [MASKED]. Since discharge he has continued to feel quite weak with very poor appetite. On [MASKED] he was very somnolent and felt even more weak in his legs than usual. He reported to his family generalized malaise. After discussion with his family and oncology team, he was referred back to the ED. He denies any new fevers or chills. No URTI symptoms. He has dry throat but no frank dysphagia or odynophagia. No CP, SOB or cough. His abdomen feels like it is getting bigger, but no abdominal pain, nausea, or vomiting. His appetite is very poor. Normal BM on day prior to admission. No dysuria. He has increasing bilateral leg swelling over the last week or two. No new rashes. His chronic back pain is currently [MASKED]. In the ED, initial VS were pain 0, T 97.5, HR 80, BP 133/89, RR 16, O2 97%RA. Initial labs notable for Na 143, K 5.1, HCO3 20, Cr 0.8. Ca 8.9, ALT 75, AST 71, ALP 373, TBili 1.8, alb 2.6, WBC 24.2 (95%N), HCT 29.1, PLT 86, trop negative x1, Lactate 5.1-->4.7. CXR showed bilateral pleural effusions. RUQ US showed innumerable metastatic hepatic lesions without biliary dilation. Patient was given IV zosyn and IVF. VS prior to admission were T 97.6, HR 69, BP 136/85, RR 21, O2 96%RA. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: Pancreatic cancer stage IV - [MASKED] Developed intermittent indigestion treated with Tums and some increased fatigue (annual jobs on the property now take longer to complete). - [MASKED] When seen for routine PE by PCP, reported [MASKED] [MASKED] week h/o of new post-prandial epigastric and LUQ/rib discomfort and fullness (different from his indigestion). Due to these symptoms, he cut back on his eating which resulted in weight loss(10lbs). Initial concern for gastritis and started on Protonix. CXR and L rib plain films were normal. - [MASKED] CT A/P was performed which unfortunately showed a large and infiltrative pancreatic body mass extending along the lesser curvature of the stomach and along the lateral aspect of the celiac axis, encasing the gastric artery. Two ill-defined lesions were noted in the liver (central/caudate and inferior R lobe) c/f mets. Extensive abdominal lymphadenopathy was also noted. Referred to Pancreas Center and imaging reviewed by [MASKED] who recommended MRI liver for further characterization of liver lesion (caudate more suspicious, but not accessible percutaneously). Plan was to attempt to biopsy R lobe lesion if suspicious enough on MRI. - [MASKED] MR liver showed multiple liver and omental mets as well as a pancreatic primary - [MASKED] Omental biopsy positive for malignant cells, HA high - [MASKED] Signed informed consent for HALO3 - [MASKED] Found to have DVT, ineligible for HALO3, consented for [MASKED] [MASKED] and randomized to edoxiban - [MASKED] C1D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - [MASKED] C2D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - [MASKED] CT torso showed interval improvement in disease with interval increase in the necrotic components of the large pancreatic body mass with extensive arterial and venous involvement and decrease in size and/or interval necrosis of some of the retroperitoneal lymph nodes and omental metastases as above. - [MASKED] C3D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - [MASKED] C4D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 [MASKED] - [MASKED] - hospitalized with severe fatigue, dizziness and anemia, improved with 2U PRBCs. He also had [MASKED] and a rash over his upper arms. Echo was normal. Hemolysis labs wnl, PE was considered but given his rapid improvement after blood transfusion was not performed. Edoxaban was briefly held but stool guiac was negative on several occasions and resumed with stable Hgb. - [MASKED] - C5D1 gemcitabine 1000 mg/m2 NAB paclitaxel 100 mg/m2 D1,8,15 (dose reduced 20%) - [MASKED] - C5D15 treatment held due to progressive neuropathy and severe leg edema leading to worse performance status - [MASKED] - admitted with fever and found to have E coli bacteremia with sepsis. MRCP showed micro-hepatic abscesses and mild intrahepatic biliary ductal dilatation involving the left of the liver. He underwent ERCP and plastic CBD stent was placed prophylactically on [MASKED] with plan for repeat ERCP in [MASKED] weeks. He was initially treated with IV zosyn, cx remained negative and he completed 4 week course of oral ciprofloxacin after discharge. Stent was removed [MASKED]. - [MASKED] treatment break - [MASKED] CT torso: progression with increase in multiple hepatic lesions, peritoneal and omental disease. Stable mass. - [MASKED]: C1D1 26 hr [MASKED] infusion 2400mg/m2 plus leucovorin 400mg/m2 with liposomal irinotecan 70mg/m2 (per [MASKED] regimen) - [MASKED]: C2D1 [MASKED] irinotecan - [MASKED]: C3D1 [MASKED] irinotecan - [MASKED]: C4D1 [MASKED] irinotecan - [MASKED]: C5D1 [MASKED] irinotecan - [MASKED]: C6D1 [MASKED] irinotecan - [MASKED]: C7D1 [MASKED] irinotecan - [MASKED]: C8D1 [MASKED] irinotecan - [MASKED]: CT torso with disease progression in hepatic mets, large pancreatic mass, abdominal carcinomatosis with ascites - [MASKED]: C1D1 Clinical trial [MASKED] - [MASKED] - [MASKED]: Admitted for hypercalcemia and confusion PAST MEDICAL HISTORY: - Metastatic pancreatic cancer, as above - DVT - E. coli bacteremia; hepatic microabscess/biliary obstruction; sp ERCP [MASKED] with plastic stent removal on [MASKED] - Gastric outlet obstruction: EGD [MASKED] with stent placement deferred - Neuropathy Social History: [MASKED] Family History: As per admitting MD: Mother with dementia, possibly with cancer at the end of her life. Father with hypertension and [MASKED]. Paternal cousin with some sort of cancer, unknown type. Daughter with thyroid cancer. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== T 97.6 BP 131/87 HR 73 RR 18 O2 97%RA GENERAL: Pleasant, chronically ill appearing man but in no acute distress EYES: Anicteric sclerea, PERLL, EOMI; ENT: Dry MM with white plaque over tongue, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, decreased BS halfway up lungs bilaterally with fair air movement GASTROINTESTINAL: Normal bowel sounds; moderately distended but not tense; soft, nontender without rebound or guarding MUSKULOSKELATAL: 2+ lower extremity edema bilaterally up to knees; Decreased bulk NEURO: Alert, oriented, CN III-XII intact, antigravity strength intact in all limbs. SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE PHYSICAL EXAM ======================== VS: RR 16 GENERAL: Chronically-ill appearing, emaciated gentleman in anasarca. Somnolent, in no distress. HEENT: Mild scleral icterus, PERLL, Mucous membranes dry, oropharynx clear. CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops. LUNG: Appears in no respiratory distress, clear to anterior auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Globulous but non-tense, no collateral circulation, normal bowel sounds, soft, non-tender. EXT: Warm, well perfused. 1+ bilateral lower extremity edema (R>L). No erythema or tenderness. NEURO: Somnolent, short attention span. Diffusely weak but able to move four extremities at will. SKIN: No significant rashes. Pertinent Results: [MASKED] 07:30PM BLOOD WBC-24.2* RBC-3.13* Hgb-9.5* Hct-29.1* MCV-93 MCH-30.4 MCHC-32.6 RDW-22.8* RDWSD-71.4* Plt Ct-86* [MASKED] 06:00AM BLOOD WBC-18.2* RBC-2.93* Hgb-9.0* Hct-27.4* MCV-94 MCH-30.7 MCHC-32.8 RDW-25.5* RDWSD-82.8* Plt Ct-77* [MASKED] 07:30PM BLOOD Neuts-94.8* Lymphs-1.5* Monos-2.7* Eos-0.0* Baso-0.1 Im [MASKED] AbsNeut-22.89* AbsLymp-0.36* AbsMono-0.66 AbsEos-0.01* AbsBaso-0.02 [MASKED] 06:00AM BLOOD Neuts-91.7* Lymphs-2.1* Monos-5.3 Eos-0.0* Baso-0.1 Im [MASKED] AbsNeut-16.70* AbsLymp-0.38* AbsMono-0.97* AbsEos-0.00* AbsBaso-0.01 [MASKED] 04:21AM BLOOD [MASKED] PTT-41.8* [MASKED] [MASKED] 06:00AM BLOOD [MASKED] PTT-141.1* [MASKED] [MASKED] 07:30PM BLOOD Glucose-161* UreaN-39* Creat-0.8 Na-143 K-5.1 Cl-105 HCO3-20* AnGap-18 [MASKED] 06:00AM BLOOD Glucose-139* UreaN-30* Creat-0.9 Na-141 K-4.3 Cl-102 HCO3-23 AnGap-16 [MASKED] 07:30PM BLOOD ALT-75* AST-71* AlkPhos-373* TotBili-1.8* [MASKED] 06:00AM BLOOD ALT-144* AST-162* LD(LDH)-517* AlkPhos-244* TotBili-3.7* [MASKED] 07:30PM BLOOD Albumin-2.6* Calcium-8.9 Phos-2.7 Mg-2.1 [MASKED] 06:00AM BLOOD Albumin-3.6 Calcium-9.6 Phos-2.7 Mg-2.0 [MASKED] 07:50PM BLOOD Lactate-5.1* [MASKED] 08:27AM BLOOD Lactate-4.7* Brief Hospital Course: Mr. [MASKED] is a pleasant [MASKED] year-old gentleman with metastatic pancreatic cancer c/b DVT, gastric outlet obstruction now on [MASKED] presenting with weakness, volume overload and found to have impending liver failure due to diffuse malignant infiltration of the liver. Now transitioned to [MASKED] [MASKED] care, discharged home with hospice #Metastatic Pancreatic Adenocarcinoma: Having failed 4 lines of treatment. On MRCP was found to have progression of disease with complete replacement of liver parenchyma by tumor leading to imminent liver failure. No longer a candidate for clinical trial. After discussions with primary oncologist, patient's goal is home with hospice. #Weakness #Acute Liver failure Patient presented with apparent rapid decline from discharge. Even though it is difficult to exclude an underlying acute process there was clear evidence of liver failure per his rising bilirubin and INR with now some evidence of hypoactive encephalopathy. The cause of his liver failure is irreversible, diffuse replacement of liver parenchyma by metastatic disease which is refractory to all treatment options offered. He received supportive care. #Chronic cancer related pain: Had minimal pain until day of discharge when he developed [MASKED] back pain. As wife preferred to avoid narcotics or acetaminophen initially, ketorolac iv was given with some improvement. He was then agreable to start liquid acetaminophen and oral concentrated morphine to good effect. #Concern for cholangitis vs. SBP Per report he appeared well and walked on [MASKED] prior to discharge to rehab but immediately became weak upon arrival to rehab. He did not have any fevers but disi present with leukocytosis. His urine was sterile, he did not have productive cough or a consolidation in his chest imaging. His leukocytosis decreased with initiation of antibiotics favoring the hypothesis of underlying infection will complete course for cholangitis vs. SBP at home with oral amoxicillin-clavulanate. #Anasarca: Secondary to aggressive fluid resusctiation during recent episode of hypercalcemia as well as severe hypoalbuminemia in setting of malnutrition and cachexia. Improved with initial aggressive diuresis. #Malignant ascites: Secondary to peritoneal involvement by adenocarcinoma. Abdomen is globulous but non-tense. [MASKED] partially contribute to early satiety. Patient felt his abdomen did not bother him enough to undergo paracentesis. #DVT: Chronic vs recurrent. Patient was switched back to enoxaparin given ongoing liver failure and unpredictable pharmacokinetics of DOAC in this setting. Also having coagulopathy from liver failure which tends to favor thrombosis more than bleeding. Nonetheless given nuisance of subcutaneous injections in setting of new goal of comfort enoxaparin stopped per patient preference. #Severe protein calorie malnutrition: Poor po intake >7 days, temporal wasting and severe hypoalbuminemia. Nutrition recommended TF but no longer within goals. Received food for pleasure. #Oral candidiasis: Completed course of fluconazole. Resolved. TRANSITIONAL ISSUES =================== #NEW CODE STATUS: DNAR/DNI, COMFORT MEASURES ONLY #To complete 2 more days of amoxicillin-clavulanate for cholangitis This patient's discharge plan formulation, coordination and communication took 120 minutes. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Atenolol 25 mg PO DAILY 3. Finasteride 5 mg PO QHS 4. FoLIC Acid 1 mg PO DAILY 5. Mirtazapine 30 mg PO QHS 6. Nystatin Oral Suspension 5 mL PO QID 7. Ondansetron 8 mg PO Q8H:PRN nausea 8. Pantoprazole 40 mg PO Q24H 9. Prochlorperazine 10 mg PO Q6H:PRN nausea 10. Bisacodyl 10 mg PO DAILY 11. Docusate Sodium 100 mg PO BID 12. Fluconazole 200 mg PO Q24H 13. Lidocaine 5% Patch 1 PTCH TD QPM 14. Senna 8.6 mg PO BID 15. Centrum Silver (multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1 tav oral DAILY 16. cod liver oil 1,250-135 unit oral DAILY 17. Pyridoxine 100 mg PO DAILY 18. saw [MASKED] 1080 mg oral BID Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild part of care package 2. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H Duration: 3 Days RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #6 Tablet Refills:0 3. Caphosol 30 mL ORAL QID:PRN dry mouth RX saliva substitute combo no.2 [Caphosol] 30mL, swish and spit/swallow four times a day Refills:0 4. Dexamethasone 4 mg PO QAM RX dexamethasone 4 mg 1 tablet(s) by mouth every morning Disp #30 Tablet Refills:0 5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY RX lansoprazole [Prevacid SoluTab] 30 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 6. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL [MASKED] mg PO Q2H:PRN Pain - Severe part of care package 7. Spironolactone 25 mg PO DAILY RX spironolactone 25 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 8. Torsemide 10 mg PO BID:PRN discomfort with edema RX torsemide 10 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:*0 9. Lidocaine 5% Patch 1 PTCH TD QAM 10. Lidocaine 5% Patch 1 PTCH TD QPM 11. Mirtazapine 30 mg PO QHS Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Acute liver failure from tumor infiltration Chronic cancer associated pain Anasarca Malignant ascites Cholangitis Metastatic pancreatic adenocarcinoma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital with fatigue, leg swelling and liver failure. We found it was due to your cancer getting worse. After discussing it with Dr. [MASKED] decided to go home to be comfortable. It was a pleasure to take care of you. Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "Z515", "Z66", "Z86718", "Z8673" ]	[ "K7200: Acute and subacute hepatic failure without coma", "E43: Unspecified severe protein-calorie malnutrition", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "K311: Adult hypertrophic pyloric stenosis", "C251: Malignant neoplasm of body of pancreas", "E8809: Other disorders of plasma-protein metabolism, not elsewhere classified", "D6481: Anemia due to antineoplastic chemotherapy", "D6959: Other secondary thrombocytopenia", "E8339: Other disorders of phosphorus metabolism", "Z6825: Body mass index [BMI] 25.0-25.9, adult", "Z923: Personal history of irradiation", "Z515: Encounter for palliative care", "Z66: Do not resuscitate", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Z86718: Personal history of other venous thrombosis and embolism", "B379: Candidiasis, unspecified", "E8342: Hypomagnesemia", "G893: Neoplasm related pain (acute) (chronic)", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]
10,095,417	20,698,864	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: tramadol Attending: ___ Chief Complaint: anemia Major Surgical or Invasive Procedure: none History of Present Illness: ============================================================= ONCOLOGY HOSPITALIST ADMISSION NOTE ___ ============================================================= PRIMARY ONCOLOGIST: ___ PRIMARY DIAGNOSIS: Metastatic pancreatic cancer TREATMENT REGIMEN: Gemcitabine/Abraxane C4D1 ___ CC: ___ HISTORY OF PRESENTING ILLNESS: ___ is a ___ man with metastatic pancreatic cancer on palliative gemcitabine who is admitted from clinic with several days of progressive fatigue found to have acutely worsened anemia and ___. Patient underwent C4D15 gem/abraxane last ___. On ___ he began to develop generalized malaise and fatigue. Over the week this progressed and he began to feel very unsteady, dizzy, and'wobbly' on his feet. No frank vertigo. By morning of admission he had developed such profound dyspnea on exertion he could only take a few steps. During this time he has also noted a new non-pruritic rash over his arms and legs, with a separate painful lesion on his left distal leg. Due to these symptoms he was urgently seen in ___ clinic today. In clinic he was found to have acute worsening of his anemia to 7.3 (was 9.2 on ___. Also with ___ with Cr to 1.4 (1.2 on ___, Na of 132, and HCO3 of 18. He was ill appearing and functioning well below his baseline. He was given 1L IVF and 1 unit pRBC before direct admission. On arrival to the floor, patient reports generalized malaise, rash, and DOE as above. Otherwise, he denies any fevers or chills. No headaches. No dysphagia. He has chronic rhinitis with mild sore throat in the morning. No shortness of breath at rest. No chest pain or pleuritic pain. No cough. No N/V. Appetitite is good. Has had loose stool after chemotherapy, but had formed BM today. No hematochezia or melena. No dysuria. No leg pain or swelling. Past Medical History: PAST ONCOLOGIC HISTORY: Pancreatic cancer stage IV - ___ Developed intermittent indigestion treated with Tums and some increased fatigue (annual jobs on the property now take longer to complete). - ___ When seen for routine PE by PCP, reported ___ ___ week h/o of new post-prandial epigastric and LUQ/rib discomfort and fullness (different from his indigestion). Due to these symptoms, he cut back on his eating which resulted in weight loss (10lbs). Initial concern for gastritis and started on Protonix. CXR and L rib plain films were normal. - ___ CT A/P was performed which unfortunately showed a large and infiltrative pancreatic body mass extending along the lesser curvature of the stomach and along the lateral aspect of the celiac axis, encasing the gastric artery. Two ill-defined lesions were noted in the liver (central/caudate and inferior R lobe) c/f mets. Extensive abdominal lymphadenopathy was also noted. Referred to Pancreas Center and imaging reviewed by ___ who recommended MRI liver for further characterization of liver lesion (caudate more suspicious, but not accessible percutaneously). Plan was to attempt to biopsy R lobe lesion if suspicious enough on MRI. - ___ MR liver showed multiple liver and omental mets as well as a pancreatic primary - ___ Omental biopsy positive for malignant cells, HA high - ___ Signed informed consent for HALO3 - ___ Found to have DVT, ineligible for HALO3, consented for ___ ___ and randomized to edoxiban - ___ C1D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - ___ C2D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - ___ CT torso showed interval improvement in disease with interval increase in the necrotic components of the large pancreatic body mass with extensive arterial and venous involvement and decrease in size and/or interval necrosis of some of the retroperitoneal lymph nodes and omental metastases as above. - ___ C3D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - ___ C4D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 PAST MEDICAL HISTORY: 1. Knee replacement x 2. 2. Hernia x 2. 3. Status post PE postoperatively in ___ status post six months of anticoagulation with no recurrent clots. 4. Hypertension. 5. BPH. 6. Folate deficiency. 7. Osteoarthritis. 8. DVT ___ Social History: ___ Family History: FAMILY HISTORY: 1. Mother with dementia, possibly with cancer at the end of her life. 2. Father with hypertension and ___. 3. Paternal cousin with some sort of cancer, unknown type. 4. Daughter with thyroid cancer. Physical Exam: VITAL SIGNS: 98.1 ___ 94Ra General: NAD HEENT: MMM, no OP lesions, no cervical adenopathy CV: RR, NL S1S2 no S3S4, no MRG PULM: CTAB, respirations unlabored ABD: BS+, soft, NTND LIMBS: No ___ SKIN: Rash on ext now desquamating w/ bright pink skin underneath, no blisters or bleeding, no petechiae Pertinent Results: ___ 05:39AM BLOOD WBC-3.8* RBC-2.74* Hgb-8.5* Hct-26.3* MCV-96 MCH-31.0 MCHC-32.3 RDW-18.5* RDWSD-64.4* Plt ___ ___ 05:39AM BLOOD Glucose-139* UreaN-23* Creat-0.9 Na-138 K-4.0 Cl-108 HCO3-23 AnGap-11 ___ 05:39AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.___ w/ metastatic pancreatic cancer on palliative gemcitabine who is admitted from clinic with several days of progressive fatigue found to have acutely worsened anemia and ___. # Weakness # Dyspnea on exertion: DOE is much improved after PRBC. No acute findings on CXR. EKG non-ischemic. Infectious w/u neg. Continues to have DOE but that has preceded the anemia and chronic. He is on treatment dose edoxaban. He was able to ambulate in the hallways at the time of discharge w/o DOE. # Anemia: Initially concern for gemcitabine induced HUS given ___ and ___, labs not c/w hemolysis. History and exam not c/w occult hemorrhage. Stool from ___ is guaiac neg. Vit b12 wnl, Iron studies WNL, folate wnl, as well as TSH. Received 1 unit pRBC in clinic PTA w/ improvement of hg from 7.3 to 8.3. Edoxaban was resumed on ___. However it dropped again to 7.6 on ___ am, so received 1U PRBC w/ improvement to 8.6. No obv source of bleeding nor hemolysis, now stable at 8.5 at time of discharge. He will have repeat CBC on ___ in ___ clinic. Seems to do best w/ Hg >8, so consider transfusing for Hg <8. Most likely etiology chemotherapy induced. # ___: Creatinine elevated to 1.4 in clinic. Improved w/ hydration and PRBC. Resumed home lisinopril at lower dose # Sinus Tach Pt is persistently tachy to 130s-150s on ambulation w/ DOE and no CP. This resolved w/ transfusion and resuming home atenolol. TTE did not reveal any overt causes or changes from his cardiologist's TTE done last year. # Rash: Unclear etiology but resolving spontaneously. Does not appear to be a typical drug eruption. In light of low grade fevers, possibly viral vs idiosyncratic chemo reaction. # DVT: Currently on ___ ___. Resumed edoxaban ___ and monitor closely for overt bleeding. # Pancreatic cancer: Currently C4 palliative gemcitabine. Known mets to liver and abdominal LAD. Will f/u with oncology team on ___. # GERD: On PPI # HTN: Discussed plan w/ his PCP/cardiologist. Had to make adjustments due to orthostatic hypotension and relative hypotension on admission. - stopped home amlodipine - resumed atenolol and lisinopril - can uptitrate lisinopril as outpatient # Hyperglycemia Pt had persistent ___ 130s-180s fasting c/w dx of diabetes, likely due to pancreatic ca. Seen by ___ and pt was set up with glucometer and ___, instructed to keep logs at home to bring to his ___ clinic appointment. They recommend considering giving low dose 5U Lantus if giving dexamethasone w/ chemotherapy, or at least close monitoring. # Deconditioning: Pt needs to use walker and was set up w/ home ___ ACCESS: POC CODE: Full (presumed) COMMUNICATION: Patient EMERGENCY CONTACT HCP: Health care proxy chosen: Yes Name of health care proxy: ___ Relationship: wife Phone number: ___ Cell phone: ___ DISPO: home w/ ___ BILLING: >30 min spent coordinating care for discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Atenolol 25 mg PO 3X/WEEK (___) 3. Finasteride 5 mg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. Ondansetron 8 mg PO Q8H:PRN nausea 6. Pantoprazole 40 mg PO Q24H 7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 8. Prochlorperazine 10 mg PO Q6H:PRN nausea 9. Centrum Silver Ultra Mens (multivit-min-FA-lycopen-lutein) ___ mcg oral DAILY 10. saw ___ 1000 mg oral DAILY 11. cod liver oil 1,250-135 unit oral DAILY Discharge Medications: 1. edoxaban Study Med 60 mg po DAILY 2. Atenolol 12.5 mg PO DAILY RX atenolol 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Lisinopril 10 mg PO DAILY RX lisinopril 10 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Centrum Silver Ultra Mens (multivit-min-FA-lycopen-lutein) ___ mcg oral DAILY 6. Finasteride 5 mg PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN nausea 8. Pantoprazole 40 mg PO Q24H 9. Prochlorperazine 10 mg PO Q6H:PRN nausea 10. saw ___ 1000 mg oral DAILY 11. HELD- cod liver oil 1,250-135 unit oral DAILY This medication was held. Do not restart cod liver oil until discussed with your oncology team 12.Outpatient Lab Work please check labs prior to your appointment with Dr ___ ___, CMP, Blood type, Reticulocyte count ICD 9 157.9 13.Outpatient Physical Therapy ___ diagnosis: pancreatic cancer 157.9 prognosis: good length of need: 13 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Pancreatic Cancer Anemia Hypertension Acute kidney injury (resolved) Rash (resolving) New Diabetes Mellitus Deep Vein Thrombosis GERD HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires walker Discharge Instructions: Dear Mr ___, It was a pleasure caring for you in the hospital. You were admitted because you were very anemic and your blood pressure was low. You didn't have any evidence of bleeding so we resumed your trial blood thinner drug called edoxaban. You were transfused a total of 2 units of blood, once on ___ and another ___. Dr ___ will follow up on your hemoglobin level when you see him next and transfuse as needed. We initially had to hold your blood pressure medications because your blood pressure was so low. However this improved with blood and IV fluids. We resumed some of your home medications. You will continue atenolol and lisinopril. Your ___ will work with your doctors to help adjust your blood pressure medications. Your cardiologist recommended that we increase the Lisinopril dose if your blood pressure is high before resuming your amlodipine. But ultimately this needs to be reviewed by your oncologist Dr ___. Your blood sugar levels were slightly elevated while you were inpatient. You have a touch of diabetes mellitus, most likely because your pancreas isnt making as much insulin as you need. This is not uncommon with pancreatic cancer. You were seen by our diabetes experts from ___. They recommended that you check your fingersticks every morning when you wake up on an empty stomach, and 2 hours after every meal. Keep a log of these and share with your oncologist. Although right now you do not need any diabetes medications or insulin, you may need to receive a small amount of insulin when you receive Dexamethasone with your chemo because that will raise your sugar levels. The best treatment right now is a healthy diet that is low in sugar and carbs. Please continue the diet recommendations discussed. If your sugars are <70, please drink a sugary drink like orange juice and recheck your finger stick after 15 minutes. If your sugars are >250, please call your oncologist office. Please refer to ___ and ___/ for more diabetes information You were set up with physical therapy to help you regain your strength. Please use a walker at all times. The nutritionist recommended Glucerna shakes three times a day if you have a hard time taking in meals. Please also continue using vaseline or bacitracin ointment to keep your nostrils moist from the dry air to prevent major nose bleeds. Regards, Dr ___ your ___ team Followup Instructions: ___	[ "D6481", "N179", "C251", "C787", "C786", "C772", "I9589", "I10", "K219", "E089", "R21", "J310", "N400", "T451X5A", "Y929", "Z86718", "Z86711", "Z96653" ]	Allergies: tramadol Chief Complaint: anemia Major Surgical or Invasive Procedure: none History of Present Illness: ============================================================= ONCOLOGY HOSPITALIST ADMISSION NOTE [MASKED] ============================================================= PRIMARY ONCOLOGIST: [MASKED] PRIMARY DIAGNOSIS: Metastatic pancreatic cancer TREATMENT REGIMEN: Gemcitabine/Abraxane C4D1 [MASKED] CC: [MASKED] HISTORY OF PRESENTING ILLNESS: [MASKED] is a [MASKED] man with metastatic pancreatic cancer on palliative gemcitabine who is admitted from clinic with several days of progressive fatigue found to have acutely worsened anemia and [MASKED]. Patient underwent C4D15 gem/abraxane last [MASKED]. On [MASKED] he began to develop generalized malaise and fatigue. Over the week this progressed and he began to feel very unsteady, dizzy, and'wobbly' on his feet. No frank vertigo. By morning of admission he had developed such profound dyspnea on exertion he could only take a few steps. During this time he has also noted a new non-pruritic rash over his arms and legs, with a separate painful lesion on his left distal leg. Due to these symptoms he was urgently seen in [MASKED] clinic today. In clinic he was found to have acute worsening of his anemia to 7.3 (was 9.2 on [MASKED]. Also with [MASKED] with Cr to 1.4 (1.2 on [MASKED], Na of 132, and HCO3 of 18. He was ill appearing and functioning well below his baseline. He was given 1L IVF and 1 unit pRBC before direct admission. On arrival to the floor, patient reports generalized malaise, rash, and DOE as above. Otherwise, he denies any fevers or chills. No headaches. No dysphagia. He has chronic rhinitis with mild sore throat in the morning. No shortness of breath at rest. No chest pain or pleuritic pain. No cough. No N/V. Appetitite is good. Has had loose stool after chemotherapy, but had formed BM today. No hematochezia or melena. No dysuria. No leg pain or swelling. Past Medical History: PAST ONCOLOGIC HISTORY: Pancreatic cancer stage IV - [MASKED] Developed intermittent indigestion treated with Tums and some increased fatigue (annual jobs on the property now take longer to complete). - [MASKED] When seen for routine PE by PCP, reported [MASKED] [MASKED] week h/o of new post-prandial epigastric and LUQ/rib discomfort and fullness (different from his indigestion). Due to these symptoms, he cut back on his eating which resulted in weight loss (10lbs). Initial concern for gastritis and started on Protonix. CXR and L rib plain films were normal. - [MASKED] CT A/P was performed which unfortunately showed a large and infiltrative pancreatic body mass extending along the lesser curvature of the stomach and along the lateral aspect of the celiac axis, encasing the gastric artery. Two ill-defined lesions were noted in the liver (central/caudate and inferior R lobe) c/f mets. Extensive abdominal lymphadenopathy was also noted. Referred to Pancreas Center and imaging reviewed by [MASKED] who recommended MRI liver for further characterization of liver lesion (caudate more suspicious, but not accessible percutaneously). Plan was to attempt to biopsy R lobe lesion if suspicious enough on MRI. - [MASKED] MR liver showed multiple liver and omental mets as well as a pancreatic primary - [MASKED] Omental biopsy positive for malignant cells, HA high - [MASKED] Signed informed consent for HALO3 - [MASKED] Found to have DVT, ineligible for HALO3, consented for [MASKED] [MASKED] and randomized to edoxiban - [MASKED] C1D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - [MASKED] C2D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - [MASKED] CT torso showed interval improvement in disease with interval increase in the necrotic components of the large pancreatic body mass with extensive arterial and venous involvement and decrease in size and/or interval necrosis of some of the retroperitoneal lymph nodes and omental metastases as above. - [MASKED] C3D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - [MASKED] C4D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 PAST MEDICAL HISTORY: 1. Knee replacement x 2. 2. Hernia x 2. 3. Status post PE postoperatively in [MASKED] status post six months of anticoagulation with no recurrent clots. 4. Hypertension. 5. BPH. 6. Folate deficiency. 7. Osteoarthritis. 8. DVT [MASKED] Social History: [MASKED] Family History: FAMILY HISTORY: 1. Mother with dementia, possibly with cancer at the end of her life. 2. Father with hypertension and [MASKED]. 3. Paternal cousin with some sort of cancer, unknown type. 4. Daughter with thyroid cancer. Physical Exam: VITAL SIGNS: 98.1 [MASKED] 94Ra General: NAD HEENT: MMM, no OP lesions, no cervical adenopathy CV: RR, NL S1S2 no S3S4, no MRG PULM: CTAB, respirations unlabored ABD: BS+, soft, NTND LIMBS: No [MASKED] SKIN: Rash on ext now desquamating w/ bright pink skin underneath, no blisters or bleeding, no petechiae Pertinent Results: [MASKED] 05:39AM BLOOD WBC-3.8* RBC-2.74* Hgb-8.5* Hct-26.3* MCV-96 MCH-31.0 MCHC-32.3 RDW-18.5* RDWSD-64.4* Plt [MASKED] [MASKED] 05:39AM BLOOD Glucose-139* UreaN-23* Creat-0.9 Na-138 K-4.0 Cl-108 HCO3-23 AnGap-11 [MASKED] 05:39AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.[MASKED] w/ metastatic pancreatic cancer on palliative gemcitabine who is admitted from clinic with several days of progressive fatigue found to have acutely worsened anemia and [MASKED]. # Weakness # Dyspnea on exertion: DOE is much improved after PRBC. No acute findings on CXR. EKG non-ischemic. Infectious w/u neg. Continues to have DOE but that has preceded the anemia and chronic. He is on treatment dose edoxaban. He was able to ambulate in the hallways at the time of discharge w/o DOE. # Anemia: Initially concern for gemcitabine induced HUS given [MASKED] and [MASKED], labs not c/w hemolysis. History and exam not c/w occult hemorrhage. Stool from [MASKED] is guaiac neg. Vit b12 wnl, Iron studies WNL, folate wnl, as well as TSH. Received 1 unit pRBC in clinic PTA w/ improvement of hg from 7.3 to 8.3. Edoxaban was resumed on [MASKED]. However it dropped again to 7.6 on [MASKED] am, so received 1U PRBC w/ improvement to 8.6. No obv source of bleeding nor hemolysis, now stable at 8.5 at time of discharge. He will have repeat CBC on [MASKED] in [MASKED] clinic. Seems to do best w/ Hg >8, so consider transfusing for Hg <8. Most likely etiology chemotherapy induced. # [MASKED]: Creatinine elevated to 1.4 in clinic. Improved w/ hydration and PRBC. Resumed home lisinopril at lower dose # Sinus Tach Pt is persistently tachy to 130s-150s on ambulation w/ DOE and no CP. This resolved w/ transfusion and resuming home atenolol. TTE did not reveal any overt causes or changes from his cardiologist's TTE done last year. # Rash: Unclear etiology but resolving spontaneously. Does not appear to be a typical drug eruption. In light of low grade fevers, possibly viral vs idiosyncratic chemo reaction. # DVT: Currently on [MASKED] [MASKED]. Resumed edoxaban [MASKED] and monitor closely for overt bleeding. # Pancreatic cancer: Currently C4 palliative gemcitabine. Known mets to liver and abdominal LAD. Will f/u with oncology team on [MASKED]. # GERD: On PPI # HTN: Discussed plan w/ his PCP/cardiologist. Had to make adjustments due to orthostatic hypotension and relative hypotension on admission. - stopped home amlodipine - resumed atenolol and lisinopril - can uptitrate lisinopril as outpatient # Hyperglycemia Pt had persistent [MASKED] 130s-180s fasting c/w dx of diabetes, likely due to pancreatic ca. Seen by [MASKED] and pt was set up with glucometer and [MASKED], instructed to keep logs at home to bring to his [MASKED] clinic appointment. They recommend considering giving low dose 5U Lantus if giving dexamethasone w/ chemotherapy, or at least close monitoring. # Deconditioning: Pt needs to use walker and was set up w/ home [MASKED] ACCESS: POC CODE: Full (presumed) COMMUNICATION: Patient EMERGENCY CONTACT HCP: Health care proxy chosen: Yes Name of health care proxy: [MASKED] Relationship: wife Phone number: [MASKED] Cell phone: [MASKED] DISPO: home w/ [MASKED] BILLING: >30 min spent coordinating care for discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Atenolol 25 mg PO 3X/WEEK ([MASKED]) 3. Finasteride 5 mg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. Ondansetron 8 mg PO Q8H:PRN nausea 6. Pantoprazole 40 mg PO Q24H 7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 8. Prochlorperazine 10 mg PO Q6H:PRN nausea 9. Centrum Silver Ultra Mens (multivit-min-FA-lycopen-lutein) [MASKED] mcg oral DAILY 10. saw [MASKED] 1000 mg oral DAILY 11. cod liver oil 1,250-135 unit oral DAILY Discharge Medications: 1. edoxaban Study Med 60 mg po DAILY 2. Atenolol 12.5 mg PO DAILY RX atenolol 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Lisinopril 10 mg PO DAILY RX lisinopril 10 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Centrum Silver Ultra Mens (multivit-min-FA-lycopen-lutein) [MASKED] mcg oral DAILY 6. Finasteride 5 mg PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN nausea 8. Pantoprazole 40 mg PO Q24H 9. Prochlorperazine 10 mg PO Q6H:PRN nausea 10. saw [MASKED] 1000 mg oral DAILY 11. HELD- cod liver oil 1,250-135 unit oral DAILY This medication was held. Do not restart cod liver oil until discussed with your oncology team 12.Outpatient Lab Work please check labs prior to your appointment with Dr [MASKED] [MASKED], CMP, Blood type, Reticulocyte count ICD 9 157.9 13.Outpatient Physical Therapy [MASKED] diagnosis: pancreatic cancer 157.9 prognosis: good length of need: 13 months Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Pancreatic Cancer Anemia Hypertension Acute kidney injury (resolved) Rash (resolving) New Diabetes Mellitus Deep Vein Thrombosis GERD HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires walker Discharge Instructions: Dear Mr [MASKED], It was a pleasure caring for you in the hospital. You were admitted because you were very anemic and your blood pressure was low. You didn't have any evidence of bleeding so we resumed your trial blood thinner drug called edoxaban. You were transfused a total of 2 units of blood, once on [MASKED] and another [MASKED]. Dr [MASKED] will follow up on your hemoglobin level when you see him next and transfuse as needed. We initially had to hold your blood pressure medications because your blood pressure was so low. However this improved with blood and IV fluids. We resumed some of your home medications. You will continue atenolol and lisinopril. Your [MASKED] will work with your doctors to help adjust your blood pressure medications. Your cardiologist recommended that we increase the Lisinopril dose if your blood pressure is high before resuming your amlodipine. But ultimately this needs to be reviewed by your oncologist Dr [MASKED]. Your blood sugar levels were slightly elevated while you were inpatient. You have a touch of diabetes mellitus, most likely because your pancreas isnt making as much insulin as you need. This is not uncommon with pancreatic cancer. You were seen by our diabetes experts from [MASKED]. They recommended that you check your fingersticks every morning when you wake up on an empty stomach, and 2 hours after every meal. Keep a log of these and share with your oncologist. Although right now you do not need any diabetes medications or insulin, you may need to receive a small amount of insulin when you receive Dexamethasone with your chemo because that will raise your sugar levels. The best treatment right now is a healthy diet that is low in sugar and carbs. Please continue the diet recommendations discussed. If your sugars are <70, please drink a sugary drink like orange juice and recheck your finger stick after 15 minutes. If your sugars are >250, please call your oncologist office. Please refer to [MASKED] and [MASKED]/ for more diabetes information You were set up with physical therapy to help you regain your strength. Please use a walker at all times. The nutritionist recommended Glucerna shakes three times a day if you have a hard time taking in meals. Please also continue using vaseline or bacitracin ointment to keep your nostrils moist from the dry air to prevent major nose bleeds. Regards, Dr [MASKED] your [MASKED] team Followup Instructions: [MASKED]	[]	[ "N179", "I10", "K219", "N400", "Y929", "Z86718" ]	[ "D6481: Anemia due to antineoplastic chemotherapy", "N179: Acute kidney failure, unspecified", "C251: Malignant neoplasm of body of pancreas", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes", "I9589: Other hypotension", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "E089: Diabetes mellitus due to underlying condition without complications", "R21: Rash and other nonspecific skin eruption", "J310: Chronic rhinitis", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y929: Unspecified place or not applicable", "Z86718: Personal history of other venous thrombosis and embolism", "Z86711: Personal history of pulmonary embolism", "Z96653: Presence of artificial knee joint, bilateral" ]
10,095,417	22,994,703	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: tramadol Attending: ___. Chief Complaint: Confusion Major Surgical or Invasive Procedure: None History of Present Illness: As per admitting MD: Mr. ___ is a pleasant ___ w/ pancreatic cancer (mets to liver, omentum) c/b DVT, gastric outlet obstruction, and hypercalcemia, now on an ivestigational drug, who is directly admitted from clinic for hypercalcemia. He was found to be newly hypercalcemic just prior to initiating the first treatment on trial of AbGn-107. He received 2L IVF ad Zometa on ___ and returned to clinic for recheck of his labs and his calcium remained elevated. He is fatigued and noted to appear slightly confused per the family and the outpatient providers. On arrival to ___, pt's chief complaint was fatigue, constipation. Noted increased abd distention and ___. Expressed good insight into the reason for admission and the management. REVIEW OF SYSTEMS: 10 point ROS reviewed in detail and negative except for what is mentioned above in HPI Past Medical History: As per admitting MD: PAST ONCOLOGIC HISTORY (per OMR): Pancreatic cancer stage IV - ___ Developed intermittent indigestion treated with Tums and some increased fatigue (annual jobs on the property now take longer to complete). - ___ When seen for routine PE by PCP, reported ___ ___ week h/o of new post-prandial epigastric and LUQ/rib discomfort and fullness (different from his indigestion). Due to these symptoms, he cut back on his eating which resulted in weight loss(10lbs). Initial concern for gastritis and started on Protonix. CXR and L rib plain films were normal. - ___ CT A/P was performed which unfortunately showed a large and infiltrative pancreatic body mass extending along the lesser curvature of the stomach and along the lateral aspect of the celiac axis, encasing the gastric artery. Two ill-defined lesions were noted in the liver (central/caudate and inferior R lobe) c/f mets. Extensive abdominal lymphadenopathy was also noted. Referred to Pancre___ Center and imaging reviewed by ___ who recommended MRI liver for further characterization of liver lesion (caudate more suspicious, but not accessible percutaneously). Plan was to attempt to biopsy R lobe lesion if suspicious enough on MRI. - ___ MR liver showed multiple liver and omental mets as well as a pancreatic primary - ___ Omental biopsy positive for malignant cells, HA high - ___ Signed informed consent for HALO3 - ___ Found to have DVT, ineligible for HALO3, consented for ___ ___ and randomized to edoxiban - ___ C1D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - ___ C2D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - ___ CT torso showed interval improvement in disease with interval increase in the necrotic components of the large pancreatic body mass with extensive arterial and venous involvement and decrease in size and/or interval necrosis of some of the retroperitoneal lymph nodes and omental metastases as above. - ___ C3D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - ___ C4D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 ___ - ___ - hospitalized with severe fatigue, dizziness and anemia, improved with 2U PRBCs. He also had ___ and a rash over his upper arms. Echo was normal. Hemolysis labs wnl, PE was considered but given his rapid improvement after blood transfusion was not performed. Edoxaban was briefly held but stool guiac was negative on several occasions and resumed with stable Hgb. - ___ - C5D1 gemcitabine 1000 mg/m2 NAB paclitaxel 100 mg/m2 D1,8,15 (dose reduced 20%) - ___ - C5D15 treatment held due to progressive neuropathy and severe leg edema leading to worse performance status - ___ - admitted with fever and found to have E coli bacteremia with sepsis. MRCP showed micro-hepatic abscesses and mild intrahepatic biliary ductal dilatation involving the left of the liver. He underwent ERCP and plastic CBD stent was placed prophylactically on ___ with plan for repeat ERCP in ___ weeks. He was initially treated with IV zosyn, cx remained negative and he completed 4 week course of oral ciprofloxacin after discharge. Stent was removed ___. - ___ treatment break - ___ CT torso: progression with increase in multiple hepatic lesions, peritoneal and omental disease. Stable mass. - ___: C1D1 26 hr ___ infusion 2400mg/m2 plus leucovorin 400mg/m2 with liposomal irinotecan 70mg/m2 (per ___ regimen) - ___: C2D1 ___ irinotecan - ___: C3D1 ___ irinotecan - ___: C4D1 ___ irinotecan - ___: C5D1 ___ irinotecan - ___: C6D1 ___ irinotecan - ___: C7D1 ___ irinotecan - ___: C8D1 ___ irinotecan - ___: CT torso with disease progression in hepatic mets, large pancreatic mass, abdominal carcinomatosis with ascites - ___: C1D1 Clinical trial ___ PAST MEDICAL HISTORY (per OMR): PANCREATIC CANCER Social History: ___ Family History: As per admitting MD: Mother with dementia, possibly with cancer at the end of her life. Father with hypertension and ___. Paternal cousin with some sort of cancer, unknown type. Daughter with thyroid cancer. Physical Exam: Admission: VITAL SIGNS: 97.3 PO 152 / 91 18 18 95 RA General: NAD, Resting in bed comfortably with wife at bedside, appears lethargic and tired HEENT: MM very dry, + thrush CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NT, distended abd with fluid wave LIMBS: WWP, 2+ ___, no tremors SKIN: No rashes on the extremities NEURO: Lethargic, speech clear, appropriate, slow, AOx3 but took him a while to relay the info Discharge: General: NAD, sitting up in bed comfortably with daughter at bedside, smiling, pleasant HEENT: MMM, + thrush (improved but persistent) CV: RRR, no m/r/g, normal distal perfusion with 2+ lower extremity edema PULM: CTAB but decreased lung sounds at bases, No respiratory distress, normal RR, no wheezes/rales/rhonchi ABD: BS+, soft, NT, ND, no rebound or guarding LIMBS: WWP, no deformity, decreased muscle bulk SKIN: No rashes on the extremities NEURO: Speech clear, appropriate, interactive, AOx3, appears energetic PSYCH: Normal mood, insight, judgment, affect Pertinent Results: Admission: ___ 06:02PM BLOOD WBC-23.1* RBC-3.08* Hgb-9.1* Hct-29.4* MCV-96 MCH-29.5 MCHC-31.0* RDW-18.1* RDWSD-61.4* Plt ___ ___ 06:02PM BLOOD Glucose-136* UreaN-21* Creat-0.8 Na-139 K-4.3 Cl-105 HCO3-26 AnGap-8* ___ 06:02PM BLOOD ALT-43* AST-40 LD(LDH)-387* AlkPhos-260* TotBili-1.1 ___ 06:02PM BLOOD Albumin-2.5* Calcium-12.1* Phos-1.6* Mg-1.6 ___ 11:00AM BLOOD CEA-110.4* ___ 05:40PM BLOOD 25VitD-34 ___ 05:40PM BLOOD PTH-18 Discharge: ___ 05:00AM BLOOD WBC-20.4* RBC-2.71* Hgb-8.2* Hct-25.2* MCV-93 MCH-30.3 MCHC-32.5 RDW-20.2* RDWSD-64.3* Plt Ct-85* ___ 07:08AM BLOOD ___ PTT-34.6 ___ ___ 05:00AM BLOOD Glucose-189* UreaN-44* Creat-0.9 Na-143 K-4.3 Cl-106 HCO3-24 AnGap-13 ___ 04:31AM BLOOD ALT-58* AST-51* AlkPhos-308* TotBili-1.1 ___ 05:00AM BLOOD Calcium-9.0 Phos-2.2* Mg-2.0 Micro: /___ pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. ___ 5:30 am BLOOD CULTURE Source: Line-port. Blood Culture, Routine (Pending): Brief Hospital Course: ___ PMH of Metastatic Pancreatic Cancer (on an investigational drug), DVT, gastric outlet obstruction, and hypercalcemia, who was directly admitted from clinic for hypercalcemia of malignancy c/b encephalopathy which resolved with appropriate treatment, whose hospital course was complicated by back pain, thrush, volume overload, malnutritrion, who was discharged to rehab, with outpatient oncology followup #Sinus Tachycardia Likely combination of deconditioning + chronic pain + withholding home atenolol. Given hx of malignancy PE was on differential (despite anticoagulation) but CTA negative. No fever and WBC downtrending so infection less likely. No ischemic symptoms or findings on EKG. No arrhythmia on 24 hrs of tele so was discontinued. Once atenolol was restarted tachycardia resolved. #Hypercalcemia: Occurred prior to initiating AbGn-107 so most likely due to disease process. Was also thought to be partially due to hypovolemia and concomitant use of HCTZ which had been stopped. Does not have osseous disease. PTH on the lower end of normal at 18 and Vit D adequate at 34. PTHRP elevated. Had been taking dexamethasone intermittently. Improved dramatically with IVF, calcitonin, and zometa now in the normal range after correcting for albumin. Patient will have repeat labs on ___ in clinic where it can be trended further #Leukocytosis #Rising TBili Patient with fluctuating leukocytosis and Tbili which may be ___ metastatic disease in liver which was noted to have worsened on ___ CT torso as did not have fever to suggest sepsis/cholangitis. Fortunately values now downtrending daily. Levels to be trended on ___ in clinic #Chronic Low Back Pain As per patient is thought to be ___ degenerative disease and is chronic, CT Torso from ___ without osseous lesions to suggest malignant involvement. No symptoms to suggest cauda equina. Patient noted that he was awaiting outpatient appt for steroid injection. Given unchanged symptomatology but slight worsening in severity which had been seen previously with inactivity, will not pursue further imaging. Acute pain service noted that they could not do any procedure without 3 day A/C washout so rec'd that he followup in pain clinic instead. Accordingly, patient was given 5 day burst of prednisone and lidocaine patch to good effect. Patient should continue physical therapy and f/u in outpatient pain clinic. #Constipation Possibly ___ inactivity vs opiates vs little PO intake, resolved with bowel regimen. # Pancreatic ca As above, metastatic and on clinical trial. As per Dr ___, patient to return to clinic aq2weeks for labs and re-evaluation. Next count check and clinic apt on ___, next chemo on ___. # Severe Protein Calorie Malnutrition Nutrition is paramount to helping improving his functional status. He was instructed to continue to augment his intake so that his peripheral edema would improve. # Anemia: Likely of antineoplastic therapy. Stable during hospital course. To be trended at outpatient appointments. # Thrombocytopenia: Likely due to BM suppression due to antineoplastic therapy. Was fluctuating but did not drop to the point that his anticoagulation needed to be interrupted. However he should be closely monitored in the outpatient setting to ensure that plt do not drop below 50K otherwise anticoagulation should be held. # Hypophosphatemia/Hypomagnesemia Likely from zometa, repleted as needed # DVT/PE: DVT dx ___, was continued on home dose A/C during stay. As above, plt to be closely trended in outpatient setting. # Thrush: Continued on nystatin during stay, added fluconazole because was persistent after 4 days of therapy. To be trended at rehab. Transitional Issues: 1. Patient with significant lower extremity edema, b/l pleural effusions, likely ___ hypoalbuminemia which should improve as he augments his PO intake. If his nutritional status improved but edema does not would consider gentle diuresis. 2. Patient will have repeat labs on ___ in clinic where LFTS, Ca, CBC can be trended further 3. Thrush to be monitored at rehab 4. Pt to f/u in ___ clinic for next chemo dose on ___. Pt to have back pain evaluated in clinic and regimen adjusted as needed 6. Pending blood cultures to be followed up at next outpatient f/u appt 49 minutes were spent preparing discharge paperwork, communicating with outpatient providers, discussing instructions with patient and answering questions Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Finasteride 5 mg PO QHS 3. FoLIC Acid 1 mg PO DAILY 4. Pantoprazole 40 mg PO Q24H 5. Pyridoxine 100 mg PO DAILY 6. Centrum Silver (multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1 tav oral DAILY 7. cod liver oil 1,250-135 unit oral DAILY 8. saw ___ 1080 mg oral BID 9. Apixaban 5 mg PO BID 10. Mirtazapine 30 mg PO QHS 11. Nystatin Oral Suspension 5 mL PO QID 12. Ondansetron 8 mg PO Q8H:PRN nausea 13. Prochlorperazine 10 mg PO Q6H:PRN nausea Discharge Medications: 1. Bisacodyl 10 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Fluconazole 200 mg PO Q24H Duration: 7 Days 4. Lidocaine 5% Patch 1 PTCH TD QPM 5. PredniSONE 40 mg PO DAILY Duration: 2 Days 6. Senna 8.6 mg PO BID 7. Apixaban 5 mg PO BID 8. Atenolol 25 mg PO DAILY 9. Centrum Silver (multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1 tav oral DAILY 10. cod liver oil 1,250-135 unit oral DAILY 11. Finasteride 5 mg PO QHS 12. FoLIC Acid 1 mg PO DAILY 13. Mirtazapine 30 mg PO QHS 14. Nystatin Oral Suspension 5 mL PO QID 15. Ondansetron 8 mg PO Q8H:PRN nausea 16. Pantoprazole 40 mg PO Q24H 17. Prochlorperazine 10 mg PO Q6H:PRN nausea 18. Pyridoxine 100 mg PO DAILY 19. saw ___ 1080 mg oral BID Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: #Sinus Tachycardia #Hypercalcemia of malignancy #Leukocytosis #Chronic Low Back Pain #Pancreatic Cancer #Constipation #Anemia/Thrombocytopenia # Severe Protein Calorie Malnutrition # Hypophosphatemia/Hypomagnesemia # Thrush: #DVT/PE 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: Mr ___ It was a pleasure taking care of you while you were hospitalized at ___. As you know you were admitted for elevated calcium which was due to your cancer but improved with treatment. You were also found to have thrush and were started on medication for it. You were very malnourished, so we recommend that you try your best to eat as much as possible. Improving your nutritional status will help with your lower extremity fluid retention. You will followup in clinic with Dr ___. Followup Instructions: ___	[ "E8352", "E43", "J90", "G9340", "C786", "C787", "K311", "D6959", "C259", "B379", "D649", "E8339", "D72829", "M5136", "Z006", "Z66", "Z86718", "T451X5A", "Y92009", "E8342", "Z7901", "T50995A", "Y92230", "K5900", "R000", "N400", "M21372", "Z6825" ]	Allergies: tramadol Chief Complaint: Confusion Major Surgical or Invasive Procedure: None History of Present Illness: As per admitting MD: Mr. [MASKED] is a pleasant [MASKED] w/ pancreatic cancer (mets to liver, omentum) c/b DVT, gastric outlet obstruction, and hypercalcemia, now on an ivestigational drug, who is directly admitted from clinic for hypercalcemia. He was found to be newly hypercalcemic just prior to initiating the first treatment on trial of AbGn-107. He received 2L IVF ad Zometa on [MASKED] and returned to clinic for recheck of his labs and his calcium remained elevated. He is fatigued and noted to appear slightly confused per the family and the outpatient providers. On arrival to [MASKED], pt's chief complaint was fatigue, constipation. Noted increased abd distention and [MASKED]. Expressed good insight into the reason for admission and the management. REVIEW OF SYSTEMS: 10 point ROS reviewed in detail and negative except for what is mentioned above in HPI Past Medical History: As per admitting MD: PAST ONCOLOGIC HISTORY (per OMR): Pancreatic cancer stage IV - [MASKED] Developed intermittent indigestion treated with Tums and some increased fatigue (annual jobs on the property now take longer to complete). - [MASKED] When seen for routine PE by PCP, reported [MASKED] [MASKED] week h/o of new post-prandial epigastric and LUQ/rib discomfort and fullness (different from his indigestion). Due to these symptoms, he cut back on his eating which resulted in weight loss(10lbs). Initial concern for gastritis and started on Protonix. CXR and L rib plain films were normal. - [MASKED] CT A/P was performed which unfortunately showed a large and infiltrative pancreatic body mass extending along the lesser curvature of the stomach and along the lateral aspect of the celiac axis, encasing the gastric artery. Two ill-defined lesions were noted in the liver (central/caudate and inferior R lobe) c/f mets. Extensive abdominal lymphadenopathy was also noted. Referred to Pancre Center and imaging reviewed by [MASKED] who recommended MRI liver for further characterization of liver lesion (caudate more suspicious, but not accessible percutaneously). Plan was to attempt to biopsy R lobe lesion if suspicious enough on MRI. - [MASKED] MR liver showed multiple liver and omental mets as well as a pancreatic primary - [MASKED] Omental biopsy positive for malignant cells, HA high - [MASKED] Signed informed consent for HALO3 - [MASKED] Found to have DVT, ineligible for HALO3, consented for [MASKED] [MASKED] and randomized to edoxiban - [MASKED] C1D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - [MASKED] C2D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - [MASKED] CT torso showed interval improvement in disease with interval increase in the necrotic components of the large pancreatic body mass with extensive arterial and venous involvement and decrease in size and/or interval necrosis of some of the retroperitoneal lymph nodes and omental metastases as above. - [MASKED] C3D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - [MASKED] C4D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 [MASKED] - [MASKED] - hospitalized with severe fatigue, dizziness and anemia, improved with 2U PRBCs. He also had [MASKED] and a rash over his upper arms. Echo was normal. Hemolysis labs wnl, PE was considered but given his rapid improvement after blood transfusion was not performed. Edoxaban was briefly held but stool guiac was negative on several occasions and resumed with stable Hgb. - [MASKED] - C5D1 gemcitabine 1000 mg/m2 NAB paclitaxel 100 mg/m2 D1,8,15 (dose reduced 20%) - [MASKED] - C5D15 treatment held due to progressive neuropathy and severe leg edema leading to worse performance status - [MASKED] - admitted with fever and found to have E coli bacteremia with sepsis. MRCP showed micro-hepatic abscesses and mild intrahepatic biliary ductal dilatation involving the left of the liver. He underwent ERCP and plastic CBD stent was placed prophylactically on [MASKED] with plan for repeat ERCP in [MASKED] weeks. He was initially treated with IV zosyn, cx remained negative and he completed 4 week course of oral ciprofloxacin after discharge. Stent was removed [MASKED]. - [MASKED] treatment break - [MASKED] CT torso: progression with increase in multiple hepatic lesions, peritoneal and omental disease. Stable mass. - [MASKED]: C1D1 26 hr [MASKED] infusion 2400mg/m2 plus leucovorin 400mg/m2 with liposomal irinotecan 70mg/m2 (per [MASKED] regimen) - [MASKED]: C2D1 [MASKED] irinotecan - [MASKED]: C3D1 [MASKED] irinotecan - [MASKED]: C4D1 [MASKED] irinotecan - [MASKED]: C5D1 [MASKED] irinotecan - [MASKED]: C6D1 [MASKED] irinotecan - [MASKED]: C7D1 [MASKED] irinotecan - [MASKED]: C8D1 [MASKED] irinotecan - [MASKED]: CT torso with disease progression in hepatic mets, large pancreatic mass, abdominal carcinomatosis with ascites - [MASKED]: C1D1 Clinical trial [MASKED] PAST MEDICAL HISTORY (per OMR): PANCREATIC CANCER Social History: [MASKED] Family History: As per admitting MD: Mother with dementia, possibly with cancer at the end of her life. Father with hypertension and [MASKED]. Paternal cousin with some sort of cancer, unknown type. Daughter with thyroid cancer. Physical Exam: Admission: VITAL SIGNS: 97.3 PO 152 / 91 18 18 95 RA General: NAD, Resting in bed comfortably with wife at bedside, appears lethargic and tired HEENT: MM very dry, + thrush CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NT, distended abd with fluid wave LIMBS: WWP, 2+ [MASKED], no tremors SKIN: No rashes on the extremities NEURO: Lethargic, speech clear, appropriate, slow, AOx3 but took him a while to relay the info Discharge: General: NAD, sitting up in bed comfortably with daughter at bedside, smiling, pleasant HEENT: MMM, + thrush (improved but persistent) CV: RRR, no m/r/g, normal distal perfusion with 2+ lower extremity edema PULM: CTAB but decreased lung sounds at bases, No respiratory distress, normal RR, no wheezes/rales/rhonchi ABD: BS+, soft, NT, ND, no rebound or guarding LIMBS: WWP, no deformity, decreased muscle bulk SKIN: No rashes on the extremities NEURO: Speech clear, appropriate, interactive, AOx3, appears energetic PSYCH: Normal mood, insight, judgment, affect Pertinent Results: Admission: [MASKED] 06:02PM BLOOD WBC-23.1* RBC-3.08* Hgb-9.1* Hct-29.4* MCV-96 MCH-29.5 MCHC-31.0* RDW-18.1* RDWSD-61.4* Plt [MASKED] [MASKED] 06:02PM BLOOD Glucose-136* UreaN-21* Creat-0.8 Na-139 K-4.3 Cl-105 HCO3-26 AnGap-8* [MASKED] 06:02PM BLOOD ALT-43* AST-40 LD(LDH)-387* AlkPhos-260* TotBili-1.1 [MASKED] 06:02PM BLOOD Albumin-2.5* Calcium-12.1* Phos-1.6* Mg-1.6 [MASKED] 11:00AM BLOOD CEA-110.4* [MASKED] 05:40PM BLOOD 25VitD-34 [MASKED] 05:40PM BLOOD PTH-18 Discharge: [MASKED] 05:00AM BLOOD WBC-20.4* RBC-2.71* Hgb-8.2* Hct-25.2* MCV-93 MCH-30.3 MCHC-32.5 RDW-20.2* RDWSD-64.3* Plt Ct-85* [MASKED] 07:08AM BLOOD [MASKED] PTT-34.6 [MASKED] [MASKED] 05:00AM BLOOD Glucose-189* UreaN-44* Creat-0.9 Na-143 K-4.3 Cl-106 HCO3-24 AnGap-13 [MASKED] 04:31AM BLOOD ALT-58* AST-51* AlkPhos-308* TotBili-1.1 [MASKED] 05:00AM BLOOD Calcium-9.0 Phos-2.2* Mg-2.0 Micro: /[MASKED] pm URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL. [MASKED] 5:30 am BLOOD CULTURE Source: Line-port. Blood Culture, Routine (Pending): Brief Hospital Course: [MASKED] PMH of Metastatic Pancreatic Cancer (on an investigational drug), DVT, gastric outlet obstruction, and hypercalcemia, who was directly admitted from clinic for hypercalcemia of malignancy c/b encephalopathy which resolved with appropriate treatment, whose hospital course was complicated by back pain, thrush, volume overload, malnutritrion, who was discharged to rehab, with outpatient oncology followup #Sinus Tachycardia Likely combination of deconditioning + chronic pain + withholding home atenolol. Given hx of malignancy PE was on differential (despite anticoagulation) but CTA negative. No fever and WBC downtrending so infection less likely. No ischemic symptoms or findings on EKG. No arrhythmia on 24 hrs of tele so was discontinued. Once atenolol was restarted tachycardia resolved. #Hypercalcemia: Occurred prior to initiating AbGn-107 so most likely due to disease process. Was also thought to be partially due to hypovolemia and concomitant use of HCTZ which had been stopped. Does not have osseous disease. PTH on the lower end of normal at 18 and Vit D adequate at 34. PTHRP elevated. Had been taking dexamethasone intermittently. Improved dramatically with IVF, calcitonin, and zometa now in the normal range after correcting for albumin. Patient will have repeat labs on [MASKED] in clinic where it can be trended further #Leukocytosis #Rising TBili Patient with fluctuating leukocytosis and Tbili which may be [MASKED] metastatic disease in liver which was noted to have worsened on [MASKED] CT torso as did not have fever to suggest sepsis/cholangitis. Fortunately values now downtrending daily. Levels to be trended on [MASKED] in clinic #Chronic Low Back Pain As per patient is thought to be [MASKED] degenerative disease and is chronic, CT Torso from [MASKED] without osseous lesions to suggest malignant involvement. No symptoms to suggest cauda equina. Patient noted that he was awaiting outpatient appt for steroid injection. Given unchanged symptomatology but slight worsening in severity which had been seen previously with inactivity, will not pursue further imaging. Acute pain service noted that they could not do any procedure without 3 day A/C washout so rec'd that he followup in pain clinic instead. Accordingly, patient was given 5 day burst of prednisone and lidocaine patch to good effect. Patient should continue physical therapy and f/u in outpatient pain clinic. #Constipation Possibly [MASKED] inactivity vs opiates vs little PO intake, resolved with bowel regimen. # Pancreatic ca As above, metastatic and on clinical trial. As per Dr [MASKED], patient to return to clinic aq2weeks for labs and re-evaluation. Next count check and clinic apt on [MASKED], next chemo on [MASKED]. # Severe Protein Calorie Malnutrition Nutrition is paramount to helping improving his functional status. He was instructed to continue to augment his intake so that his peripheral edema would improve. # Anemia: Likely of antineoplastic therapy. Stable during hospital course. To be trended at outpatient appointments. # Thrombocytopenia: Likely due to BM suppression due to antineoplastic therapy. Was fluctuating but did not drop to the point that his anticoagulation needed to be interrupted. However he should be closely monitored in the outpatient setting to ensure that plt do not drop below 50K otherwise anticoagulation should be held. # Hypophosphatemia/Hypomagnesemia Likely from zometa, repleted as needed # DVT/PE: DVT dx [MASKED], was continued on home dose A/C during stay. As above, plt to be closely trended in outpatient setting. # Thrush: Continued on nystatin during stay, added fluconazole because was persistent after 4 days of therapy. To be trended at rehab. Transitional Issues: 1. Patient with significant lower extremity edema, b/l pleural effusions, likely [MASKED] hypoalbuminemia which should improve as he augments his PO intake. If his nutritional status improved but edema does not would consider gentle diuresis. 2. Patient will have repeat labs on [MASKED] in clinic where LFTS, Ca, CBC can be trended further 3. Thrush to be monitored at rehab 4. Pt to f/u in [MASKED] clinic for next chemo dose on [MASKED]. Pt to have back pain evaluated in clinic and regimen adjusted as needed 6. Pending blood cultures to be followed up at next outpatient f/u appt 49 minutes were spent preparing discharge paperwork, communicating with outpatient providers, discussing instructions with patient and answering questions Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Finasteride 5 mg PO QHS 3. FoLIC Acid 1 mg PO DAILY 4. Pantoprazole 40 mg PO Q24H 5. Pyridoxine 100 mg PO DAILY 6. Centrum Silver (multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1 tav oral DAILY 7. cod liver oil 1,250-135 unit oral DAILY 8. saw [MASKED] 1080 mg oral BID 9. Apixaban 5 mg PO BID 10. Mirtazapine 30 mg PO QHS 11. Nystatin Oral Suspension 5 mL PO QID 12. Ondansetron 8 mg PO Q8H:PRN nausea 13. Prochlorperazine 10 mg PO Q6H:PRN nausea Discharge Medications: 1. Bisacodyl 10 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Fluconazole 200 mg PO Q24H Duration: 7 Days 4. Lidocaine 5% Patch 1 PTCH TD QPM 5. PredniSONE 40 mg PO DAILY Duration: 2 Days 6. Senna 8.6 mg PO BID 7. Apixaban 5 mg PO BID 8. Atenolol 25 mg PO DAILY 9. Centrum Silver (multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1 tav oral DAILY 10. cod liver oil 1,250-135 unit oral DAILY 11. Finasteride 5 mg PO QHS 12. FoLIC Acid 1 mg PO DAILY 13. Mirtazapine 30 mg PO QHS 14. Nystatin Oral Suspension 5 mL PO QID 15. Ondansetron 8 mg PO Q8H:PRN nausea 16. Pantoprazole 40 mg PO Q24H 17. Prochlorperazine 10 mg PO Q6H:PRN nausea 18. Pyridoxine 100 mg PO DAILY 19. saw [MASKED] 1080 mg oral BID Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: #Sinus Tachycardia #Hypercalcemia of malignancy #Leukocytosis #Chronic Low Back Pain #Pancreatic Cancer #Constipation #Anemia/Thrombocytopenia # Severe Protein Calorie Malnutrition # Hypophosphatemia/Hypomagnesemia # Thrush: #DVT/PE 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: Mr [MASKED] It was a pleasure taking care of you while you were hospitalized at [MASKED]. As you know you were admitted for elevated calcium which was due to your cancer but improved with treatment. You were also found to have thrush and were started on medication for it. You were very malnourished, so we recommend that you try your best to eat as much as possible. Improving your nutritional status will help with your lower extremity fluid retention. You will followup in clinic with Dr [MASKED]. Followup Instructions: [MASKED]	[]	[ "D649", "Z66", "Z86718", "Z7901", "Y92230", "K5900", "N400" ]	[ "E8352: Hypercalcemia", "E43: Unspecified severe protein-calorie malnutrition", "J90: Pleural effusion, not elsewhere classified", "G9340: Encephalopathy, unspecified", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "K311: Adult hypertrophic pyloric stenosis", "D6959: Other secondary thrombocytopenia", "C259: Malignant neoplasm of pancreas, unspecified", "B379: Candidiasis, unspecified", "D649: Anemia, unspecified", "E8339: Other disorders of phosphorus metabolism", "D72829: Elevated white blood cell count, unspecified", "M5136: Other intervertebral disc degeneration, lumbar region", "Z006: Encounter for examination for normal comparison and control in clinical research program", "Z66: Do not resuscitate", "Z86718: Personal history of other venous thrombosis and embolism", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "E8342: Hypomagnesemia", "Z7901: Long term (current) use of anticoagulants", "T50995A: Adverse effect of other drugs, medicaments and biological substances, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "K5900: Constipation, unspecified", "R000: Tachycardia, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "M21372: Foot drop, left foot", "Z6825: Body mass index [BMI] 25.0-25.9, adult" ]
10,095,417	27,570,136	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: tramadol Attending: ___. Chief Complaint: ERCP Major Surgical or Invasive Procedure: ERCP with sphincterotomy History of Present Illness: This is an ___ male with metastatic pancreatic cancer status post five cycles of gemcitabine and nab-paclitaxel, pulmonary embolus on edoxaban, and recent admission for sepsis and Gram-negative bacteremia from cholangitis and micro-hepatic abscesses. During that admission he underwent prophylactic CBD plastic stent placement and was discharged on p.o. ciprofloxacin. Today he was brought for elective CBD stent removal and sphincterectomy. He underwent uncomplicated ERCP and is being admitted for post procedural overnight observation. Of note he has been holding Edoxaban since ___. On my evaluation he denies any complaints and states that he feels fine. Specifically he denies any abdominal pain, nausea, vomiting. See detailed 12 point review of systems below. Past Medical History: PAST ONCOLOGIC HISTORY: Pancreatic cancer stage IV - ___ Developed intermittent indigestion treated with Tums and some increased fatigue (annual jobs on the property now take longer to complete). - ___ When seen for routine PE by PCP, reported ___ ___ week h/o of new post-prandial epigastric and LUQ/rib discomfort and fullness (different from his indigestion). Due to these symptoms, he cut back on his eating which resulted in weight loss (10lbs). Initial concern for gastritis and started on Protonix. CXR and L rib plain films were normal. - ___ CT A/P was performed which unfortunately showed a large and infiltrative pancreatic body mass extending along the lesser curvature of the stomach and along the lateral aspect of the celiac axis, encasing the gastric artery. Two ill-defined lesions were noted in the liver (central/caudate and inferior R lobe) c/f mets. Extensive abdominal lymphadenopathy was also noted. Referred to Pan___ and imaging reviewed by ___ who recommended MRI liver for further characterization of liver lesion (caudate more suspicious, but not accessible percutaneously). Plan was to attempt to biopsy R lobe lesion if suspicious enough on MRI. - ___ MR liver showed multiple liver and omental mets as well as a pancreatic primary - ___ Omental biopsy positive for malignant cells, HA high - ___ Signed informed consent for HALO3 - ___ Found to have DVT, ineligible for HALO3, consented for ___ ___ and randomized to edoxiban - ___ C1D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - ___ C2D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,___ - ___ CT torso showed interval improvement in disease with interval increase in the necrotic components of the large pancreatic body mass with extensive arterial and venous involvement and decrease in size and/or interval necrosis of some of the retroperitoneal lymph nodes and omental metastases as above. - ___ C3D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - ___ C4D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 PAST MEDICAL HISTORY: 1. Knee replacement x 2. 2. Hernia x 2. 3. Status post PE postoperatively in ___ status post six months of anticoagulation with no recurrent clots. 4. Hypertension. 5. BPH. 6. Folate deficiency. 7. Osteoarthritis. 8. DVT ___ Social History: ___ Family History: Mother with dementia, possibly with cancer at the end of her life. Father with hypertension and ___. Paternal cousin with some sort of cancer, unknown type. Daughter with thyroid cancer. Physical Exam: gen-well appearing, NAD vitals- 98.0 PO 131 / 80 66 16 96 RA HEENT-ncat eomi anicteric mmm neck-supple chest-b/l ae no w/c/r port in place C/D/I heart-s1s2 rr no m/r/g abd-+bs, soft, NT, ND, no guarding or rebound ext-no c/c/e 2+pulses neuro-face symmetric speech fluent psych-calm cooperative Pertinent Results: ___ 08:19AM BLOOD WBC-3.3* RBC-3.22* Hgb-9.7* Hct-30.1* MCV-94 MCH-30.1 MCHC-32.2 RDW-16.0* RDWSD-55.0* Plt ___ ___ 09:50AM BLOOD WBC-5.3 RBC-3.41* Hgb-10.2* Hct-31.8* MCV-93 MCH-29.9 MCHC-32.1 RDW-16.1* RDWSD-55.5* Plt ___ ___ 09:50AM BLOOD Neuts-65.6 ___ Monos-9.8 Eos-3.2 Baso-1.3* Im ___ AbsNeut-3.46 AbsLymp-1.04* AbsMono-0.52 AbsEos-0.17 AbsBaso-0.07 ___ 09:50AM BLOOD ___ PTT-52.9* ___ ___ 08:19AM BLOOD Glucose-107* UreaN-20 Creat-1.0 Na-141 K-3.7 Cl-104 HCO3-24 AnGap-17 ___ 09:50AM BLOOD UreaN-22* Creat-1.0 Na-141 K-3.9 Cl-105 HCO3-25 AnGap-15 ___ 08:19AM BLOOD ALT-10 AST-18 AlkPhos-131* Amylase-30 TotBili-0.8 ___ 08:19AM BLOOD Lipase-10 ___ 08:19AM BLOOD Calcium-8.9 ___ 09:50AM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.5 Mg-1.9 ___ 09:50AM BLOOD CEA-29.7* ___ 09:50AM BLOOD CA ___ -PND Impression: The scout film showed a plastic stent in the RUQ. A plastic stent was emerging from the major papilla. The stent was successfully removed using a snare. The CBD was successfully cannulated using a CleverCut sphincterotome preloaded with 0.025in guidewire. Contrast injection revealed dilated CBD at approximately 15mm in diameter with few filling defects consistent with sludge. A biliary sphincterotomy was successfully performed at 12 O'clock position. There was no post-sphincterotomy bleeding. The bile duct was swept multiple times using a biliary balloon. A small amount of sludge material was successfully removed. Occlusion cholangiogram revealed no more filling defects. There was excellent contrast and bile drainaige at the end of the procedure. Recommendations: Admit to hospital for monitoring 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 If safe, hold blood thinner for 3 days. Follow-up with referring physician as previously scheduled. Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call Advanced Endoscopy Fellow on call ___ Brief Hospital Course: Pt is a ___ y.o man with h.o metastatic pancreatic cancer s/p gemcitabine and paclitaxel, h.o PE, recent cholangitis/bacteremia with ERCP now s/p ERCP. #pancreatic cancer #recent cholangitis/GNR bacteremia Pt now s/p ERCP with stent removal and sphincterotomy. No pain or other notable complications. Diet advanced to regular without complication. He was advised to take cipro for 5 days and to hold his anticoagulation for 3 days. He will follow up with oncology after discharge. #h.o PE-plan to restart anticoagulation in 3 days #HTN-amlodipine continued #lower extremity edema-HCTZ restarted. #BPH-home finasteride continued. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. amLODIPine 5 mg PO DAILY 3. Pantoprazole 40 mg PO Q24H 4. Finasteride 5 mg PO QHS 5. Hydrochlorothiazide 12.5 mg PO DAILY 6. cod liver oil 1,250-135 unit oral DAILY 7. saw ___ 1080 mg oral BID 8. FoLIC Acid 1 mg PO DAILY 9. Centrum Silver (multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1 tav oral DAILY 10. Pyridoxine 100 mg PO DAILY 11. edoxaban 60 mg oral QHS 12. Ciprofloxacin HCl 500 mg PO Q12H Discharge Medications: 1. amLODIPine 5 mg PO DAILY 2. Atenolol 25 mg PO DAILY 3. Centrum Silver (multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1 tav oral DAILY 4. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #8 Tablet Refills:*0 5. cod liver oil 1,250-135 unit oral DAILY 6. Finasteride 5 mg PO QHS 7. FoLIC Acid 1 mg PO DAILY 8. Hydrochlorothiazide 12.5 mg PO DAILY 9. Pantoprazole 40 mg PO Q24H 10. Pyridoxine 100 mg PO DAILY 11. saw ___ 1080 mg oral BID 12. HELD- edoxaban 60 mg oral QHS This medication was held. Do not restart edoxaban until ___ Discharge Disposition: Home Discharge Diagnosis: pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for observation following an ERCP where you had a sphincterotomy performed. You tolerated this procedure well. The GI doctors have recommended that you take an antibiotic called ciprofloxacin for a total of 5 days after this procedure. In addition, they have recommended that you hold your blood thinner for a total of 3 days after the procedure to decrease the risk of bleeding. Followup Instructions: ___	[ "K838", "C251", "C787", "C786", "R600", "I10", "N400", "D649", "Z7902", "Z86718", "Z86711" ]	Allergies: tramadol Chief Complaint: ERCP Major Surgical or Invasive Procedure: ERCP with sphincterotomy History of Present Illness: This is an [MASKED] male with metastatic pancreatic cancer status post five cycles of gemcitabine and nab-paclitaxel, pulmonary embolus on edoxaban, and recent admission for sepsis and Gram-negative bacteremia from cholangitis and micro-hepatic abscesses. During that admission he underwent prophylactic CBD plastic stent placement and was discharged on p.o. ciprofloxacin. Today he was brought for elective CBD stent removal and sphincterectomy. He underwent uncomplicated ERCP and is being admitted for post procedural overnight observation. Of note he has been holding Edoxaban since [MASKED]. On my evaluation he denies any complaints and states that he feels fine. Specifically he denies any abdominal pain, nausea, vomiting. See detailed 12 point review of systems below. Past Medical History: PAST ONCOLOGIC HISTORY: Pancreatic cancer stage IV - [MASKED] Developed intermittent indigestion treated with Tums and some increased fatigue (annual jobs on the property now take longer to complete). - [MASKED] When seen for routine PE by PCP, reported [MASKED] [MASKED] week h/o of new post-prandial epigastric and LUQ/rib discomfort and fullness (different from his indigestion). Due to these symptoms, he cut back on his eating which resulted in weight loss (10lbs). Initial concern for gastritis and started on Protonix. CXR and L rib plain films were normal. - [MASKED] CT A/P was performed which unfortunately showed a large and infiltrative pancreatic body mass extending along the lesser curvature of the stomach and along the lateral aspect of the celiac axis, encasing the gastric artery. Two ill-defined lesions were noted in the liver (central/caudate and inferior R lobe) c/f mets. Extensive abdominal lymphadenopathy was also noted. Referred to Pan and imaging reviewed by [MASKED] who recommended MRI liver for further characterization of liver lesion (caudate more suspicious, but not accessible percutaneously). Plan was to attempt to biopsy R lobe lesion if suspicious enough on MRI. - [MASKED] MR liver showed multiple liver and omental mets as well as a pancreatic primary - [MASKED] Omental biopsy positive for malignant cells, HA high - [MASKED] Signed informed consent for HALO3 - [MASKED] Found to have DVT, ineligible for HALO3, consented for [MASKED] [MASKED] and randomized to edoxiban - [MASKED] C1D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - [MASKED] C2D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,[MASKED] - [MASKED] CT torso showed interval improvement in disease with interval increase in the necrotic components of the large pancreatic body mass with extensive arterial and venous involvement and decrease in size and/or interval necrosis of some of the retroperitoneal lymph nodes and omental metastases as above. - [MASKED] C3D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - [MASKED] C4D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 PAST MEDICAL HISTORY: 1. Knee replacement x 2. 2. Hernia x 2. 3. Status post PE postoperatively in [MASKED] status post six months of anticoagulation with no recurrent clots. 4. Hypertension. 5. BPH. 6. Folate deficiency. 7. Osteoarthritis. 8. DVT [MASKED] Social History: [MASKED] Family History: Mother with dementia, possibly with cancer at the end of her life. Father with hypertension and [MASKED]. Paternal cousin with some sort of cancer, unknown type. Daughter with thyroid cancer. Physical Exam: gen-well appearing, NAD vitals- 98.0 PO 131 / 80 66 16 96 RA HEENT-ncat eomi anicteric mmm neck-supple chest-b/l ae no w/c/r port in place C/D/I heart-s1s2 rr no m/r/g abd-+bs, soft, NT, ND, no guarding or rebound ext-no c/c/e 2+pulses neuro-face symmetric speech fluent psych-calm cooperative Pertinent Results: [MASKED] 08:19AM BLOOD WBC-3.3* RBC-3.22* Hgb-9.7* Hct-30.1* MCV-94 MCH-30.1 MCHC-32.2 RDW-16.0* RDWSD-55.0* Plt [MASKED] [MASKED] 09:50AM BLOOD WBC-5.3 RBC-3.41* Hgb-10.2* Hct-31.8* MCV-93 MCH-29.9 MCHC-32.1 RDW-16.1* RDWSD-55.5* Plt [MASKED] [MASKED] 09:50AM BLOOD Neuts-65.6 [MASKED] Monos-9.8 Eos-3.2 Baso-1.3* Im [MASKED] AbsNeut-3.46 AbsLymp-1.04* AbsMono-0.52 AbsEos-0.17 AbsBaso-0.07 [MASKED] 09:50AM BLOOD [MASKED] PTT-52.9* [MASKED] [MASKED] 08:19AM BLOOD Glucose-107* UreaN-20 Creat-1.0 Na-141 K-3.7 Cl-104 HCO3-24 AnGap-17 [MASKED] 09:50AM BLOOD UreaN-22* Creat-1.0 Na-141 K-3.9 Cl-105 HCO3-25 AnGap-15 [MASKED] 08:19AM BLOOD ALT-10 AST-18 AlkPhos-131* Amylase-30 TotBili-0.8 [MASKED] 08:19AM BLOOD Lipase-10 [MASKED] 08:19AM BLOOD Calcium-8.9 [MASKED] 09:50AM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.5 Mg-1.9 [MASKED] 09:50AM BLOOD CEA-29.7* [MASKED] 09:50AM BLOOD CA [MASKED] -PND Impression: The scout film showed a plastic stent in the RUQ. A plastic stent was emerging from the major papilla. The stent was successfully removed using a snare. The CBD was successfully cannulated using a CleverCut sphincterotome preloaded with 0.025in guidewire. Contrast injection revealed dilated CBD at approximately 15mm in diameter with few filling defects consistent with sludge. A biliary sphincterotomy was successfully performed at 12 O'clock position. There was no post-sphincterotomy bleeding. The bile duct was swept multiple times using a biliary balloon. A small amount of sludge material was successfully removed. Occlusion cholangiogram revealed no more filling defects. There was excellent contrast and bile drainaige at the end of the procedure. Recommendations: Admit to hospital for monitoring 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 If safe, hold blood thinner for 3 days. Follow-up with referring physician as previously scheduled. Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call Advanced Endoscopy Fellow on call [MASKED] Brief Hospital Course: Pt is a [MASKED] y.o man with h.o metastatic pancreatic cancer s/p gemcitabine and paclitaxel, h.o PE, recent cholangitis/bacteremia with ERCP now s/p ERCP. #pancreatic cancer #recent cholangitis/GNR bacteremia Pt now s/p ERCP with stent removal and sphincterotomy. No pain or other notable complications. Diet advanced to regular without complication. He was advised to take cipro for 5 days and to hold his anticoagulation for 3 days. He will follow up with oncology after discharge. #h.o PE-plan to restart anticoagulation in 3 days #HTN-amlodipine continued #lower extremity edema-HCTZ restarted. #BPH-home finasteride continued. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. amLODIPine 5 mg PO DAILY 3. Pantoprazole 40 mg PO Q24H 4. Finasteride 5 mg PO QHS 5. Hydrochlorothiazide 12.5 mg PO DAILY 6. cod liver oil 1,250-135 unit oral DAILY 7. saw [MASKED] 1080 mg oral BID 8. FoLIC Acid 1 mg PO DAILY 9. Centrum Silver (multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1 tav oral DAILY 10. Pyridoxine 100 mg PO DAILY 11. edoxaban 60 mg oral QHS 12. Ciprofloxacin HCl 500 mg PO Q12H Discharge Medications: 1. amLODIPine 5 mg PO DAILY 2. Atenolol 25 mg PO DAILY 3. Centrum Silver (multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1 tav oral DAILY 4. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #8 Tablet Refills:*0 5. cod liver oil 1,250-135 unit oral DAILY 6. Finasteride 5 mg PO QHS 7. FoLIC Acid 1 mg PO DAILY 8. Hydrochlorothiazide 12.5 mg PO DAILY 9. Pantoprazole 40 mg PO Q24H 10. Pyridoxine 100 mg PO DAILY 11. saw [MASKED] 1080 mg oral BID 12. HELD- edoxaban 60 mg oral QHS This medication was held. Do not restart edoxaban until [MASKED] Discharge Disposition: Home Discharge Diagnosis: pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for observation following an ERCP where you had a sphincterotomy performed. You tolerated this procedure well. The GI doctors have recommended that you take an antibiotic called ciprofloxacin for a total of 5 days after this procedure. In addition, they have recommended that you hold your blood thinner for a total of 3 days after the procedure to decrease the risk of bleeding. Followup Instructions: [MASKED]	[]	[ "I10", "N400", "D649", "Z7902", "Z86718" ]	[ "K838: Other specified diseases of biliary tract", "C251: Malignant neoplasm of body of pancreas", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "R600: Localized edema", "I10: Essential (primary) hypertension", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "D649: Anemia, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z86718: Personal history of other venous thrombosis and embolism", "Z86711: Personal history of pulmonary embolism" ]
10,095,417	29,119,262	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: tramadol Attending: ___. Chief Complaint: Fever/malaise Major Surgical or Invasive Procedure: ___ ERCP History of Present Illness: Mr. ___ is an ___ male with history of with metastatic pancreatic cancer s/p five months of gemcitabine and nab-paclitaxel (currently on hold) and DVT who presents with fever. Patient reports day prior to admission developed chills and malaise. Day of admission spiked a fever to 102.5 with chills and he took 2 Tylenols. Wife reporting she has been sick with URI symptoms with cough and chills for the past week which left her pretty much bedbound for 3 days although she is currently feeling much improved. Patient also had small cold last week when he felt malaise for a few days and then improved. No other sick contacts. No recent travel. Denies nausea, vomiting, chest pain, shortness of breath, headache, abdominal pain, diarrhea, and urinary symptoms. He denies sore throat, nasal congestion, and sinus pressure. Last bowel movement yesterday. Also notes appetite decreased over last few days. Patient also has had left-sided back pain for several years seen by ___ previously and had mild worsening in setting of inactivity for which he saw PCP and had negative x-ray with plan for future ___. On arrival to the ED, initial vitals were 99.0 84 130/73 20 100% RA. Exam was unremarkable. Labs were notable WBC 17.3 (PMNs 89%, bands 6%), H/H 10.0/32.9, Plt 185, Na 139, K 4.6, BUN/Cr ___, LFTs wnl, lactate 2.9, and influenza PCR negative. CXR was negative for pneumonia. RUQ US was negative for cholecystitis. Patient was given cefepime 2g IV, vancomcyin 1g IV, flaygl 500mg IV, Tylenol 1g PO, and 2L NS. Prior to transfer vitals were 102.7 104 143/74 22 96% RA. On arrival to the floor, patient denies pain. He has no acute issues or concerns. He denies headache, vision changes, dizziness/lightheadedness, weakness/numbnesss, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, 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: Pancreatic cancer stage IV - ___ Developed intermittent indigestion treated with Tums and some increased fatigue (annual jobs on the property now take longer to complete). - ___ When seen for routine PE by PCP, reported ___ ___ week h/o of new post-prandial epigastric and LUQ/rib discomfort and fullness (different from his indigestion). Due to these symptoms, he cut back on his eating which resulted in weight loss (10lbs). Initial concern for gastritis and started on Protonix. CXR and L rib plain films were normal. - ___ CT A/P was performed which unfortunately showed a large and infiltrative pancreatic body mass extending along the lesser curvature of the stomach and along the lateral aspect of the celiac axis, encasing the gastric artery. Two ill-defined lesions were noted in the liver (central/caudate and inferior R lobe) c/f mets. Extensive abdominal lymphadenopathy was also noted. Referred to Pancreas Center and imaging reviewed by ___ who recommended MRI liver for further characterization of liver lesion (caudate more suspicious, but not accessible percutaneously). Plan was to attempt to biopsy R lobe lesion if suspicious enough on MRI. - ___ MR liver showed multiple liver and omental mets as well as a pancreatic primary - ___ Omental biopsy positive for malignant cells, HA high - ___ Signed informed consent for HALO3 - ___ Found to have DVT, ineligible for HALO3, consented for ___ ___ and randomized to edoxiban - ___ C1D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - ___ C2D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - ___ CT torso showed interval improvement in disease with interval increase in the necrotic components of the large pancreatic body mass with extensive arterial and venous involvement and decrease in size and/or interval necrosis of some of the retroperitoneal lymph nodes and omental metastases as above. - ___ C3D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - ___ C4D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 PAST MEDICAL HISTORY: 1. Knee replacement x 2. 2. Hernia x 2. 3. Status post PE postoperatively in ___ status post six months of anticoagulation with no recurrent clots. 4. Hypertension. 5. BPH. 6. Folate deficiency. 7. Osteoarthritis. 8. DVT ___ Social History: ___ Family History: FAMILY HISTORY: 1. Mother with dementia, possibly with cancer at the end of her life. 2. Father with hypertension and ___. 3. Paternal cousin with some sort of cancer, unknown type. 4. Daughter with thyroid cancer. Physical Exam: ADMISSION EXAM: VS: Temp 98.1, BP 112/68, HR 97, 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, normal bowel sounds, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, 1+ ___ edema bilaterally. NEURO: A&Ox2 (name, ___, private room at ___), good attention and linear thought, CN II-XII intact. Strength full throughout. Sensation to light touch intact. Able to state ___ forwards. SKIN: No significant rashes. BACK: No spinal or paraspinal tenderness to palpation. ACCESS: Left chest wall port without erythema. DISCHARGE EXAM: VS:97.5, 163 / 83, 75 18 97% RA GENERAL: Pleasant man, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Soft, non-tender, non-distended, normal bowel sounds, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, 1+ ___ edema bilaterally. NEURO: AO x 3, good attention and linear thought, CN II-XII intact. SKIN: No significant rashes. ACCESS: Left chest wall port without erythema. Pertinent Results: ADMISSION LABS: ___ 01:04PM BLOOD WBC-17.3# RBC-3.34 Hgb-10.0* Hct-32.9* MCV-99* MCH-29.9 MCHC-30.4* RDW-17.8* RDWSD-64.7* Plt ___ ___ 01:04PM BLOOD Neuts-89* Bands-6* Lymphs-5* Monos-0 Eos-0 Baso-0 ___ Myelos-0 AbsNeut-16.44* AbsLymp-0.87* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 01:04PM BLOOD Glucose-175* UreaN-29* Creat-1.5* Na-139 K-5.9* Cl-101 HCO3-20* AnGap-24* ___ 01:04PM BLOOD ALT-29 AST-69* AlkPhos-198* TotBili-0.5 ___ 01:04PM BLOOD Albumin-2.8* ___ 02:16PM BLOOD Lactate-2.9* K-4.6 ___ 06:02PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 06:02PM URINE Blood-MOD Nitrite-POS Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 06:02PM URINE RBC-8* WBC-8* Bacteri-FEW Yeast-NONE Epi-0 ___ 12:00AM URINE Hours-RANDOM Creat-147 Na-<20 K-60 Cl-<20 DISCHARGE LABS: ___ 05:25AM BLOOD WBC-9.9 RBC-2.88* Hgb-8.5* Hct-27.1* MCV-94 MCH-29.5 MCHC-31.4* RDW-18.0* RDWSD-62.5* Plt ___ ___ 05:25AM BLOOD Glucose-138* UreaN-25* Creat-1.0 Na-141 K-3.9 Cl-110* HCO3-19* AnGap-16 ___ 05:25AM BLOOD ALT-23 AST-33 AlkPhos-282* TotBili-0.6 ___ 05:25AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9 MICROBIOLOGY: ___ BLOOD CULTURE: No growth ___ BLOOD CULTURE: ESCHERICHIA COLI \| AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R ___ URINE CULTURE: NO GROWTH ___ BLOOD CULTURE X2: NO GROWTH TO DATE ___ BLOOD CULTURE X2: NO GROWTH TO DATE IMAGING: ___ CXR: No focal consolidation to suggest pneumonia. Small bilateral pleural effusions, as noted previously. Bilateral calcified pleural plaques with streaky bibasilar atelectasis. ___ RUQUS: 1. Evaluation limited due to patient motion. 2. No evidence of acute cholecystitis. Focal mild intrahepatic biliary ductal dilatation is seen in the left lobe of the liver as also demonstrated on prior CT. 3. Heterogeneous echotexture of the left hepatic lobe is noted. An underlying lesion cannot be excluded. Better assessment on CT or MRI may be obtained if clinically indicated. 4. The pancreas is not visualized. ___ MRCP: 1. Mild intrahepatic biliary ductal dilatation involving the left of the liver is redemonstrated secondary to previously obstructing metastatic lesion. Note is made of new appearing subcentimeter rim enhancing lesions in the left lobe of the liver associated with surrounding hyperemia raising concern for tiny hepatic abscesses. 2. Overall stable tumor burden as evidenced by pancreatic mass, which is again noted to encase the celiac trunk and splenic artery,hepatic metastases, retroperitoneal lymphadenopathy and omental nodules. 3. Diffuse atrophy of the pancreatic parenchyma is redemonstrated in keeping with chronic pancreatitis, with unchanged large cystic lesion about the pancreas likely representing a pseudocyst. 4. Chronic thrombosis of the splenic vein is redemonstrated. 5. Further interval decrease in size in small cystic collection inferior to the gastric fundus. ___ ERCP: The common bile duct, common hepatic duct and left hepatic ducts were normal. A sphincterotomy was deferred because of the elevated INR. Due to the clinical history, concern for biliary obstruction and cholangitis, the decision was made to place a plastic biliary stent. A ___ FR X 7 cm ___ biliary stent was placed successfully using a ___ stent introducer kit. The final occlusion cholangiogram showed no evidence of filling defects in the CBD. Excellent bile and contrast drainage was seen endoscopically and fluoroscopically Otherwise normal ercp to third part of the duodenum Brief Hospital Course: Mr. ___ is an ___ male with history of with metastatic pancreatic cancer s/p five months of gemcitabine and nab-paclitaxel (currently on hold) and DVT who presented with sepsis, E. coli bacteremia, likely biliary source. ACUTE ISSUES: #E. coli bacteremia: #Sepsis: Patient presented with fever, malaise & septic physiology. Blood culture on admission grew E. coli. CXR/Urine negative for infection. MRCP showed micro-hepatic abscesses and Mild intrahepatic biliary ductal dilatation involving the left of the liver. As such, ERCP was performed and visualized biliary ductal system was clear. A plastic CBD stent was placed prophylactically on ___ with plan for repeat ERCP in ___ weeks. He was initially treated with IV zosyn. ID was consulted and after discussion with patient/primary oncologist, decision was made to transition to oral ciprofloxacin, given patient's wishes to avoid intravenous antibiotics. He was discharged with plan for up to 4 weeks of ciprofloxacin. ___: Likely related to sepsis/pre-renal. Resolved with IVF. #Toxic metabolic encephalopathy: Likely related to infection. Resolved with IVF & treatment of his infection. CHRONIC ISSUES: # Metastatic Pancreatic Cancer: No specific interventions performed/treatments given during this hospitalization. #DVT: Currently on ___ ___ on edoxaban. He continued edoxaban during the admission. #Anemia: Remained at baseline. # Hypertension: Initially held home atenolol and amlodipine, but restarted once patient stable. # BPH: He continued home finasteride. TRANSITIONAL ISSUES: ==================== -ABx Course: Ciprofloxacin 500 mg BID x 4 weeks ___ Duration ___ weeks per ID -GI would like to repeat ERCP in ___ weeks; Pt will need to hold edoxoban ___ days prior & after the procedure -CODE: DNR/OK to Intubate -COMMUNICATION: Patient -EMERGENCY CONTACT HCP: ___ (wife/HCP) ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Finasteride 5 mg PO DAILY 3. Pantoprazole 40 mg PO Q24H 4. Centrum Silver Ultra Mens (multivit-min-FA-lycopen-lutein) ___ mcg oral DAILY 5. cod liver oil 1,250-135 unit oral DAILY 6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 7. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 8. saw ___ 500 mg oral DAILY 9. Atenolol 25 mg PO DAILY 10. FoLIC Acid 1 mg PO DAILY 11. amLODIPine 5 mg PO DAILY 12. Pyridoxine 50 mg PO DAILY 13. edoxaban 60 mg oral DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #50 Tablet Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. amLODIPine 5 mg PO DAILY 4. Atenolol 25 mg PO DAILY 5. Centrum Silver Ultra Mens (multivit-min-FA-lycopen-lutein) ___ mcg oral DAILY 6. cod liver oil 1,250-135 unit oral DAILY 7. edoxaban 60 mg oral DAILY 8. Finasteride 5 mg PO DAILY 9. FoLIC Acid 1 mg PO DAILY 10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 11. Pantoprazole 40 mg PO Q24H 12. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 13. Pyridoxine 50 mg PO DAILY 14. saw ___ 500 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: E. coli bacteremia Sepsis Acute kidney injury Toxic metabolic encephalopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___. Why were you here: -You felt ill for several days with fever at home What was done while you were here: -We diagnosed you with a blood infection -The source is your gastrointestinal tract, specifically your gallbladder tract -A stent was placed in your gallbladder tract in an attempt to prevent a future blockage, which could cause another infection -We treated you with intravenous antibiotics, but then changed them to orals What do to next: -Continue taking your oral antibiotics as prescribed -Follow-up at the appointments listed below We wish you all the best, Your ___ team Followup Instructions: ___	[ "A4151", "K750", "N179", "G9341", "R6520", "C257", "K831", "C786", "C772", "C787", "E860", "D6481", "Z006", "E538", "I10", "N400", "R791", "R600", "Z86711", "Z86718", "Z9221" ]	Allergies: tramadol Chief Complaint: Fever/malaise Major Surgical or Invasive Procedure: [MASKED] ERCP History of Present Illness: Mr. [MASKED] is an [MASKED] male with history of with metastatic pancreatic cancer s/p five months of gemcitabine and nab-paclitaxel (currently on hold) and DVT who presents with fever. Patient reports day prior to admission developed chills and malaise. Day of admission spiked a fever to 102.5 with chills and he took 2 Tylenols. Wife reporting she has been sick with URI symptoms with cough and chills for the past week which left her pretty much bedbound for 3 days although she is currently feeling much improved. Patient also had small cold last week when he felt malaise for a few days and then improved. No other sick contacts. No recent travel. Denies nausea, vomiting, chest pain, shortness of breath, headache, abdominal pain, diarrhea, and urinary symptoms. He denies sore throat, nasal congestion, and sinus pressure. Last bowel movement yesterday. Also notes appetite decreased over last few days. Patient also has had left-sided back pain for several years seen by [MASKED] previously and had mild worsening in setting of inactivity for which he saw PCP and had negative x-ray with plan for future [MASKED]. On arrival to the ED, initial vitals were 99.0 84 130/73 20 100% RA. Exam was unremarkable. Labs were notable WBC 17.3 (PMNs 89%, bands 6%), H/H 10.0/32.9, Plt 185, Na 139, K 4.6, BUN/Cr [MASKED], LFTs wnl, lactate 2.9, and influenza PCR negative. CXR was negative for pneumonia. RUQ US was negative for cholecystitis. Patient was given cefepime 2g IV, vancomcyin 1g IV, flaygl 500mg IV, Tylenol 1g PO, and 2L NS. Prior to transfer vitals were 102.7 104 143/74 22 96% RA. On arrival to the floor, patient denies pain. He has no acute issues or concerns. He denies headache, vision changes, dizziness/lightheadedness, weakness/numbnesss, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, 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: Pancreatic cancer stage IV - [MASKED] Developed intermittent indigestion treated with Tums and some increased fatigue (annual jobs on the property now take longer to complete). - [MASKED] When seen for routine PE by PCP, reported [MASKED] [MASKED] week h/o of new post-prandial epigastric and LUQ/rib discomfort and fullness (different from his indigestion). Due to these symptoms, he cut back on his eating which resulted in weight loss (10lbs). Initial concern for gastritis and started on Protonix. CXR and L rib plain films were normal. - [MASKED] CT A/P was performed which unfortunately showed a large and infiltrative pancreatic body mass extending along the lesser curvature of the stomach and along the lateral aspect of the celiac axis, encasing the gastric artery. Two ill-defined lesions were noted in the liver (central/caudate and inferior R lobe) c/f mets. Extensive abdominal lymphadenopathy was also noted. Referred to Pancreas Center and imaging reviewed by [MASKED] who recommended MRI liver for further characterization of liver lesion (caudate more suspicious, but not accessible percutaneously). Plan was to attempt to biopsy R lobe lesion if suspicious enough on MRI. - [MASKED] MR liver showed multiple liver and omental mets as well as a pancreatic primary - [MASKED] Omental biopsy positive for malignant cells, HA high - [MASKED] Signed informed consent for HALO3 - [MASKED] Found to have DVT, ineligible for HALO3, consented for [MASKED] [MASKED] and randomized to edoxiban - [MASKED] C1D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - [MASKED] C2D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - [MASKED] CT torso showed interval improvement in disease with interval increase in the necrotic components of the large pancreatic body mass with extensive arterial and venous involvement and decrease in size and/or interval necrosis of some of the retroperitoneal lymph nodes and omental metastases as above. - [MASKED] C3D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 - [MASKED] C4D1 gemcitabine 1000 mg/m2 NAB paclitaxel 125 mg/m2 D1,8,15 PAST MEDICAL HISTORY: 1. Knee replacement x 2. 2. Hernia x 2. 3. Status post PE postoperatively in [MASKED] status post six months of anticoagulation with no recurrent clots. 4. Hypertension. 5. BPH. 6. Folate deficiency. 7. Osteoarthritis. 8. DVT [MASKED] Social History: [MASKED] Family History: FAMILY HISTORY: 1. Mother with dementia, possibly with cancer at the end of her life. 2. Father with hypertension and [MASKED]. 3. Paternal cousin with some sort of cancer, unknown type. 4. Daughter with thyroid cancer. Physical Exam: ADMISSION EXAM: VS: Temp 98.1, BP 112/68, HR 97, 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, normal bowel sounds, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, 1+ [MASKED] edema bilaterally. NEURO: A&Ox2 (name, [MASKED], private room at [MASKED]), good attention and linear thought, CN II-XII intact. Strength full throughout. Sensation to light touch intact. Able to state [MASKED] forwards. SKIN: No significant rashes. BACK: No spinal or paraspinal tenderness to palpation. ACCESS: Left chest wall port without erythema. DISCHARGE EXAM: VS:97.5, 163 / 83, 75 18 97% RA GENERAL: Pleasant man, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Soft, non-tender, non-distended, normal bowel sounds, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, 1+ [MASKED] edema bilaterally. NEURO: AO x 3, good attention and linear thought, CN II-XII intact. SKIN: No significant rashes. ACCESS: Left chest wall port without erythema. Pertinent Results: ADMISSION LABS: [MASKED] 01:04PM BLOOD WBC-17.3# RBC-3.34 Hgb-10.0* Hct-32.9* MCV-99* MCH-29.9 MCHC-30.4* RDW-17.8* RDWSD-64.7* Plt [MASKED] [MASKED] 01:04PM BLOOD Neuts-89* Bands-6* Lymphs-5* Monos-0 Eos-0 Baso-0 [MASKED] Myelos-0 AbsNeut-16.44* AbsLymp-0.87* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* [MASKED] 01:04PM BLOOD Glucose-175* UreaN-29* Creat-1.5* Na-139 K-5.9* Cl-101 HCO3-20* AnGap-24* [MASKED] 01:04PM BLOOD ALT-29 AST-69* AlkPhos-198* TotBili-0.5 [MASKED] 01:04PM BLOOD Albumin-2.8* [MASKED] 02:16PM BLOOD Lactate-2.9* K-4.6 [MASKED] 06:02PM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 06:02PM URINE Blood-MOD Nitrite-POS Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [MASKED] 06:02PM URINE RBC-8* WBC-8* Bacteri-FEW Yeast-NONE Epi-0 [MASKED] 12:00AM URINE Hours-RANDOM Creat-147 Na-<20 K-60 Cl-<20 DISCHARGE LABS: [MASKED] 05:25AM BLOOD WBC-9.9 RBC-2.88* Hgb-8.5* Hct-27.1* MCV-94 MCH-29.5 MCHC-31.4* RDW-18.0* RDWSD-62.5* Plt [MASKED] [MASKED] 05:25AM BLOOD Glucose-138* UreaN-25* Creat-1.0 Na-141 K-3.9 Cl-110* HCO3-19* AnGap-16 [MASKED] 05:25AM BLOOD ALT-23 AST-33 AlkPhos-282* TotBili-0.6 [MASKED] 05:25AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9 MICROBIOLOGY: [MASKED] BLOOD CULTURE: No growth [MASKED] BLOOD CULTURE: ESCHERICHIA COLI \| AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R [MASKED] URINE CULTURE: NO GROWTH [MASKED] BLOOD CULTURE X2: NO GROWTH TO DATE [MASKED] BLOOD CULTURE X2: NO GROWTH TO DATE IMAGING: [MASKED] CXR: No focal consolidation to suggest pneumonia. Small bilateral pleural effusions, as noted previously. Bilateral calcified pleural plaques with streaky bibasilar atelectasis. [MASKED] RUQUS: 1. Evaluation limited due to patient motion. 2. No evidence of acute cholecystitis. Focal mild intrahepatic biliary ductal dilatation is seen in the left lobe of the liver as also demonstrated on prior CT. 3. Heterogeneous echotexture of the left hepatic lobe is noted. An underlying lesion cannot be excluded. Better assessment on CT or MRI may be obtained if clinically indicated. 4. The pancreas is not visualized. [MASKED] MRCP: 1. Mild intrahepatic biliary ductal dilatation involving the left of the liver is redemonstrated secondary to previously obstructing metastatic lesion. Note is made of new appearing subcentimeter rim enhancing lesions in the left lobe of the liver associated with surrounding hyperemia raising concern for tiny hepatic abscesses. 2. Overall stable tumor burden as evidenced by pancreatic mass, which is again noted to encase the celiac trunk and splenic artery,hepatic metastases, retroperitoneal lymphadenopathy and omental nodules. 3. Diffuse atrophy of the pancreatic parenchyma is redemonstrated in keeping with chronic pancreatitis, with unchanged large cystic lesion about the pancreas likely representing a pseudocyst. 4. Chronic thrombosis of the splenic vein is redemonstrated. 5. Further interval decrease in size in small cystic collection inferior to the gastric fundus. [MASKED] ERCP: The common bile duct, common hepatic duct and left hepatic ducts were normal. A sphincterotomy was deferred because of the elevated INR. Due to the clinical history, concern for biliary obstruction and cholangitis, the decision was made to place a plastic biliary stent. A [MASKED] FR X 7 cm [MASKED] biliary stent was placed successfully using a [MASKED] stent introducer kit. The final occlusion cholangiogram showed no evidence of filling defects in the CBD. Excellent bile and contrast drainage was seen endoscopically and fluoroscopically Otherwise normal ercp to third part of the duodenum Brief Hospital Course: Mr. [MASKED] is an [MASKED] male with history of with metastatic pancreatic cancer s/p five months of gemcitabine and nab-paclitaxel (currently on hold) and DVT who presented with sepsis, E. coli bacteremia, likely biliary source. ACUTE ISSUES: #E. coli bacteremia: #Sepsis: Patient presented with fever, malaise & septic physiology. Blood culture on admission grew E. coli. CXR/Urine negative for infection. MRCP showed micro-hepatic abscesses and Mild intrahepatic biliary ductal dilatation involving the left of the liver. As such, ERCP was performed and visualized biliary ductal system was clear. A plastic CBD stent was placed prophylactically on [MASKED] with plan for repeat ERCP in [MASKED] weeks. He was initially treated with IV zosyn. ID was consulted and after discussion with patient/primary oncologist, decision was made to transition to oral ciprofloxacin, given patient's wishes to avoid intravenous antibiotics. He was discharged with plan for up to 4 weeks of ciprofloxacin. [MASKED]: Likely related to sepsis/pre-renal. Resolved with IVF. #Toxic metabolic encephalopathy: Likely related to infection. Resolved with IVF & treatment of his infection. CHRONIC ISSUES: # Metastatic Pancreatic Cancer: No specific interventions performed/treatments given during this hospitalization. #DVT: Currently on [MASKED] [MASKED] on edoxaban. He continued edoxaban during the admission. #Anemia: Remained at baseline. # Hypertension: Initially held home atenolol and amlodipine, but restarted once patient stable. # BPH: He continued home finasteride. TRANSITIONAL ISSUES: ==================== -ABx Course: Ciprofloxacin 500 mg BID x 4 weeks [MASKED] Duration [MASKED] weeks per ID -GI would like to repeat ERCP in [MASKED] weeks; Pt will need to hold edoxoban [MASKED] days prior & after the procedure -CODE: DNR/OK to Intubate -COMMUNICATION: Patient -EMERGENCY CONTACT HCP: [MASKED] (wife/HCP) [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Finasteride 5 mg PO DAILY 3. Pantoprazole 40 mg PO Q24H 4. Centrum Silver Ultra Mens (multivit-min-FA-lycopen-lutein) [MASKED] mcg oral DAILY 5. cod liver oil 1,250-135 unit oral DAILY 6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 7. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 8. saw [MASKED] 500 mg oral DAILY 9. Atenolol 25 mg PO DAILY 10. FoLIC Acid 1 mg PO DAILY 11. amLODIPine 5 mg PO DAILY 12. Pyridoxine 50 mg PO DAILY 13. edoxaban 60 mg oral DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #50 Tablet Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. amLODIPine 5 mg PO DAILY 4. Atenolol 25 mg PO DAILY 5. Centrum Silver Ultra Mens (multivit-min-FA-lycopen-lutein) [MASKED] mcg oral DAILY 6. cod liver oil 1,250-135 unit oral DAILY 7. edoxaban 60 mg oral DAILY 8. Finasteride 5 mg PO DAILY 9. FoLIC Acid 1 mg PO DAILY 10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 11. Pantoprazole 40 mg PO Q24H 12. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 13. Pyridoxine 50 mg PO DAILY 14. saw [MASKED] 500 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: E. coli bacteremia Sepsis Acute kidney injury Toxic metabolic encephalopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]. Why were you here: -You felt ill for several days with fever at home What was done while you were here: -We diagnosed you with a blood infection -The source is your gastrointestinal tract, specifically your gallbladder tract -A stent was placed in your gallbladder tract in an attempt to prevent a future blockage, which could cause another infection -We treated you with intravenous antibiotics, but then changed them to orals What do to next: -Continue taking your oral antibiotics as prescribed -Follow-up at the appointments listed below We wish you all the best, Your [MASKED] team Followup Instructions: [MASKED]	[]	[ "N179", "I10", "N400", "Z86718" ]	[ "A4151: Sepsis due to Escherichia coli [E. coli]", "K750: Abscess of liver", "N179: Acute kidney failure, unspecified", "G9341: Metabolic encephalopathy", "R6520: Severe sepsis without septic shock", "C257: Malignant neoplasm of other parts of pancreas", "K831: Obstruction of bile duct", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "E860: Dehydration", "D6481: Anemia due to antineoplastic chemotherapy", "Z006: Encounter for examination for normal comparison and control in clinical research program", "E538: Deficiency of other specified B group vitamins", "I10: Essential (primary) hypertension", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "R791: Abnormal coagulation profile", "R600: Localized edema", "Z86711: Personal history of pulmonary embolism", "Z86718: Personal history of other venous thrombosis and embolism", "Z9221: Personal history of antineoplastic chemotherapy" ]
10,095,483	20,705,264	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: trazodone Attending: ___. Chief Complaint: Priapism Major Surgical or Invasive Procedure: Penile corporal injections History of Present Illness: HPI: Patient is a ___ male who presents with 15 hours of priapism starting at 630am (possibly earlier) after taking a dose of trazodone last night. he had severe pain and presented to the ED in ___ where they tried 500mcg of phenylephrine which initially worked but had recurrence. he was transferred here. He remains in severe pain and denies any other medical history. Past Medical History: None Social History: Works for ___ at ___. Physical Exam: Gen: No acute distress, alert & oriented HEENT: Extraocular movements intact, face symmetric CHEST: Warm and well-perfused BACK: Non-labored breathing, no CVA tenderness bilaterally ABD: Soft, non-tender, non-distended, no guarding or rebound GU: soft penis with bruising and hematoma at base. No erection present EXT: Moves all extremities well PSY: Appropriately interactive Pertinent Results: ___ 06:08AM BLOOD Hct-38.8* Brief Hospital Course: Patient was transferred from ___ after receiving 500mg of intra-corporal phenylephrine with recurrent priapism. In the ED pt was given 2,800mg of phenylephrine intra-corporal injection with irrigation of the corpora. Significant improvement in the patient's erection was achieved. He developed hematomas at the base of his penis. he was admitted for observation. Overnight the patient's pain remained ___. On exam on day one his erection was gone and his penis was soft with ongoing bruising and hematoma. He started to have pain in the morning which was controlled with Tylenol and oxycodone. By lunch he was determined to be safe for discharge home. He will follow up with his PCP and ___ in his home town. Medications on Admission: Trazodone - discontinued Discharge Medications: Oxycodone Colace Discharge Disposition: Home Discharge Diagnosis: Priapism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: - Do not have sex for 1 month. DO not participate in masturbation for one month. -You may shower, but do NOT bathe, swim or otherwise immerse your incision. -Do NOT lift anything heavier than a phone book and no sports, vigorous physical activity (including sexual). -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthough pain >4. The maximum daily Tylenol/Acetaminophen dose is ___ grams FROM ALL sources. -Do NOT drive or drink alcohol while taking narcotics and do NOT operate dangerous machinery. For your safety, please do NOT DRIVE WHILE TAKING NARCOTIC PAIN MEDICATION -Colace has been prescribed to avoid post-surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. Colace is a stool "softener"- it is NOT a laxative - NEVER TAKE TRAZODONE AGAIN -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest emergency room. Followup Instructions: ___	[ "N4833", "T43215A", "Y92003" ]	Allergies: trazodone Chief Complaint: Priapism Major Surgical or Invasive Procedure: Penile corporal injections History of Present Illness: HPI: Patient is a [MASKED] male who presents with 15 hours of priapism starting at 630am (possibly earlier) after taking a dose of trazodone last night. he had severe pain and presented to the ED in [MASKED] where they tried 500mcg of phenylephrine which initially worked but had recurrence. he was transferred here. He remains in severe pain and denies any other medical history. Past Medical History: None Social History: Works for [MASKED] at [MASKED]. Physical Exam: Gen: No acute distress, alert & oriented HEENT: Extraocular movements intact, face symmetric CHEST: Warm and well-perfused BACK: Non-labored breathing, no CVA tenderness bilaterally ABD: Soft, non-tender, non-distended, no guarding or rebound GU: soft penis with bruising and hematoma at base. No erection present EXT: Moves all extremities well PSY: Appropriately interactive Pertinent Results: [MASKED] 06:08AM BLOOD Hct-38.8* Brief Hospital Course: Patient was transferred from [MASKED] after receiving 500mg of intra-corporal phenylephrine with recurrent priapism. In the ED pt was given 2,800mg of phenylephrine intra-corporal injection with irrigation of the corpora. Significant improvement in the patient's erection was achieved. He developed hematomas at the base of his penis. he was admitted for observation. Overnight the patient's pain remained [MASKED]. On exam on day one his erection was gone and his penis was soft with ongoing bruising and hematoma. He started to have pain in the morning which was controlled with Tylenol and oxycodone. By lunch he was determined to be safe for discharge home. He will follow up with his PCP and [MASKED] in his home town. Medications on Admission: Trazodone - discontinued Discharge Medications: Oxycodone Colace Discharge Disposition: Home Discharge Diagnosis: Priapism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: - Do not have sex for 1 month. DO not participate in masturbation for one month. -You may shower, but do NOT bathe, swim or otherwise immerse your incision. -Do NOT lift anything heavier than a phone book and no sports, vigorous physical activity (including sexual). -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthough pain >4. The maximum daily Tylenol/Acetaminophen dose is [MASKED] grams FROM ALL sources. -Do NOT drive or drink alcohol while taking narcotics and do NOT operate dangerous machinery. For your safety, please do NOT DRIVE WHILE TAKING NARCOTIC PAIN MEDICATION -Colace has been prescribed to avoid post-surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. Colace is a stool "softener"- it is NOT a laxative - NEVER TAKE TRAZODONE AGAIN -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest emergency room. Followup Instructions: [MASKED]	[]	[]	[ "N4833: Priapism, drug-induced", "T43215A: Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, initial encounter", "Y92003: Bedroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]
10,095,655	20,183,285	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PSYCHIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: "I had a few tough days" Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ year old female with a history of bipolar disorder, diverticulitis s/p ileostomy in ___, one previous hospitalization at ___ in ___ for depression, and no prior suicide attempts, who was BIBA on ___ after patient was found down and minimally responsive by her husband, with concern for intentional overdose. Psychiatry was consulted for safety assessment, medication and disposition recommendations. Around 11:00pm on ___, patient's husband heard a thud and found patient floor next to the bed, able to open her eyes, but otherwise not responsive. Husband also found a bottle of Diazepam that was empty (approx. 10 5mg pills missing). When patient arrived to the ED, she was unresponsive with GCS of 7 (Localizes to painful stimuli) and was intubated. Head CT revealed small right frontal SAH. Patient was admitted to the SICU and was extubated on ___. Patient spiked fever to 102.9 overnight, had tachypnea and increased secretions, so pt was started on broad spectrum abx for ?PNA vs UTI. On interview this morning, patient says that she is in the hospital because she took extra pills. She reports intentionally taking Valium with the hope of dying and not waking up. She wishes that she were successful in her suicide attempt and says that she is not happy to be alive. She expresses a lot of shame that her attempt was not successful. She denies current suicidal intent or plan. She feels guilty that she ruined ___ for her family. She reports two months of feeling down, depressed, and anxious. She describes feeling useless and unable to do anything. She endorses difficulty sleeping over the past month and says that is why she was prescribed Valium. She denies current or a history of auditory and visual hallucinations. When revisited in the afternoon, patient reports that she may have also taken additional olanzapine with the valium. Past Medical History: PAST PSYCHIATRIC HISTORY: Hospitalizations: ___ ___ for depression Current treaters and treatment: Psychiatrist- Dr. ___ (___), Therapist-Dr. ___ (___) Medication and ECT trials: olanzapine, Lexapro, diazepam Self-injury: denies history of prior suicide attempts or self injurious behavior, confirmed with husband Harm to others: denies Access to weapons: denies, confirmed with husband PAST MEDICAL HISTORY - PCP: ___ (___) - Hx of head trauma: not prior to ___ this hospitalization - Hx of seizure: denies - PMHx: Diverticulitis s/p ileostomy (___) Fibromuscular dysplasia Social History: ___ Family History: Maternal Aunt: committed suicide ___ years ago Maternal cousins with psychiatric illness, details unknown Middle Son: ___ Oldest Son: ___ Daughter: anxiety and ADHD Physical Exam: GENERAL - HEENT: - normocephalic, atraumatic - moist mucous membranes, oropharynx clear, supple neck - no scleral icterus - Cardiovascular: - regular rate and rhythm, S1/S2 heard, no murmurs/rubs/gallops - Pulmonary: - no increased work of breathing - lungs clear to auscultation bilaterally - no wheezes/rhonchi/rales -occasional cough - Abdominal: - non-distended, bowel sounds normoactive - no tenderness to palpation in all quadrants - no guarding, no rebound tenderness - Extremities: - warm and well-perfused - no edema of the limbs - Skin: - no rashes or lesions noted NEUROLOGICAL - Cranial Nerves: - I: olfaction not tested - II: PERRL 3 to 2 mm, both directly and consentually; brisk bilaterally, VFF to confrontation - III, IV, VI: EOMI without nystagmus - V: facial sensation intact to light touch in all distributions - VII: no facial droop, facial musculature symmetric and ___ strength in upper and lower distributions, bilaterally - VIII: hearing intact to finger rub bilaterally - IX, X: palate elevates symmetrically - XI: ___ strength in trapezii and SCM bilaterally - XII: tongue protrudes in midline - Motor: - normal bulk and tone bilaterally - no abnormal movements, no tremor - strength ___ throughout - Sensory: - no deficits to fine touch throughout - Gait: - good initiation - narrow-based, normal stride and arm swing - able to walk in tandem with mild instability COGNITION - Wakefulness/alertness: - awake and alert - Attention: - MOYb--pausing at ___ and needing to be refocused, but resumes the task - Orientation: - oriented to person, not time (says it is early ___, place, situation - Executive function (go-no go, Luria, trails, FAS): - not tested - Memory: - ___ registration - ___ spontaneous recall after 5 min, ___ with hinting - long-term grossly intact - Fund of knowledge: - consistent with education - intact to last 3 presidents - Calculations: - $1.75 = 7 quarters - Abstraction: - "The apple doesn't fall far from the tree" = If a mother is very beautiful, her daughter will have that beauty too--it can also be for traits that aren't physical - bicycle/train: both move, both have wheels - Visuospatial: - not assessed - Language: - fluent ___ speaker, no paraphasic errors, appropriate to conversation MENTAL STATUS - Appearance: - woman appearing stated age, adequate hygiene and grooming, wearing hospital gown and scrub pants - Behavior: - seated on couch, appropriate eye contact, mild psychomotor retardation - Attitude: - cooperative, engaged, friendly - Mood: - "I feel regret" - Affect: - mood-congruent, dysthymic, full range, occasional tearfulness, appropriate to situation - Speech: - slow rate, normal volume, and prosody - Thought process: - linear, coherent, goal-oriented, no loose associations, expressing remorse about pain she has caused family - Thought Content: - Safety: Denies SI/HI - Delusions: No evidence of paranoia, etc. - Obsessions/Compulsions: No evidence based on current encounter - Hallucinations: Denies AVH, not appearing to be attending to internal stimuli - Insight: - fair - Judgment: - fair Pertinent Results: ___ 05:50PM CHOLEST-184 ___ 05:50PM %HbA1c-5.9 eAG-123 ___ 05:50PM TRIGLYCER-471* HDL CHOL-28* CHOL/HDL-6.6 ___ ___ 05:50PM TSH-2.1 ___ 07:20AM GLUCOSE-115* UREA N-9 CREAT-0.6 SODIUM-141 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-11 ___ 07:20AM CALCIUM-9.3 PHOSPHATE-4.3 MAGNESIUM-2.3 ___ 07:20AM WBC-4.4 RBC-3.69* HGB-10.7* HCT-34.0 MCV-92 MCH-29.0 MCHC-31.5* RDW-14.0 RDWSD-47.2* ___ 07:20AM PLT COUNT-334 ___ 06:42AM GLUCOSE-114* UREA N-7 CREAT-0.6 SODIUM-143 POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-25 ANION GAP-12 ___ 06:42AM estGFR-Using this ___ 06:42AM CALCIUM-9.0 PHOSPHATE-4.3 MAGNESIUM-2.2 ___ 06:42AM WBC-5.3 RBC-3.69* HGB-10.8* HCT-33.6* MCV-91 MCH-29.3 MCHC-32.1 RDW-13.9 RDWSD-46.3 ___ 06:42AM PLT COUNT-___. 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. Starting on ___ the pt was permitted to leave the unit for fresh air walks. 2. PSYCHIATRIC: #)Bipolar Disorder-current episode depressed Pt presented to the unit on ___ after an intentional overdose on diazepam and Zyprexa on ___. Prior to admission to ___ she required medical hospitalization with initial ICU level of care, intubation, and subsequent treatment for pneumonia and altered mental status. On presentation to our unit she was profoundly dysphoric and tearful, expressing remorse about her recent attempt and the effect that it had on her family. She described the attempt as impulsive and does not recall the decision-making process that lead up to the overdose. She frequently mention the change in the dose of her Zyprexa and Escitalopram and attributed her attempt to these changes. Given pt's psychiatric history and current presentation our diagnostic assessment was that this represented a depressive episode of Bipolar I Disorder. She describes periods of depression as well as mania, which have a negative effect on her life and relationship with family. She describes neurovegetative symptoms of depression since ___, which left her feeling hopeless, worthless, and burdensome to her family. This depressive episode followed an episode of mania that had occurred after her ileostomy in ___. On the unit, the pt began to exhibit signs of hypomania--talkativeness, becoming uninterruptable, and elevation of mood. By time of discharge, her mood had leveled significantly with no signs of dysphoria or depression or manic behavior. The pt was followed by the psychiatry consult service while on medicine and was maintained on a 5mg dose of qHS Zyprexa. On Deacon___, Zyprexa was discontinued and the pt was initiated on Lithium. She started on a dose of 300mg and was tapered up to 900mg qHS. Pt expressed concern about pills becoming lodged in her stoma and opening capsules resulted in a taste that was unpalatable to the patient. Ultimately, she was put on a liquid formula to maximize compliance with the medication regimen. By time of discharge on ___ her mood was improved and she was actively participating in groups and social in the milieu. She was bright, pleasant and interactive. The team did note ongoing perseveration on some topics--medication side effects, her son's diagnosis of bipolar disorder, and her prior treatment regimen, which she believed to be inappropriate. Frequent repetition and some restricted affect called into question possibility of underlying neurocognitive disorder or element of post-concussive syndrome due to recent head injury sustained after overdose. We will defer to outpatient treatment providers to provide more longitudinal clarification to potential diagnoses, as this can be difficult in the acute psychiatric setting. We would recommend ongoing psychoeducation and personal as well as family therapy for this patient. We would recommend continuation of Lithium for mood maintenance. At a 600mg qHS dose, her level here on the unit was 0.4. We subsequently increased her dose to 900mg qHS and would recommend weekly following of levels until she is at a stable dose. We would also recommend routine monitoring of TSH, Ca, CBC, and BMP as detailed below: --Please recheck lipid profile in ___ weeks to monitor for improvement off of Zyprexa --Please check lithium level twice weekly until stable--then continue to monitor q month --Please recheck TSH in ___ months, then continue to monitor every 6-months --Please check Ca level in ___ months --BMP, CBC monitoring every ___ months 3. SUBSTANCE USE DISORDERS: #)no active or historical substance use disorders 4. MEDICAL #GBS PNA Aspiration vs PNA vs ASA PNA vs VAP. Treated with IV cefepime-->CTX for 7-day course on medicine service. -No need for further abx treatment. -Pt no longer using PRN nebulizers--will not continue as outpatient #Odynophagia Initial speech/swallow eval notable for oropharyngeal dysphagia with improvement on re-evaluation after resolution of AMS. Could be ___ intubation. Pt with no further complaints while on psychiatry service. Tolerating regular diet. #SAH, bilateral #fibromuscular dysplasia Sm SAH of b/l anterior frontal lobes on admission. EEG without seizure activity. Possible FMD/vascular abnormality seen on imaging. -Patient will need to ___ in stroke clinic (Dr. ___ ___ for outpatient ___ of fibromuscular dysplasia. PCP ___ have to call and schedule this appointment. #asymptomatic bacteruria Urine culture on admission as well as repeat culture with pan-sensitive E. Coli. Deferred treatment due to lack of symptoms. Covered by PNA abx. #diverticulitis s/p ileostomy -Continue ostomy care every other day; pt changes own ostomy but will need supplies 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, as well as yoga classes, music classes and project groups. She was active and social in the milieu with positive therapeutic effect. #) COLLATERAL INFORMATION AND FAMILY INVOLVEMENT -Husband, ___, was very active in the care of the patient. He met with the team on ___ to discuss initiation on Lithium. He was also present at time of discharge for family meeting with son, ___. Family was agreeable with discharge plan, medication plan, and plan for patient to attend partial at ___. -An attempt was made to reach Dr. ___ at ___ ___ Associates. ___ was scheduled by the patient. Dr. ___ out to the patient prior to her hospitalization on ___. -Therapist, Dr. ___ was contacted and updated with patient information. She also reached out to the patient multiple times during her inpatient admission. ___ was scheduled for #) INTERVENTIONS - Medications: Lithium was initiated and uptitrated to dose of 900mg qHS. - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: Pt will start at ___ ___ on ___ at 8:45. She will also ___ with her PCP ___ ___ at 3:30. She will see her prescriber, Dr. ___ should ___ with her outpatient therapist, Dr. ___ she is done with partial. - Behavioral Interventions (e.g. encouraged DBT skills, ect): encourage psychoeducation, coping skills, continued medication compliance -Guardianships: none pursued INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of starting Lithium. We discussed the possibility of increased thirst, increased urination, and possible damage to the kidneys with ongoing use. We also discussed the risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team. The patient appeared able to understand and consented to begin the medication. She asked many questions over the course of treatment and education was provided. RISK ASSESSMENT & PROGNOSIS On presentation, the patient was evaluated and felt to be at an increased risk of harm to herself and/or others based upon her recent intentional overdose. Her static factors noted at that time include chronic mental illness and recent medical illness resulting in recent increase in necessary care. The modifiable risk factors were also addressed at that time including suicidal ideation with intent, disorganized and unpredictable behavior. These were addressed with psychoeducation, medication adjustments and family meetings with her husband and son. Finally, the patient is being discharged with many protective risk factors, help-seeking nature, future-oriented viewpoint, sense of responsibility to family, children in the home, life satisfaction, reality testing ability, positive therapeutic relationship with outpatient providers,and strong social supports. Overall, the patient is not at an acutely elevated risk of self-harm nor danger to others due to acutely decompensated psychiatric illness. PERTINENT LAB VALUES Lipids: Chol 184; ___ 471; HDL 28; LDL 76 A1c: 5.9 BP: 106/70 TSH: 2.1 BMI: 30 Lithium: 0.4 TSH: 2.1 Medications on Admission: -Olanzapine 10mg qHS -Escitalopram 10mg daily -Diazepam 5mg qHS Discharge Medications: -Lithium 800mg qHS--oral solution (8mEQ/5ml) -You can take 8mg of melatonin 30-minutes before bed, available over the counter, if you are having trouble sleeping Discharge Disposition: Home Discharge Diagnosis: Bipolar Disorder--current episode depressed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: -Appearance: Age-appearing woman, good hygiene and grooming, nicely dressed, no acute distress -Behavior/Attitude: calm, cooperative, pleasant -Mood: 'Things are good' -Affect: bright today, less restricted, occasionally smiling and laughing -Speech: slower rate today, regular prosody, regular volume -Thought process: remains perseverative on certain subjects--lithium side effects, concern about son, financial concerns, improved tangentiality -Thought Content: denies SI, HI, AH, VH. No delusions or paranoia. -Insight: fair -Judgment: fair 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: ___	[ "F319", "Z932", "Z915" ]	Allergies: No Known Allergies / Adverse Drug Reactions [MASKED] Complaint: "I had a few tough days" Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] is a [MASKED] year old female with a history of bipolar disorder, diverticulitis s/p ileostomy in [MASKED], one previous hospitalization at [MASKED] in [MASKED] for depression, and no prior suicide attempts, who was BIBA on [MASKED] after patient was found down and minimally responsive by her husband, with concern for intentional overdose. Psychiatry was consulted for safety assessment, medication and disposition recommendations. Around 11:00pm on [MASKED], patient's husband heard a thud and found patient floor next to the bed, able to open her eyes, but otherwise not responsive. Husband also found a bottle of Diazepam that was empty (approx. 10 5mg pills missing). When patient arrived to the ED, she was unresponsive with GCS of 7 (Localizes to painful stimuli) and was intubated. Head CT revealed small right frontal SAH. Patient was admitted to the SICU and was extubated on [MASKED]. Patient spiked fever to 102.9 overnight, had tachypnea and increased secretions, so pt was started on broad spectrum abx for ?PNA vs UTI. On interview this morning, patient says that she is in the hospital because she took extra pills. She reports intentionally taking Valium with the hope of dying and not waking up. She wishes that she were successful in her suicide attempt and says that she is not happy to be alive. She expresses a lot of shame that her attempt was not successful. She denies current suicidal intent or plan. She feels guilty that she ruined [MASKED] for her family. She reports two months of feeling down, depressed, and anxious. She describes feeling useless and unable to do anything. She endorses difficulty sleeping over the past month and says that is why she was prescribed Valium. She denies current or a history of auditory and visual hallucinations. When revisited in the afternoon, patient reports that she may have also taken additional olanzapine with the valium. Past Medical History: PAST PSYCHIATRIC HISTORY: Hospitalizations: [MASKED] [MASKED] for depression Current treaters and treatment: Psychiatrist- Dr. [MASKED] ([MASKED]), Therapist-Dr. [MASKED] ([MASKED]) Medication and ECT trials: olanzapine, Lexapro, diazepam Self-injury: denies history of prior suicide attempts or self injurious behavior, confirmed with husband Harm to others: denies Access to weapons: denies, confirmed with husband PAST MEDICAL HISTORY - PCP: [MASKED] ([MASKED]) - Hx of head trauma: not prior to [MASKED] this hospitalization - Hx of seizure: denies - PMHx: Diverticulitis s/p ileostomy ([MASKED]) Fibromuscular dysplasia Social History: [MASKED] Family History: Maternal Aunt: committed suicide [MASKED] years ago Maternal cousins with psychiatric illness, details unknown Middle Son: [MASKED] Oldest Son: [MASKED] Daughter: anxiety and ADHD Physical Exam: GENERAL - HEENT: - normocephalic, atraumatic - moist mucous membranes, oropharynx clear, supple neck - no scleral icterus - Cardiovascular: - regular rate and rhythm, S1/S2 heard, no murmurs/rubs/gallops - Pulmonary: - no increased work of breathing - lungs clear to auscultation bilaterally - no wheezes/rhonchi/rales -occasional cough - Abdominal: - non-distended, bowel sounds normoactive - no tenderness to palpation in all quadrants - no guarding, no rebound tenderness - Extremities: - warm and well-perfused - no edema of the limbs - Skin: - no rashes or lesions noted NEUROLOGICAL - Cranial Nerves: - I: olfaction not tested - II: PERRL 3 to 2 mm, both directly and consentually; brisk bilaterally, VFF to confrontation - III, IV, VI: EOMI without nystagmus - V: facial sensation intact to light touch in all distributions - VII: no facial droop, facial musculature symmetric and [MASKED] strength in upper and lower distributions, bilaterally - VIII: hearing intact to finger rub bilaterally - IX, X: palate elevates symmetrically - XI: [MASKED] strength in trapezii and SCM bilaterally - XII: tongue protrudes in midline - Motor: - normal bulk and tone bilaterally - no abnormal movements, no tremor - strength [MASKED] throughout - Sensory: - no deficits to fine touch throughout - Gait: - good initiation - narrow-based, normal stride and arm swing - able to walk in tandem with mild instability COGNITION - Wakefulness/alertness: - awake and alert - Attention: - MOYb--pausing at [MASKED] and needing to be refocused, but resumes the task - Orientation: - oriented to person, not time (says it is early [MASKED], place, situation - Executive function (go-no go, Luria, trails, FAS): - not tested - Memory: - [MASKED] registration - [MASKED] spontaneous recall after 5 min, [MASKED] with hinting - long-term grossly intact - Fund of knowledge: - consistent with education - intact to last 3 presidents - Calculations: - $1.75 = 7 quarters - Abstraction: - "The apple doesn't fall far from the tree" = If a mother is very beautiful, her daughter will have that beauty too--it can also be for traits that aren't physical - bicycle/train: both move, both have wheels - Visuospatial: - not assessed - Language: - fluent [MASKED] speaker, no paraphasic errors, appropriate to conversation MENTAL STATUS - Appearance: - woman appearing stated age, adequate hygiene and grooming, wearing hospital gown and scrub pants - Behavior: - seated on couch, appropriate eye contact, mild psychomotor retardation - Attitude: - cooperative, engaged, friendly - Mood: - "I feel regret" - Affect: - mood-congruent, dysthymic, full range, occasional tearfulness, appropriate to situation - Speech: - slow rate, normal volume, and prosody - Thought process: - linear, coherent, goal-oriented, no loose associations, expressing remorse about pain she has caused family - Thought Content: - Safety: Denies SI/HI - Delusions: No evidence of paranoia, etc. - Obsessions/Compulsions: No evidence based on current encounter - Hallucinations: Denies AVH, not appearing to be attending to internal stimuli - Insight: - fair - Judgment: - fair Pertinent Results: [MASKED] 05:50PM CHOLEST-184 [MASKED] 05:50PM %HbA1c-5.9 eAG-123 [MASKED] 05:50PM TRIGLYCER-471* HDL CHOL-28* CHOL/HDL-6.6 [MASKED] [MASKED] 05:50PM TSH-2.1 [MASKED] 07:20AM GLUCOSE-115* UREA N-9 CREAT-0.6 SODIUM-141 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-11 [MASKED] 07:20AM CALCIUM-9.3 PHOSPHATE-4.3 MAGNESIUM-2.3 [MASKED] 07:20AM WBC-4.4 RBC-3.69* HGB-10.7* HCT-34.0 MCV-92 MCH-29.0 MCHC-31.5* RDW-14.0 RDWSD-47.2* [MASKED] 07:20AM PLT COUNT-334 [MASKED] 06:42AM GLUCOSE-114* UREA N-7 CREAT-0.6 SODIUM-143 POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-25 ANION GAP-12 [MASKED] 06:42AM estGFR-Using this [MASKED] 06:42AM CALCIUM-9.0 PHOSPHATE-4.3 MAGNESIUM-2.2 [MASKED] 06:42AM WBC-5.3 RBC-3.69* HGB-10.8* HCT-33.6* MCV-91 MCH-29.3 MCHC-32.1 RDW-13.9 RDWSD-46.3 [MASKED] 06:42AM PLT COUNT-[MASKED]. 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. Starting on [MASKED] the pt was permitted to leave the unit for fresh air walks. 2. PSYCHIATRIC: #)Bipolar Disorder-current episode depressed Pt presented to the unit on [MASKED] after an intentional overdose on diazepam and Zyprexa on [MASKED]. Prior to admission to [MASKED] she required medical hospitalization with initial ICU level of care, intubation, and subsequent treatment for pneumonia and altered mental status. On presentation to our unit she was profoundly dysphoric and tearful, expressing remorse about her recent attempt and the effect that it had on her family. She described the attempt as impulsive and does not recall the decision-making process that lead up to the overdose. She frequently mention the change in the dose of her Zyprexa and Escitalopram and attributed her attempt to these changes. Given pt's psychiatric history and current presentation our diagnostic assessment was that this represented a depressive episode of Bipolar I Disorder. She describes periods of depression as well as mania, which have a negative effect on her life and relationship with family. She describes neurovegetative symptoms of depression since [MASKED], which left her feeling hopeless, worthless, and burdensome to her family. This depressive episode followed an episode of mania that had occurred after her ileostomy in [MASKED]. On the unit, the pt began to exhibit signs of hypomania--talkativeness, becoming uninterruptable, and elevation of mood. By time of discharge, her mood had leveled significantly with no signs of dysphoria or depression or manic behavior. The pt was followed by the psychiatry consult service while on medicine and was maintained on a 5mg dose of qHS Zyprexa. On Deacon , Zyprexa was discontinued and the pt was initiated on Lithium. She started on a dose of 300mg and was tapered up to 900mg qHS. Pt expressed concern about pills becoming lodged in her stoma and opening capsules resulted in a taste that was unpalatable to the patient. Ultimately, she was put on a liquid formula to maximize compliance with the medication regimen. By time of discharge on [MASKED] her mood was improved and she was actively participating in groups and social in the milieu. She was bright, pleasant and interactive. The team did note ongoing perseveration on some topics--medication side effects, her son's diagnosis of bipolar disorder, and her prior treatment regimen, which she believed to be inappropriate. Frequent repetition and some restricted affect called into question possibility of underlying neurocognitive disorder or element of post-concussive syndrome due to recent head injury sustained after overdose. We will defer to outpatient treatment providers to provide more longitudinal clarification to potential diagnoses, as this can be difficult in the acute psychiatric setting. We would recommend ongoing psychoeducation and personal as well as family therapy for this patient. We would recommend continuation of Lithium for mood maintenance. At a 600mg qHS dose, her level here on the unit was 0.4. We subsequently increased her dose to 900mg qHS and would recommend weekly following of levels until she is at a stable dose. We would also recommend routine monitoring of TSH, Ca, CBC, and BMP as detailed below: --Please recheck lipid profile in [MASKED] weeks to monitor for improvement off of Zyprexa --Please check lithium level twice weekly until stable--then continue to monitor q month --Please recheck TSH in [MASKED] months, then continue to monitor every 6-months --Please check Ca level in [MASKED] months --BMP, CBC monitoring every [MASKED] months 3. SUBSTANCE USE DISORDERS: #)no active or historical substance use disorders 4. MEDICAL #GBS PNA Aspiration vs PNA vs ASA PNA vs VAP. Treated with IV cefepime-->CTX for 7-day course on medicine service. -No need for further abx treatment. -Pt no longer using PRN nebulizers--will not continue as outpatient #Odynophagia Initial speech/swallow eval notable for oropharyngeal dysphagia with improvement on re-evaluation after resolution of AMS. Could be [MASKED] intubation. Pt with no further complaints while on psychiatry service. Tolerating regular diet. #SAH, bilateral #fibromuscular dysplasia Sm SAH of b/l anterior frontal lobes on admission. EEG without seizure activity. Possible FMD/vascular abnormality seen on imaging. -Patient will need to [MASKED] in stroke clinic (Dr. [MASKED] [MASKED] for outpatient [MASKED] of fibromuscular dysplasia. PCP [MASKED] have to call and schedule this appointment. #asymptomatic bacteruria Urine culture on admission as well as repeat culture with pan-sensitive E. Coli. Deferred treatment due to lack of symptoms. Covered by PNA abx. #diverticulitis s/p ileostomy -Continue ostomy care every other day; pt changes own ostomy but will need supplies 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, as well as yoga classes, music classes and project groups. She was active and social in the milieu with positive therapeutic effect. #) COLLATERAL INFORMATION AND FAMILY INVOLVEMENT -Husband, [MASKED], was very active in the care of the patient. He met with the team on [MASKED] to discuss initiation on Lithium. He was also present at time of discharge for family meeting with son, [MASKED]. Family was agreeable with discharge plan, medication plan, and plan for patient to attend partial at [MASKED]. -An attempt was made to reach Dr. [MASKED] at [MASKED] [MASKED] Associates. [MASKED] was scheduled by the patient. Dr. [MASKED] out to the patient prior to her hospitalization on [MASKED]. -Therapist, Dr. [MASKED] was contacted and updated with patient information. She also reached out to the patient multiple times during her inpatient admission. [MASKED] was scheduled for #) INTERVENTIONS - Medications: Lithium was initiated and uptitrated to dose of 900mg qHS. - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: Pt will start at [MASKED] [MASKED] on [MASKED] at 8:45. She will also [MASKED] with her PCP [MASKED] [MASKED] at 3:30. She will see her prescriber, Dr. [MASKED] should [MASKED] with her outpatient therapist, Dr. [MASKED] she is done with partial. - Behavioral Interventions (e.g. encouraged DBT skills, ect): encourage psychoeducation, coping skills, continued medication compliance -Guardianships: none pursued INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of starting Lithium. We discussed the possibility of increased thirst, increased urination, and possible damage to the kidneys with ongoing use. We also discussed the risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team. The patient appeared able to understand and consented to begin the medication. She asked many questions over the course of treatment and education was provided. RISK ASSESSMENT & PROGNOSIS On presentation, the patient was evaluated and felt to be at an increased risk of harm to herself and/or others based upon her recent intentional overdose. Her static factors noted at that time include chronic mental illness and recent medical illness resulting in recent increase in necessary care. The modifiable risk factors were also addressed at that time including suicidal ideation with intent, disorganized and unpredictable behavior. These were addressed with psychoeducation, medication adjustments and family meetings with her husband and son. Finally, the patient is being discharged with many protective risk factors, help-seeking nature, future-oriented viewpoint, sense of responsibility to family, children in the home, life satisfaction, reality testing ability, positive therapeutic relationship with outpatient providers,and strong social supports. Overall, the patient is not at an acutely elevated risk of self-harm nor danger to others due to acutely decompensated psychiatric illness. PERTINENT LAB VALUES Lipids: Chol 184; [MASKED] 471; HDL 28; LDL 76 A1c: 5.9 BP: 106/70 TSH: 2.1 BMI: 30 Lithium: 0.4 TSH: 2.1 Medications on Admission: -Olanzapine 10mg qHS -Escitalopram 10mg daily -Diazepam 5mg qHS Discharge Medications: -Lithium 800mg qHS--oral solution (8mEQ/5ml) -You can take 8mg of melatonin 30-minutes before bed, available over the counter, if you are having trouble sleeping Discharge Disposition: Home Discharge Diagnosis: Bipolar Disorder--current episode depressed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: -Appearance: Age-appearing woman, good hygiene and grooming, nicely dressed, no acute distress -Behavior/Attitude: calm, cooperative, pleasant -Mood: 'Things are good' -Affect: bright today, less restricted, occasionally smiling and laughing -Speech: slower rate today, regular prosody, regular volume -Thought process: remains perseverative on certain subjects--lithium side effects, concern about son, financial concerns, improved tangentiality -Thought Content: denies SI, HI, AH, VH. No delusions or paranoia. -Insight: fair -Judgment: fair 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]	[]	[]	[ "F319: Bipolar disorder, unspecified", "Z932: Ileostomy status", "Z915: Personal history of self-harm" ]
10,095,655	22,335,037	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: Intubated ___ Extubated ___ History of Present Illness: Patient is a ___ with history of Bipolar disorder with valium, lexapro, and zyprexa as home medications. She had a recent ___ procedure in ___. Her husband heard a crash in an adjacent room and found her down, and she was brought to the hospital where she was intubated for lethargy and inability to protect airway. EMS reported concern for seizure activity during transport. Per her husband, she has had poor control recently of her bipolar disorder and he was worried that she has been depressed and the psychiatrist she sees has not been appropriately managing her medications. Based upon her pill bottles provided by husband, she took 120mg of lexapro and likely a significant amount of valium (filled prescription ___ with 60 pills now empty). Past Medical History: Past Medical History: arthritis Bipolar disorder Past Surgical History: ___ procedure Social History: ___ Family History: Reviewed and non-contributory Physical Exam: Admission exam: Vitals: 88 115/81 18 100% Intubation GEN: intubated, sedated NEURO: moving all extremities, withdraws to painful stimuli, pupils pinpoint HEENT: No scleral icterus, mucus membranes moist. pupils round, pinpoint. No hemotypanum or blood in nares/mouth. No raccoon eyes or Battle's sign. c collar in place, no step off. CV: RRR PULM: intubated, no evidence of chest wall trauma Back: No evidence of trauma, no step off ABD: Soft, nondistended, nontender. Ext: No ___ edema, ___ warm and well perfused. No evidence of trauma Discharge exam: GENERAL: Oriented x3. Arousable and engageable, brightens with conversation HEENT: Dry mucosa. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Respiration is unlabored with no accessory muscle use. No crackles. ABDOMEN: Soft, non-tender, non-distended. Left ostomy stoma with bag clean without erythema. EXTREMITIES: Warm, well perfused. No peripheral edema. NEURO: Increased tone in bilateral arms Pertinent Results: Admission labs: ___ 12:23AM BLOOD WBC-5.1 RBC-4.26 Hgb-12.6 Hct-38.3 MCV-90 MCH-29.6 MCHC-32.9 RDW-14.0 RDWSD-46.4* Plt ___ ___ 12:23AM BLOOD ___ PTT-33.6 ___ ___ 01:02PM BLOOD ___ 12:23AM BLOOD Glucose-116* UreaN-11 Creat-0.7 Na-144 K-3.7 Cl-105 HCO3-24 AnGap-15 ___ 12:23AM BLOOD ALT-17 AST-18 AlkPhos-92 TotBili-0.3 ___ 12:23AM BLOOD Albumin-4.2 Calcium-8.7 Phos-3.7 Mg-2.2 ___ 12:23AM BLOOD Osmolal-292 ___ 12:23AM BLOOD HCG-<5 ___ 12:23AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 12:34AM BLOOD ___ pO2-34* pCO2-54* pH-7.36 calTCO2-32* Base XS-2 ___ 12:34AM BLOOD Lactate-1.2 Notable imaging: ___ MRA brain IMPRESSION: 1. Mild subarachnoid hemorrhage is again seen in the frontal sulci, right greater than left. Associated leptomeningeal enhancement with the same distribution as the hemorrhage is most likely reactive, though correlation with CSF studies could be considered to exclude other etiologies. 2. Small chronic hemorrhage in the right pons without associated mass effect or contrast enhancement. No clear features of an underlying cavernous malformation. Diagnostic considerations include sequela of hypertension or sequela of prior trauma. Sequela of amyloid angiopathy are somewhat less likely. 3. No acute infarction. 4. Few small T2/FLAIR hyperintense foci in the subcortical white matter are nonspecific but likely sequela of mild chronic small vessel ischemic disease in this age group. However, sequela of vasculitis or RCVS may have a similar appearance. 5. Diffuse beading of the bilateral mid and distal cervical internal carotid arteries is again demonstrated, suggesting fibromuscular dysplasia. No carotid stenosis by NASCET criteria. 6. MRA of the circle of ___ is mildly limited by motion. Multiple mild irregularity/beading of the bilateral distal middle cerebral artery branches, and of the left A2 segment, are again noted, though more accurately depicted on the preceding CTA. Once again, this is compatible with RCVS or vasculitis. Vasospasm is less likely given the small volume and sulcal distribution of subarachnoid hemorrhage. 7. Dural venous sinuses are patent. CTA Head and Neck ___ 1. Evolving subarachnoid hemorrhage in the bilateral frontal convexities, not significantly changed since study from ___. No intraventricular extension, new hemorrhage, mass effect or midline shift. 2. Previously seen beaded appearance of the distal MCA and ACA branches is less conspicuous on this study. 3. Similar irregular beaded appearance of the cervical segments of the bilateral cervical internal carotid arteries, suspicious for fibromuscular dysplasia. 4. Otherwise patent circle of ___ without evidence of high-grade stenosis,occlusion,or aneurysm. CT Head ___ IMPRESSION: Redemonstration of bilateral frontal convexity subarachnoid hemorrhage, right greater than left, similar to prior exam dated ___. No new areas of hemorrhage or large territorial infarction. Discharge Labs: ___ 07:20AM BLOOD WBC-4.4 RBC-3.69* Hgb-10.7* Hct-34.0 MCV-92 MCH-29.0 MCHC-31.5* RDW-14.0 RDWSD-47.2* Plt ___ ___ 07:20AM BLOOD Glucose-115* UreaN-9 Creat-0.6 Na-141 K-4.5 Cl-105 HCO3-25 AnGap-11 ___ 07:20AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.3 Brief Hospital Course: SUMMARY: ============================== ___ with bipolar disorder, diverticulitis s/p ileostomy (___), migraines who presented with unconsciousness and fall thought due to valium, zyprexa, and lexapro intentional overdose s/p ICU extubation, found to have small subarachnoid hemorrhage, course c/b fevers thought ___ pneumonia. TRANSITIONAL ISSUES: ==================== [] Patient will need to follow-up in stroke clinic (Dr ___ ___ for outpatient follow-up of fibromuscular dysplasia at time of discharge. [] The only psychiatric medication patient was restarted on was Olanzipine 2.5mg QHS. [] Patient continues to have some dysphagia, but markedly improved given resolution of altered mental status. She should continue to work with speech and swallow specialists following discharge. ACTIVE ISSUES: ============== # Benzodiazepam Overdose # Bipolar Disease Patient presented to ___ on ___ and was found to have a subarachnoid hemorrhage. She was intubated soon after arrival due to her poor mental status and inability to protect her airway. Due to a significant suspicion for Valium overdose along with Lexapro/Zyprexa ingestion, toxicology was consulted who recommended continued supportive care and consideration of a flumazenil trial. Patient was subsequently admitted to the surgical ICU given concern for a traumatic head bleed. Neurology was consulted and MRI was obtained, Keppra was initiated, EEG was started to rule out seizures, and patient was closely monitored. Her mental status improved and she was extubated ___. Given her lack of acute surgical issues, she was transferred to the medicine service. She had a 1:1 sitter and was sectioned 12 after being medically cleared. Her home olanzapine, diazepam, and escitalopram were held initially, but after resolution of her Serotonin syndrome as below, patient was restarted on QHS olanzapine 2.5mg. # Serotonin Toxicity Neuro and Psych evaluation concerning for mild serotonin toxicity bearing implication for timing of starting olanzapine. There was low suspicion for NMS given downtrending CK. Toxicology felt that after resolution of serotonin syndrome, there would be no contraindication to restarting antidepressants, and thus she was restarted on olanzapine 2.5mg QHS once her neuro findings resolved. # Pneumonia # Group B Strep positive BAL culture Fevers on ___ following extubation with tachypnea and secretions, CXR with right lung consolidation suggesting aspiration/pneumonia, possibly aspiration pneumonia vs ventilator-associated pneumonia. mini BAL was positive for group B Streptococcus. Though originally broadly covered, this was narrowed to CTX following sputum samples, with 7 day course of treatment completed on ___. Her oxygen requirement resolved following this. # Dysphagia Patient endorsing odynophagia. Speech and swallow eval finding oropharyngeal dysphagia likely secondary to inattention, AMS, recent intubation with good prognosis for return to baseline. She was kept on strict NPO and received maintenance fluids. However, as her mental status improved, her diet was advanced. # Subarachnoid Hemorrhage, bilateral # Irregularity of Distal branches of bilateral MCA and ACA segments Imaging finding small SAH of bilateral anterior frontal lobes; EEG without seizure activity, C-collar cleared. Also with focal luminal narrowing of bilateral distal anterior circulation. Repeat CT/CTA head was obtained showing similar appearance to prior studies, which was reassuring. # Asymptomatic Bacteruria Urine culture on admission and repeat with pan-sensitive E. Coli. Patient denying burning/irritation/urinary symptoms currently or prior to admission. As fevers may best be explained by pulmonary process, likely colonization. Deferred treatment, but received concurrent coverage with pneumonia antibiotics CHRONIC ISSUES: # Diverticulitis s/p ileostomy (___) Ostomy site clean without signs of infection. She was continued with ostomy care. CORE MEASURES: #LANGUAGE: ___ #CODE STATUS: Full Code, presumed #CONTACT: ___ (husband): ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OLANZapine 10 mg PO DAILY 2. Escitalopram Oxalate 10 mg PO DAILY 3. Diazepam ___ mg PO QHS:PRN insomnia/ anxiety Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN Tachypnea 2. OLANZapine 2.5 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis ==================== Benzodiazepine overdose Secondary diagnosis =================== Diverticulitis Bipolar disorder Mild serotonin syndrome Suicidal ideation Pneumonia Dysphagia Subarachnoid hemorrhage 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 taking care of you at the ___ ___. WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you took too many pills WHAT HAPPENED IN THE HOSPITAL? ============================== - You were closely monitored by our doctors and treated for the effects of taking too many pills WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications. - Please attend all of your appointments listed below. Thank you for allowing us to be involved in your care. We wish you all the best! Your ___ Healthcare Team Followup Instructions: ___	[ "T424X2A", "S066X9A", "R402112", "R402212", "G92", "J690", "A419", "F3130", "J95851", "N390", "R45851", "K5792", "R402352", "Y92013", "W19XXXA", "B951", "Y848", "Y92230", "B9620", "Z932", "I773", "R1312", "G2579", "G43909" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Fall Major Surgical or Invasive Procedure: Intubated [MASKED] Extubated [MASKED] History of Present Illness: Patient is a [MASKED] with history of Bipolar disorder with valium, lexapro, and zyprexa as home medications. She had a recent [MASKED] procedure in [MASKED]. Her husband heard a crash in an adjacent room and found her down, and she was brought to the hospital where she was intubated for lethargy and inability to protect airway. EMS reported concern for seizure activity during transport. Per her husband, she has had poor control recently of her bipolar disorder and he was worried that she has been depressed and the psychiatrist she sees has not been appropriately managing her medications. Based upon her pill bottles provided by husband, she took 120mg of lexapro and likely a significant amount of valium (filled prescription [MASKED] with 60 pills now empty). Past Medical History: Past Medical History: arthritis Bipolar disorder Past Surgical History: [MASKED] procedure Social History: [MASKED] Family History: Reviewed and non-contributory Physical Exam: Admission exam: Vitals: 88 115/81 18 100% Intubation GEN: intubated, sedated NEURO: moving all extremities, withdraws to painful stimuli, pupils pinpoint HEENT: No scleral icterus, mucus membranes moist. pupils round, pinpoint. No hemotypanum or blood in nares/mouth. No raccoon eyes or Battle's sign. c collar in place, no step off. CV: RRR PULM: intubated, no evidence of chest wall trauma Back: No evidence of trauma, no step off ABD: Soft, nondistended, nontender. Ext: No [MASKED] edema, [MASKED] warm and well perfused. No evidence of trauma Discharge exam: GENERAL: Oriented x3. Arousable and engageable, brightens with conversation HEENT: Dry mucosa. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Respiration is unlabored with no accessory muscle use. No crackles. ABDOMEN: Soft, non-tender, non-distended. Left ostomy stoma with bag clean without erythema. EXTREMITIES: Warm, well perfused. No peripheral edema. NEURO: Increased tone in bilateral arms Pertinent Results: Admission labs: [MASKED] 12:23AM BLOOD WBC-5.1 RBC-4.26 Hgb-12.6 Hct-38.3 MCV-90 MCH-29.6 MCHC-32.9 RDW-14.0 RDWSD-46.4* Plt [MASKED] [MASKED] 12:23AM BLOOD [MASKED] PTT-33.6 [MASKED] [MASKED] 01:02PM BLOOD [MASKED] 12:23AM BLOOD Glucose-116* UreaN-11 Creat-0.7 Na-144 K-3.7 Cl-105 HCO3-24 AnGap-15 [MASKED] 12:23AM BLOOD ALT-17 AST-18 AlkPhos-92 TotBili-0.3 [MASKED] 12:23AM BLOOD Albumin-4.2 Calcium-8.7 Phos-3.7 Mg-2.2 [MASKED] 12:23AM BLOOD Osmolal-292 [MASKED] 12:23AM BLOOD HCG-<5 [MASKED] 12:23AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 12:34AM BLOOD [MASKED] pO2-34* pCO2-54* pH-7.36 calTCO2-32* Base XS-2 [MASKED] 12:34AM BLOOD Lactate-1.2 Notable imaging: [MASKED] MRA brain IMPRESSION: 1. Mild subarachnoid hemorrhage is again seen in the frontal sulci, right greater than left. Associated leptomeningeal enhancement with the same distribution as the hemorrhage is most likely reactive, though correlation with CSF studies could be considered to exclude other etiologies. 2. Small chronic hemorrhage in the right pons without associated mass effect or contrast enhancement. No clear features of an underlying cavernous malformation. Diagnostic considerations include sequela of hypertension or sequela of prior trauma. Sequela of amyloid angiopathy are somewhat less likely. 3. No acute infarction. 4. Few small T2/FLAIR hyperintense foci in the subcortical white matter are nonspecific but likely sequela of mild chronic small vessel ischemic disease in this age group. However, sequela of vasculitis or RCVS may have a similar appearance. 5. Diffuse beading of the bilateral mid and distal cervical internal carotid arteries is again demonstrated, suggesting fibromuscular dysplasia. No carotid stenosis by NASCET criteria. 6. MRA of the circle of [MASKED] is mildly limited by motion. Multiple mild irregularity/beading of the bilateral distal middle cerebral artery branches, and of the left A2 segment, are again noted, though more accurately depicted on the preceding CTA. Once again, this is compatible with RCVS or vasculitis. Vasospasm is less likely given the small volume and sulcal distribution of subarachnoid hemorrhage. 7. Dural venous sinuses are patent. CTA Head and Neck [MASKED] 1. Evolving subarachnoid hemorrhage in the bilateral frontal convexities, not significantly changed since study from [MASKED]. No intraventricular extension, new hemorrhage, mass effect or midline shift. 2. Previously seen beaded appearance of the distal MCA and ACA branches is less conspicuous on this study. 3. Similar irregular beaded appearance of the cervical segments of the bilateral cervical internal carotid arteries, suspicious for fibromuscular dysplasia. 4. Otherwise patent circle of [MASKED] without evidence of high-grade stenosis,occlusion,or aneurysm. CT Head [MASKED] IMPRESSION: Redemonstration of bilateral frontal convexity subarachnoid hemorrhage, right greater than left, similar to prior exam dated [MASKED]. No new areas of hemorrhage or large territorial infarction. Discharge Labs: [MASKED] 07:20AM BLOOD WBC-4.4 RBC-3.69* Hgb-10.7* Hct-34.0 MCV-92 MCH-29.0 MCHC-31.5* RDW-14.0 RDWSD-47.2* Plt [MASKED] [MASKED] 07:20AM BLOOD Glucose-115* UreaN-9 Creat-0.6 Na-141 K-4.5 Cl-105 HCO3-25 AnGap-11 [MASKED] 07:20AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.3 Brief Hospital Course: SUMMARY: ============================== [MASKED] with bipolar disorder, diverticulitis s/p ileostomy ([MASKED]), migraines who presented with unconsciousness and fall thought due to valium, zyprexa, and lexapro intentional overdose s/p ICU extubation, found to have small subarachnoid hemorrhage, course c/b fevers thought [MASKED] pneumonia. TRANSITIONAL ISSUES: ==================== [] Patient will need to follow-up in stroke clinic (Dr [MASKED] [MASKED] for outpatient follow-up of fibromuscular dysplasia at time of discharge. [] The only psychiatric medication patient was restarted on was Olanzipine 2.5mg QHS. [] Patient continues to have some dysphagia, but markedly improved given resolution of altered mental status. She should continue to work with speech and swallow specialists following discharge. ACTIVE ISSUES: ============== # Benzodiazepam Overdose # Bipolar Disease Patient presented to [MASKED] on [MASKED] and was found to have a subarachnoid hemorrhage. She was intubated soon after arrival due to her poor mental status and inability to protect her airway. Due to a significant suspicion for Valium overdose along with Lexapro/Zyprexa ingestion, toxicology was consulted who recommended continued supportive care and consideration of a flumazenil trial. Patient was subsequently admitted to the surgical ICU given concern for a traumatic head bleed. Neurology was consulted and MRI was obtained, Keppra was initiated, EEG was started to rule out seizures, and patient was closely monitored. Her mental status improved and she was extubated [MASKED]. Given her lack of acute surgical issues, she was transferred to the medicine service. She had a 1:1 sitter and was sectioned 12 after being medically cleared. Her home olanzapine, diazepam, and escitalopram were held initially, but after resolution of her Serotonin syndrome as below, patient was restarted on QHS olanzapine 2.5mg. # Serotonin Toxicity Neuro and Psych evaluation concerning for mild serotonin toxicity bearing implication for timing of starting olanzapine. There was low suspicion for NMS given downtrending CK. Toxicology felt that after resolution of serotonin syndrome, there would be no contraindication to restarting antidepressants, and thus she was restarted on olanzapine 2.5mg QHS once her neuro findings resolved. # Pneumonia # Group B Strep positive BAL culture Fevers on [MASKED] following extubation with tachypnea and secretions, CXR with right lung consolidation suggesting aspiration/pneumonia, possibly aspiration pneumonia vs ventilator-associated pneumonia. mini BAL was positive for group B Streptococcus. Though originally broadly covered, this was narrowed to CTX following sputum samples, with 7 day course of treatment completed on [MASKED]. Her oxygen requirement resolved following this. # Dysphagia Patient endorsing odynophagia. Speech and swallow eval finding oropharyngeal dysphagia likely secondary to inattention, AMS, recent intubation with good prognosis for return to baseline. She was kept on strict NPO and received maintenance fluids. However, as her mental status improved, her diet was advanced. # Subarachnoid Hemorrhage, bilateral # Irregularity of Distal branches of bilateral MCA and ACA segments Imaging finding small SAH of bilateral anterior frontal lobes; EEG without seizure activity, C-collar cleared. Also with focal luminal narrowing of bilateral distal anterior circulation. Repeat CT/CTA head was obtained showing similar appearance to prior studies, which was reassuring. # Asymptomatic Bacteruria Urine culture on admission and repeat with pan-sensitive E. Coli. Patient denying burning/irritation/urinary symptoms currently or prior to admission. As fevers may best be explained by pulmonary process, likely colonization. Deferred treatment, but received concurrent coverage with pneumonia antibiotics CHRONIC ISSUES: # Diverticulitis s/p ileostomy ([MASKED]) Ostomy site clean without signs of infection. She was continued with ostomy care. CORE MEASURES: #LANGUAGE: [MASKED] #CODE STATUS: Full Code, presumed #CONTACT: [MASKED] (husband): [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OLANZapine 10 mg PO DAILY 2. Escitalopram Oxalate 10 mg PO DAILY 3. Diazepam [MASKED] mg PO QHS:PRN insomnia/ anxiety Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN Tachypnea 2. OLANZapine 2.5 mg PO QHS Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary diagnosis ==================== Benzodiazepine overdose Secondary diagnosis =================== Diverticulitis Bipolar disorder Mild serotonin syndrome Suicidal ideation Pneumonia Dysphagia Subarachnoid hemorrhage 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 taking care of you at the [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you took too many pills WHAT HAPPENED IN THE HOSPITAL? ============================== - You were closely monitored by our doctors and treated for the effects of taking too many pills WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications. - Please attend all of your appointments listed below. Thank you for allowing us to be involved in your care. We wish you all the best! Your [MASKED] Healthcare Team Followup Instructions: [MASKED]	[]	[ "N390", "Y92230" ]	[ "T424X2A: Poisoning by benzodiazepines, intentional self-harm, initial encounter", "S066X9A: Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, initial encounter", "R402112: Coma scale, eyes open, never, at arrival to emergency department", "R402212: Coma scale, best verbal response, none, at arrival to emergency department", "G92: Toxic encephalopathy", "J690: Pneumonitis due to inhalation of food and vomit", "A419: Sepsis, unspecified organism", "F3130: Bipolar disorder, current episode depressed, mild or moderate severity, unspecified", "J95851: Ventilator associated pneumonia", "N390: Urinary tract infection, site not specified", "R45851: Suicidal ideations", "K5792: Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding", "R402352: Coma scale, best motor response, localizes pain, at arrival to emergency department", "Y92013: Bedroom of single-family (private) house as the place of occurrence of the external cause", "W19XXXA: Unspecified fall, initial encounter", "B951: Streptococcus, group B, as the cause of diseases classified elsewhere", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "Z932: Ileostomy status", "I773: Arterial fibromuscular dysplasia", "R1312: Dysphagia, oropharyngeal phase", "G2579: Other drug induced movement disorders", "G43909: Migraine, unspecified, not intractable, without status migrainosus" ]
10,095,668	23,262,050	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Splenic laceration Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ who presents as a transfer from ___ 6 days following being hit in the left flank by a linedrive while playing baseball. He reports at the time feeling some minor pain in the left upper abdomen, but states that he did not seek medical attention at this time because the pain resolved with ibuprofen. He reports that today (6 days from the time of the trauma), he was raking leaves in his yard when he began experiencing worsening LUQ pain and called his friend to take him to the ED at ___, where CT AP demonstrated Grade 3 splenic laceration and his hct was found to be 33.7. He was HDS and was transferred to ___ for further management. Past Medical History: Past Medical History: None Past Surgical History: None Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================= Vitals: T 96.9 HR 107 BP 113/56 RR 18 SpoO2 99% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, minimally TTP LUQ, no guarding or rebound; no scars or hernias Ext: No ___ edema, ___ warm and well perfused DISCHARGE PHYSICAL EXAM: ======================= Vitals: T98.0 HR ___ BP ___ RR 18 97% RA GEN: A&O3, NAD HEENT: PERRLA, EOMI, no scleral icterus, mucus membranes moist CV: RRR, No murmurs auscultated PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound/guarding Ext: No ___ edema, ___ warm and well perfused Pertinent Results: Admission labs: ============= ___ 08:45PM BLOOD WBC-10.7* RBC-3.65* Hgb-10.2* Hct-30.9* MCV-85 MCH-27.9 MCHC-33.0 RDW-13.0 RDWSD-39.8 Plt ___ ___ 08:45PM BLOOD Neuts-81.1* Lymphs-12.0* Monos-5.7 Eos-0.7* Baso-0.2 Im ___ AbsNeut-8.71* AbsLymp-1.29 AbsMono-0.61 AbsEos-0.07 AbsBaso-0.02 ___ 08:45PM BLOOD ___ PTT-24.6* ___ ___ 08:45PM BLOOD Glucose-102* UreaN-19 Creat-0.9 Na-136 K-4.5 Cl-101 HCO3-23 AnGap-17 ___ 08:45PM BLOOD ALT-37 AST-26 AlkPhos-59 TotBili-0.5 ___ 08:45PM BLOOD Albumin-4.1 Calcium-7.9* Phos-2.9 Mg-1.6 ___ 08:45PM BLOOD GreenHd-HOLD ___ 09:10PM URINE Color-Straw Appear-Clear Sp ___ ___ 09:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 09:10PM URINE ___ 09:10PM URINE Hours-RANDOM ___ 09:10PM URINE Uhold-HOLD Discharge Labs: ============== ___ 05:12AM BLOOD WBC-5.0 RBC-3.48* Hgb-9.5* Hct-29.0* MCV-83 MCH-27.3 MCHC-32.8 RDW-12.8 RDWSD-38.8 Plt ___ ___ 05:12AM BLOOD Plt ___ ___ 05:12AM BLOOD Glucose-103* UreaN-11 Creat-0.7 Na-140 K-3.8 Cl-102 HCO3-27 AnGap-15 IMAGING RESULTS: ================= + ___BDOMEN: OSH study uploaded for reference - please see OMR for images + ___ Imaging CR CHEST: OSH study uploaded for reference - please see OMR for images + ___ Imaging SPLENIC ARTERIOGRAM FINDINGS: 1. Conventional celiac arterial anatomy with a common trunk. 2. Normal splenic arteriogram with no evidence of active extravasation or pseudoaneurysm. 3. Successful Amplatzer 4 (8mm) plug occlusion of the proximal splenic artery. 4. Post plug occlusion celiac arteriogram demonstrated delayed splenic artery opacification secondary to reconstitution indicating successful plug occlusion. IMPRESSION: No evidence of active extravasation or splenic pseudoaneurysm. Technically successful Amplatzer plug occlusion of the proximal splenic artery. Brief Hospital Course: Mr. ___ is a ___ who presented with LUQ pain and found to have a grade 3 splenic laceration 6 days following a traumatic baseball injury who was admitted for monitoring serial Hct and pain control, now s/p occlusion of the proximal splenic artery with a Amplatzer 4 plug by Interventional Radiology. Patient notes that 6 days prior to presentation to the ED he was hit by a linedrive baseball in the left flank. At the time, patient experience left flank pain which resolved with ibuprofen, however, his pain recurred and he presented to ___ ___ with new LUQ pain and was found on CT imaging to have a Grade 3 splenic laceration. At the time, patient was hemodynamically stable, and he was transferred to ___ for further management. At the time of transfer, patient was assessed by the ED and was admitted to the Acute Care trauma surgery service for evaluation and management of his splenic laceration, serial Hct and pain control. Patient was observed on this admission with serial hematocrits, which remained stable since admission (HCT 30.9->28.6->28.0->32.0->28.5->29.0). Furthermore, patient was observed with serial abdominal exams, with no evidence of abdominal tenderness or peritoneal signs noted on this admission. Patient was provided pain control with IV dilaudid, and further noted no nausea or vomiting on this admission. During this hospitalization, ___ was held due to the concern for active bleeding. Due to CT findings of Grade 3 splenic laceration, on HD2 patient was assessed by Interventional Radiology with a splenic ateriogram. No active extravastion or splenic pseudoanuersym was noted on this study, however due to the high grade nature of patients splenic laceration findings on CT, the proximal splenic artery was occluded successfully with a Amplatzer 4 (8mm) plug. Post-occlusion of the celiac arteriogram demonstrated delayed splenic artery opacification indicating successful plug occlusion. Post-procedure, patient arrived on the floor with good pain control without need for IV or oral pain medications. Pt further had stable vital signs, and his diet was advanced as tolerated to a full regular diet. Patient remained hemodynamically stable throughout his stay, with stable Hgb/Hct. On HD3, patients Hgb/Hct remained stable. Due to patients continued improvement with stable Hgb/Hct, stable abdominal exam and successful splenic artery occlusion with ___, a plan was made for patient to be discharged with close followup and strict instructions to refrain from contact sports any activity that will put strain on the abdominal area for 6 weeks. Patient was further advised to re-present to the ED if he had recurrence of his LUQ pain due to the high grade nature of his splenic laceration, and to have close followup in clinic with repeat labs within ___ weeks of discharge to ensure no further downtrending of Hgb/Hct. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and followup instructions with understanding verbalized and agreement with the discharge plan. Transitional issues: ============== [] Please followup patients LUQ pain. Pt was found to have a grade 3 splenic laceration on CT and is s/p occlusion of the proximal splenic artery with a Amplatzer 4 (8mm) plug by Interventional Radiology [] Please followup repeat Hct in ___ weeks to ensure no further downtrending of Hgb/Hct. [] Please followup patients pain control; if patient has recurrence of significant LUQ pain he has been instructed to represent to the ED due to the high grade nature of his splenic laceration [] Please encourage refraining from contact sports or any activity that will put strain on the abdominal area for 6 weeks Medications on Admission: None Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: Grade 3 splenic laceration s/p occlusion of the proximal splenic artery with a Amplatzer 4 (8mm) plug Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital with worsening left-sided abdominal pain within one week after being hit in the abdomen with a baseball. At ___ a laceration in your spleen was identified on CAT scan of your abdomen, and thus you were transferred to ___ for further management. Here, you were noted to have blood in your abdominal cavity that was appreciated at ___, likely due to your splenic laceration. You were admitted and monitored on telemetry and your red blood cell count was monitored very closely to ensure that you were not actively bleeding or losing a large volume of blood. Your red blood cell count remained stable, and your vital signs remained within normal limits during this admission. You were assessed by our Interventional Radiology team, who performed an arteriogram of your spleen and placed an occlusion plug in your splenic artery to ensure that you do not have any further blood loss from your spleen. You tolerated this procedure well, and had no further evidence of bleeding on your labs. You were feeling improved after being monitored in the hospital and being provided pain control, and thus a plan was made for you to be discharged home. It is ok to use Tylenol ___ to 1000mg three times a day for mild abdominal pain (or as directed), but please avoid any blood thinning medications as directed below. Please also avoid contact sports and/or any activity that may cause injury to your abdominal area for the next ___ weeks. Please continue to closely monitor your symptoms, and if you have any recurrence of left sided abdominal pain please come back to the Emergency Room immediately. Please also followup at the appointment listed below, which has been arranged on your behalf. It was a pleasure taking care of you. Your ___ care team Liver/ Spleen lacerations: AVOID contact sports and/or any activity that may cause injury to your abdominal area for the next ___ weeks. If you suddenly become dizzy, lightheaded, feeling as if you are going to pass out go to the nearest Emergency Room as this could be a sign that you are having internal bleeding from your liver or spleen injury. AVOID any blood thinners such as Motrin, Naprosyn, Indocin, Aspirin, Coumadin or Plavix for at least ___ days unless otherwise instructed by the MD/NP/PA. General 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. 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 510 lbs until you followup with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: ___	[ "S36032A", "F17210", "W2103XA", "Y929" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Splenic laceration Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] who presents as a transfer from [MASKED] 6 days following being hit in the left flank by a linedrive while playing baseball. He reports at the time feeling some minor pain in the left upper abdomen, but states that he did not seek medical attention at this time because the pain resolved with ibuprofen. He reports that today (6 days from the time of the trauma), he was raking leaves in his yard when he began experiencing worsening LUQ pain and called his friend to take him to the ED at [MASKED], where CT AP demonstrated Grade 3 splenic laceration and his hct was found to be 33.7. He was HDS and was transferred to [MASKED] for further management. Past Medical History: Past Medical History: None Past Surgical History: None Social History: [MASKED] Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================= Vitals: T 96.9 HR 107 BP 113/56 RR 18 SpoO2 99% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, minimally TTP LUQ, no guarding or rebound; no scars or hernias Ext: No [MASKED] edema, [MASKED] warm and well perfused DISCHARGE PHYSICAL EXAM: ======================= Vitals: T98.0 HR [MASKED] BP [MASKED] RR 18 97% RA GEN: A&O3, NAD HEENT: PERRLA, EOMI, no scleral icterus, mucus membranes moist CV: RRR, No murmurs auscultated PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound/guarding Ext: No [MASKED] edema, [MASKED] warm and well perfused Pertinent Results: Admission labs: ============= [MASKED] 08:45PM BLOOD WBC-10.7* RBC-3.65* Hgb-10.2* Hct-30.9* MCV-85 MCH-27.9 MCHC-33.0 RDW-13.0 RDWSD-39.8 Plt [MASKED] [MASKED] 08:45PM BLOOD Neuts-81.1* Lymphs-12.0* Monos-5.7 Eos-0.7* Baso-0.2 Im [MASKED] AbsNeut-8.71* AbsLymp-1.29 AbsMono-0.61 AbsEos-0.07 AbsBaso-0.02 [MASKED] 08:45PM BLOOD [MASKED] PTT-24.6* [MASKED] [MASKED] 08:45PM BLOOD Glucose-102* UreaN-19 Creat-0.9 Na-136 K-4.5 Cl-101 HCO3-23 AnGap-17 [MASKED] 08:45PM BLOOD ALT-37 AST-26 AlkPhos-59 TotBili-0.5 [MASKED] 08:45PM BLOOD Albumin-4.1 Calcium-7.9* Phos-2.9 Mg-1.6 [MASKED] 08:45PM BLOOD GreenHd-HOLD [MASKED] 09:10PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 09:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [MASKED] 09:10PM URINE [MASKED] 09:10PM URINE Hours-RANDOM [MASKED] 09:10PM URINE Uhold-HOLD Discharge Labs: ============== [MASKED] 05:12AM BLOOD WBC-5.0 RBC-3.48* Hgb-9.5* Hct-29.0* MCV-83 MCH-27.3 MCHC-32.8 RDW-12.8 RDWSD-38.8 Plt [MASKED] [MASKED] 05:12AM BLOOD Plt [MASKED] [MASKED] 05:12AM BLOOD Glucose-103* UreaN-11 Creat-0.7 Na-140 K-3.8 Cl-102 HCO3-27 AnGap-15 IMAGING RESULTS: ================= + BDOMEN: OSH study uploaded for reference - please see OMR for images + [MASKED] Imaging CR CHEST: OSH study uploaded for reference - please see OMR for images + [MASKED] Imaging SPLENIC ARTERIOGRAM FINDINGS: 1. Conventional celiac arterial anatomy with a common trunk. 2. Normal splenic arteriogram with no evidence of active extravasation or pseudoaneurysm. 3. Successful Amplatzer 4 (8mm) plug occlusion of the proximal splenic artery. 4. Post plug occlusion celiac arteriogram demonstrated delayed splenic artery opacification secondary to reconstitution indicating successful plug occlusion. IMPRESSION: No evidence of active extravasation or splenic pseudoaneurysm. Technically successful Amplatzer plug occlusion of the proximal splenic artery. Brief Hospital Course: Mr. [MASKED] is a [MASKED] who presented with LUQ pain and found to have a grade 3 splenic laceration 6 days following a traumatic baseball injury who was admitted for monitoring serial Hct and pain control, now s/p occlusion of the proximal splenic artery with a Amplatzer 4 plug by Interventional Radiology. Patient notes that 6 days prior to presentation to the ED he was hit by a linedrive baseball in the left flank. At the time, patient experience left flank pain which resolved with ibuprofen, however, his pain recurred and he presented to [MASKED] [MASKED] with new LUQ pain and was found on CT imaging to have a Grade 3 splenic laceration. At the time, patient was hemodynamically stable, and he was transferred to [MASKED] for further management. At the time of transfer, patient was assessed by the ED and was admitted to the Acute Care trauma surgery service for evaluation and management of his splenic laceration, serial Hct and pain control. Patient was observed on this admission with serial hematocrits, which remained stable since admission (HCT 30.9->28.6->28.0->32.0->28.5->29.0). Furthermore, patient was observed with serial abdominal exams, with no evidence of abdominal tenderness or peritoneal signs noted on this admission. Patient was provided pain control with IV dilaudid, and further noted no nausea or vomiting on this admission. During this hospitalization, [MASKED] was held due to the concern for active bleeding. Due to CT findings of Grade 3 splenic laceration, on HD2 patient was assessed by Interventional Radiology with a splenic ateriogram. No active extravastion or splenic pseudoanuersym was noted on this study, however due to the high grade nature of patients splenic laceration findings on CT, the proximal splenic artery was occluded successfully with a Amplatzer 4 (8mm) plug. Post-occlusion of the celiac arteriogram demonstrated delayed splenic artery opacification indicating successful plug occlusion. Post-procedure, patient arrived on the floor with good pain control without need for IV or oral pain medications. Pt further had stable vital signs, and his diet was advanced as tolerated to a full regular diet. Patient remained hemodynamically stable throughout his stay, with stable Hgb/Hct. On HD3, patients Hgb/Hct remained stable. Due to patients continued improvement with stable Hgb/Hct, stable abdominal exam and successful splenic artery occlusion with [MASKED], a plan was made for patient to be discharged with close followup and strict instructions to refrain from contact sports any activity that will put strain on the abdominal area for 6 weeks. Patient was further advised to re-present to the ED if he had recurrence of his LUQ pain due to the high grade nature of his splenic laceration, and to have close followup in clinic with repeat labs within [MASKED] weeks of discharge to ensure no further downtrending of Hgb/Hct. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and followup instructions with understanding verbalized and agreement with the discharge plan. Transitional issues: ============== [] Please followup patients LUQ pain. Pt was found to have a grade 3 splenic laceration on CT and is s/p occlusion of the proximal splenic artery with a Amplatzer 4 (8mm) plug by Interventional Radiology [] Please followup repeat Hct in [MASKED] weeks to ensure no further downtrending of Hgb/Hct. [] Please followup patients pain control; if patient has recurrence of significant LUQ pain he has been instructed to represent to the ED due to the high grade nature of his splenic laceration [] Please encourage refraining from contact sports or any activity that will put strain on the abdominal area for 6 weeks Medications on Admission: None Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: Grade 3 splenic laceration s/p occlusion of the proximal splenic artery with a Amplatzer 4 (8mm) plug Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital with worsening left-sided abdominal pain within one week after being hit in the abdomen with a baseball. At [MASKED] a laceration in your spleen was identified on CAT scan of your abdomen, and thus you were transferred to [MASKED] for further management. Here, you were noted to have blood in your abdominal cavity that was appreciated at [MASKED], likely due to your splenic laceration. You were admitted and monitored on telemetry and your red blood cell count was monitored very closely to ensure that you were not actively bleeding or losing a large volume of blood. Your red blood cell count remained stable, and your vital signs remained within normal limits during this admission. You were assessed by our Interventional Radiology team, who performed an arteriogram of your spleen and placed an occlusion plug in your splenic artery to ensure that you do not have any further blood loss from your spleen. You tolerated this procedure well, and had no further evidence of bleeding on your labs. You were feeling improved after being monitored in the hospital and being provided pain control, and thus a plan was made for you to be discharged home. It is ok to use Tylenol [MASKED] to 1000mg three times a day for mild abdominal pain (or as directed), but please avoid any blood thinning medications as directed below. Please also avoid contact sports and/or any activity that may cause injury to your abdominal area for the next [MASKED] weeks. Please continue to closely monitor your symptoms, and if you have any recurrence of left sided abdominal pain please come back to the Emergency Room immediately. Please also followup at the appointment listed below, which has been arranged on your behalf. It was a pleasure taking care of you. Your [MASKED] care team Liver/ Spleen lacerations: AVOID contact sports and/or any activity that may cause injury to your abdominal area for the next [MASKED] weeks. If you suddenly become dizzy, lightheaded, feeling as if you are going to pass out go to the nearest Emergency Room as this could be a sign that you are having internal bleeding from your liver or spleen injury. AVOID any blood thinners such as Motrin, Naprosyn, Indocin, Aspirin, Coumadin or Plavix for at least [MASKED] days unless otherwise instructed by the MD/NP/PA. General 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. 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 510 lbs until you followup with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: [MASKED]	[]	[ "F17210", "Y929" ]	[ "S36032A: Major laceration of spleen, initial encounter", "F17210: Nicotine dependence, cigarettes, uncomplicated", "W2103XA: Struck by baseball, initial encounter", "Y929: Unspecified place or not applicable" ]
10,095,681	21,101,718	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: iodine strong / Morphine / potassium iodide Attending: ___. Chief Complaint: Foot pain Major Surgical or Invasive Procedure: Left popliteal cute down with left femoral emolectomy & thrombectomy History of Present Illness: Ms. ___ is a ___ with hx afib recently taken off anticoagulation given recent fall with ___ on ___ presenting with acute onset left leg pain. She had presented to ___ last ___ after a mechanical fall while walking to the bathroom with her walker. She sustained a headstrike but no LOC. CT scan showed a right frontal 6mm subarachnoid hemorrhage and she was admitted for observation and discharged after repeat ___ showed stability of the SAH. On discharge, she was taken off anticoagulation (5 days ago). She has since been in her usual state of health until 6pm this evening, 2 hours prior to presentation, when she developed sudden pain in her left foot with associated coolness, pallor, and paresthesias. She was brought to the ED via ambulance. Vascular surgery was consulted given concern for acute limb ischemia Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS ___ DYSPNEA DIABETIC RETINOPATHY Social History: ___ Family History: mother - hx of afib, HTN, stomach cancer father - HTN, DM brother - hx of afib Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.2 94 157/59 18 100%RA GEN: AOx3, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: mottled left lower extremity 3cm distal to left knee, decreased sensation, motor intact, pain on calf, delayed capillary refill; right foot warm with palpable DP pulse Pulses: R: p/p/p/d L: p/p/-/- DISCHARGE PHYSICAL EXAM: Vitals: 98.0 60 152/64 18 99%RA GEN: AOx3, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: left: warm, without erythema/pallor/cyanosis intact sensation and motor; right foot warm with palpable DP pulse Pulses: R: p/p/p/d L: p/p/d/d Pertinent Results: LAB: ___ 08:00PM BLOOD WBC-8.3 RBC-4.01 Hgb-11.9 Hct-35.9 MCV-90 MCH-29.7 MCHC-33.1 RDW-14.1 RDWSD-46.1 Plt ___ ___ 08:00PM BLOOD Neuts-78.3 Lymphs-11.5* Monos-8.5 Eos-0.7* Baso-0.5 Im ___ AbsNeut-6.53* AbsLymp-0.96* AbsMono-0.71 AbsEos-0.06 AbsBaso-0.04 ___ 01:28AM BLOOD WBC-8.3 RBC-3.70* Hgb-10.8* Hct-32.3* MCV-87 MCH-29.2 MCHC-33.4 RDW-14.0 RDWSD-44.8 Plt ___ ___ 02:33AM BLOOD WBC-7.8 RBC-3.18* Hgb-9.2* Hct-27.8* MCV-87 MCH-28.9 MCHC-33.1 RDW-14.0 RDWSD-45.1 Plt ___ ___ 05:29AM BLOOD WBC-7.9 RBC-2.86* Hgb-8.5* Hct-25.1* MCV-88 MCH-29.7 MCHC-33.9 RDW-14.0 RDWSD-45.5 Plt ___ ___ 06:40AM BLOOD WBC-7.4 RBC-2.77* Hgb-8.0* Hct-24.5* MCV-88 MCH-28.9 MCHC-32.7 RDW-14.0 RDWSD-45.3 Plt ___ ___ 06:29AM BLOOD WBC-7.1 RBC-3.14* Hgb-9.2* Hct-27.5* MCV-88 MCH-29.3 MCHC-33.5 RDW-14.0 RDWSD-44.1 Plt ___ ___ 07:09AM BLOOD WBC-6.8 RBC-3.05* Hgb-8.8* Hct-27.0* MCV-89 MCH-28.9 MCHC-32.6 RDW-14.2 RDWSD-45.9 Plt ___ ___ 08:00PM BLOOD ___ PTT-28.5 ___ ___ 01:28AM BLOOD ___ PTT-150* ___ ___ 09:38AM BLOOD PTT-130.1* ___ 04:55PM BLOOD PTT-49.7* ___ 02:33AM BLOOD ___ PTT-62.7* ___ ___ 08:00AM BLOOD PTT-63.8* ___ 04:07PM BLOOD PTT-50.8* ___ 11:42PM BLOOD PTT-57.3* ___ 05:29AM BLOOD ___ PTT-50.9* ___ ___ 04:40PM BLOOD PTT-59.7* ___ 10:43PM BLOOD PTT-54.4* ___ 06:40AM BLOOD ___ PTT-60.8* ___ ___ 12:45PM BLOOD PTT-64.3* ___ 07:10PM BLOOD PTT-66.5* ___ 06:29AM BLOOD ___ PTT-61.2* ___ ___ 07:09AM BLOOD ___ PTT-27.3 ___ ___ 08:00PM BLOOD Glucose-160* UreaN-33* Creat-0.9 Na-134* K-4.4 Cl-99 HCO3-19* AnGap-16 ___ 01:28AM BLOOD Glucose-126* UreaN-24* Creat-0.8 Na-130* K-4.0 Cl-97 HCO3-21* AnGap-12 ___ 02:33AM BLOOD Glucose-111* UreaN-18 Creat-0.6 Na-131* K-4.2 Cl-98 HCO3-23 AnGap-10 ___ 05:29AM BLOOD Glucose-101* UreaN-21* Creat-0.7 Na-132* K-4.0 Cl-100 HCO3-23 AnGap-9* ___ 06:40AM BLOOD Glucose-95 UreaN-20 Creat-0.7 Na-132* K-4.0 Cl-100 HCO3-22 AnGap-10 ___ 06:29AM BLOOD Glucose-90 UreaN-17 Creat-0.6 Na-134* K-4.0 Cl-97 HCO3-25 AnGap-12 ___ 07:09AM BLOOD Glucose-87 UreaN-20 Creat-0.7 Na-132* K-4.9 Cl-95* HCO3-26 AnGap-11 ___ 01:28AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.9 ___ 02:33AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.8 ___ 05:29AM BLOOD Calcium-7.7* Phos-3.3 Mg-2.2 ___ 06:40AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.9 ___ 06:29AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.9 ___ 07:09AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.8 ___ 07:20PM URINE Color-Yellow Appear-Clear Sp ___ ___ 07:20PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 07:20PM URINE RBC-1 WBC-2 Bacteri-FEW* Yeast-NONE Epi-1 ___ 07:20PM URINE Mucous-RARE ___ 7:20 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. IMAGING/STUDIES: ECG ___ Intervals Axes Rate PR QRS QT QTc (___) P QRS T 80 93 ___ 108 53 CXR ___ FINDINGS: AP upright and lateral views of the chest provided. Prominent cardiomediastinal silhouette is unchanged. The lungs are clear. No focal consolidation, large effusion or pneumothorax. Tracheobronchial tree calcification noted. Bony structures are intact. NCHCT ___ No acute intracranial abnormalities. CTA abdomen/pelvis with runoff ___ 1. Complete occlusion of the lower extremity arteries on the left from the popliteal artery to the dorsalis pedis due to noncalcified thrombus. 2. Likely complete occlusion of the right lower extremity arteries extending from the trifurcation of the popliteal artery to dorsalis pedis. Possible intermittent signal in the right peroneal artery, though thought to be an artifact. 3. Evidence of 2 column hyperextension injury of L5 vertebral body. No retropulsion into the spinal canal. Given the sclerotic margins, this is likely subacute. Please correlate with clinical history. 4. Status post right hemiarthroplasty. No evidence of perihardware fracture. ECHO ___ Conclusions The left atrial volume index is severely increased. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF = 70%). The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate (___) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild posterior leaflet mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a small pericardial effusion. There are no echocardiographic signs of tamponade. ___ ___ IMPRESSION: No acute intracranial hemorrhage. Stable findings when compared to the CT scan of the head performed yesterday. Brief Hospital Course: Ms. ___ was brought to the emergency room at ___ ___ due to acute onset of severe left leg pain. She was found to have a mottled left lower extremity 3cm distal to left knee, decreased sensation, delayed capillary refill and pain on her calf. She was not taking her home Warfarin (indication: Afib) due to a fall complicated by SAH. A CTA of aorta/bifem/iliac runoff revealed complete occlusion of left lower extremity arteries from the popliteal to the DP. Noncon. head CT conducted preop showed resolution of SAH and therefore allowed for heparinization during the re-profusion procedure and postop. She was taken for an emergent left arterial cut down with embolectomy/thrombectomy. She tolerated the procedure well without complication (op details below): LEFT POPLITEAL CUT DOWN WITH LEFT FEMORAL EMBOLECTOMY & THROMBECTOMY: DETAILS OF PROCEDURE: The patient was brought to the Operating Room and placed supine on the OR table. She underwent general anesthesia and endotracheal intubation. Preoperative antibiotics were dosed prior to incision. The patient's abdomen and bilateral groins were prepped and draped in the usual sterile fashion. The left lower extremity was also prepped out and a bag was placed in the foot. We performed a preprocedural timeout. We began by making a longitudinal incision in the left groin. Dissection was carried down through the subcutaneous tissues with cautery. We carefully dissected out the femoral arteries inclusive of the superficial femoral and profunda femoris distally. Silastic vessel loops were encircled around each of these. Once inflow and outflow control had been obtained, we asked the anesthesia to give another bolus of heparin. The patient had notably already been on heparin drip, which had not been stopped during the beginning of the case. Few minutes after the bolus of heparin, a transverse arteriotomy was made in the distal common femoral artery after clamping proximal inflow. There was brisk backbleeding surprisingly. A ___ ___ balloon passed down the profunda femoris and a large amount of fresh thrombus was extracted. Once several passes had been made and a negative pass had been obtained, the lumen was irrigated with heparinized saline. The vessel loop around the profunda was then tightened and we then performed embolectomy of the superficial femoral artery and the popliteal artery. Again, a large amount of thrombus was extracted. The balloon was passed down to approximately 60 cm, which allowed it to go well into the tibialis. Again, small amounts of thrombus were extracted. Once the negative pass had been obtained, there was improved backbleeding from the superficial femoral artery. We thus decided to close the arteriotomy and assess the circulation to the foot. Therefore, using ___ Prolene, the arteriotomy was closed in a running fashion. Once flow had been restored, we noticed that the left foot looked to be a little bit pinker. Using Doppler evaluation, we were able to get flow signals in the peroneal artery. We, therefore, decided against performing a left lower extremity angiogram at this time reasoning that the arteries below the knee would likely be in severe vasospasm and we would not get a good overall indication of the revascularization anyway. We, therefore, closed the groin in three layers of running Vicryl and the skin was stapled shut. By the time the patient's dressing had been applied and she was well on her way to being awakened from anesthesia, repeat Doppler evaluation of foot demonstrated a pretty decent left posterior tibial signal as well as the peroneal signal. There was no dorsalis pedis signal appreciated. The patient was then extubated successfully and transferred to the Post Anesthesia Care Unit in good condition. Dr. ___ was present for all key portions of the procedure. Postoperative, she had dopplerable ___. She was maintained on heparin and Warfarin was restarted at 1mg and by day of discharged advanced to 3mg daily. She had some mild postop bleeding from the left groin incision site. Stiches were placed in this incision which greatly minimized the bleeding. By discharge minimal bleeding was observed and the wound was non-erythematous without discharge or induration. She has been hemodynamically stable during the entire postop course. Additionally, no neural deficits or concerning changes in mental status were ever appreciated. She was discharged to a rehab facility. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. amLODIPine 5 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Furosemide 20 mg PO DAILY 5. Levothyroxine Sodium 88 mcg PO DAILY 6. Losartan Potassium 25 mg PO BID 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Senna 17.2 mg PO HS 9. Alendronate Sodium 70 mg PO 1X/WEEK (SA) Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Aspirin EC 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 60 mg SC Q12 5. Senna 17.2 mg PO HS 6. Warfarin 5 mg PO DAILY16 7. Alendronate Sodium 70 mg PO 1X/WEEK (SA) 8. amLODIPine 5 mg PO DAILY 9. Furosemide 20 mg PO DAILY 10. Levothyroxine Sodium 88 mcg PO DAILY 11. Losartan Potassium 25 mg PO BID 12. Metoprolol Succinate XL 50 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute limb ischemia s/p left popliteal cute down with left femoral emolectomy & thrombectomy 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 ___ because MEDICATION: Take Aspirin 325mg (enteric coated) once daily If instructed, take Plavix (Clopidogrel) 75mg once daily Continue all other medications you were taking before surgery, unless otherwise directed You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort WHAT TO EXPECT: It is normal to have slight swelling of the legs: Elevate your leg above the level of your heart with pillows every ___ hours throughout the day and night Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time Drink plenty of fluids and eat small frequent meals It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication ACTIVITIES: When you go home, you may walk and use stairs You may shower (let the soapy water run over groin incision, rinse and pat dry) Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) After 1 week, you may resume sexual activity After 1 week, gradually increase your activities and distance walked as you can tolerate No driving until you are no longer taking pain medications CALL THE OFFICE FOR: ___ Numbness, coldness or pain in lower extremities Temperature greater than 101.5F for 24 hours New or increased drainage from incision or white, yellow or green drainage from incisions Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office ___. If bleeding does not stop, call ___ for transfer to closest Emergency Room. Followup Instructions: ___	[ "I743", "L7622", "I110", "I4891", "E11319", "I5032", "Y838", "Y92230", "Z87820", "D649", "E039", "M8580", "R32", "F329", "E559", "J449", "Z87891", "Z96642" ]	Allergies: iodine strong / Morphine / potassium iodide Chief Complaint: Foot pain Major Surgical or Invasive Procedure: Left popliteal cute down with left femoral emolectomy & thrombectomy History of Present Illness: Ms. [MASKED] is a [MASKED] with hx afib recently taken off anticoagulation given recent fall with [MASKED] on [MASKED] presenting with acute onset left leg pain. She had presented to [MASKED] last [MASKED] after a mechanical fall while walking to the bathroom with her walker. She sustained a headstrike but no LOC. CT scan showed a right frontal 6mm subarachnoid hemorrhage and she was admitted for observation and discharged after repeat [MASKED] showed stability of the SAH. On discharge, she was taken off anticoagulation (5 days ago). She has since been in her usual state of health until 6pm this evening, 2 hours prior to presentation, when she developed sudden pain in her left foot with associated coolness, pallor, and paresthesias. She was brought to the ED via ambulance. Vascular surgery was consulted given concern for acute limb ischemia Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS [MASKED] DYSPNEA DIABETIC RETINOPATHY Social History: [MASKED] Family History: mother - hx of afib, HTN, stomach cancer father - HTN, DM brother - hx of afib Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.2 94 157/59 18 100%RA GEN: AOx3, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: mottled left lower extremity 3cm distal to left knee, decreased sensation, motor intact, pain on calf, delayed capillary refill; right foot warm with palpable DP pulse Pulses: R: p/p/p/d L: p/p/-/- DISCHARGE PHYSICAL EXAM: Vitals: 98.0 60 152/64 18 99%RA GEN: AOx3, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: left: warm, without erythema/pallor/cyanosis intact sensation and motor; right foot warm with palpable DP pulse Pulses: R: p/p/p/d L: p/p/d/d Pertinent Results: LAB: [MASKED] 08:00PM BLOOD WBC-8.3 RBC-4.01 Hgb-11.9 Hct-35.9 MCV-90 MCH-29.7 MCHC-33.1 RDW-14.1 RDWSD-46.1 Plt [MASKED] [MASKED] 08:00PM BLOOD Neuts-78.3 Lymphs-11.5* Monos-8.5 Eos-0.7* Baso-0.5 Im [MASKED] AbsNeut-6.53* AbsLymp-0.96* AbsMono-0.71 AbsEos-0.06 AbsBaso-0.04 [MASKED] 01:28AM BLOOD WBC-8.3 RBC-3.70* Hgb-10.8* Hct-32.3* MCV-87 MCH-29.2 MCHC-33.4 RDW-14.0 RDWSD-44.8 Plt [MASKED] [MASKED] 02:33AM BLOOD WBC-7.8 RBC-3.18* Hgb-9.2* Hct-27.8* MCV-87 MCH-28.9 MCHC-33.1 RDW-14.0 RDWSD-45.1 Plt [MASKED] [MASKED] 05:29AM BLOOD WBC-7.9 RBC-2.86* Hgb-8.5* Hct-25.1* MCV-88 MCH-29.7 MCHC-33.9 RDW-14.0 RDWSD-45.5 Plt [MASKED] [MASKED] 06:40AM BLOOD WBC-7.4 RBC-2.77* Hgb-8.0* Hct-24.5* MCV-88 MCH-28.9 MCHC-32.7 RDW-14.0 RDWSD-45.3 Plt [MASKED] [MASKED] 06:29AM BLOOD WBC-7.1 RBC-3.14* Hgb-9.2* Hct-27.5* MCV-88 MCH-29.3 MCHC-33.5 RDW-14.0 RDWSD-44.1 Plt [MASKED] [MASKED] 07:09AM BLOOD WBC-6.8 RBC-3.05* Hgb-8.8* Hct-27.0* MCV-89 MCH-28.9 MCHC-32.6 RDW-14.2 RDWSD-45.9 Plt [MASKED] [MASKED] 08:00PM BLOOD [MASKED] PTT-28.5 [MASKED] [MASKED] 01:28AM BLOOD [MASKED] PTT-150* [MASKED] [MASKED] 09:38AM BLOOD PTT-130.1* [MASKED] 04:55PM BLOOD PTT-49.7* [MASKED] 02:33AM BLOOD [MASKED] PTT-62.7* [MASKED] [MASKED] 08:00AM BLOOD PTT-63.8* [MASKED] 04:07PM BLOOD PTT-50.8* [MASKED] 11:42PM BLOOD PTT-57.3* [MASKED] 05:29AM BLOOD [MASKED] PTT-50.9* [MASKED] [MASKED] 04:40PM BLOOD PTT-59.7* [MASKED] 10:43PM BLOOD PTT-54.4* [MASKED] 06:40AM BLOOD [MASKED] PTT-60.8* [MASKED] [MASKED] 12:45PM BLOOD PTT-64.3* [MASKED] 07:10PM BLOOD PTT-66.5* [MASKED] 06:29AM BLOOD [MASKED] PTT-61.2* [MASKED] [MASKED] 07:09AM BLOOD [MASKED] PTT-27.3 [MASKED] [MASKED] 08:00PM BLOOD Glucose-160* UreaN-33* Creat-0.9 Na-134* K-4.4 Cl-99 HCO3-19* AnGap-16 [MASKED] 01:28AM BLOOD Glucose-126* UreaN-24* Creat-0.8 Na-130* K-4.0 Cl-97 HCO3-21* AnGap-12 [MASKED] 02:33AM BLOOD Glucose-111* UreaN-18 Creat-0.6 Na-131* K-4.2 Cl-98 HCO3-23 AnGap-10 [MASKED] 05:29AM BLOOD Glucose-101* UreaN-21* Creat-0.7 Na-132* K-4.0 Cl-100 HCO3-23 AnGap-9* [MASKED] 06:40AM BLOOD Glucose-95 UreaN-20 Creat-0.7 Na-132* K-4.0 Cl-100 HCO3-22 AnGap-10 [MASKED] 06:29AM BLOOD Glucose-90 UreaN-17 Creat-0.6 Na-134* K-4.0 Cl-97 HCO3-25 AnGap-12 [MASKED] 07:09AM BLOOD Glucose-87 UreaN-20 Creat-0.7 Na-132* K-4.9 Cl-95* HCO3-26 AnGap-11 [MASKED] 01:28AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.9 [MASKED] 02:33AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.8 [MASKED] 05:29AM BLOOD Calcium-7.7* Phos-3.3 Mg-2.2 [MASKED] 06:40AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.9 [MASKED] 06:29AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.9 [MASKED] 07:09AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.8 [MASKED] 07:20PM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 07:20PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [MASKED] 07:20PM URINE RBC-1 WBC-2 Bacteri-FEW* Yeast-NONE Epi-1 [MASKED] 07:20PM URINE Mucous-RARE [MASKED] 7:20 pm URINE Source: Catheter. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. IMAGING/STUDIES: ECG [MASKED] Intervals Axes Rate PR QRS QT QTc ([MASKED]) P QRS T 80 93 [MASKED] 108 53 CXR [MASKED] FINDINGS: AP upright and lateral views of the chest provided. Prominent cardiomediastinal silhouette is unchanged. The lungs are clear. No focal consolidation, large effusion or pneumothorax. Tracheobronchial tree calcification noted. Bony structures are intact. NCHCT [MASKED] No acute intracranial abnormalities. CTA abdomen/pelvis with runoff [MASKED] 1. Complete occlusion of the lower extremity arteries on the left from the popliteal artery to the dorsalis pedis due to noncalcified thrombus. 2. Likely complete occlusion of the right lower extremity arteries extending from the trifurcation of the popliteal artery to dorsalis pedis. Possible intermittent signal in the right peroneal artery, though thought to be an artifact. 3. Evidence of 2 column hyperextension injury of L5 vertebral body. No retropulsion into the spinal canal. Given the sclerotic margins, this is likely subacute. Please correlate with clinical history. 4. Status post right hemiarthroplasty. No evidence of perihardware fracture. ECHO [MASKED] Conclusions The left atrial volume index is severely increased. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF = 70%). The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([MASKED]) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild posterior leaflet mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a small pericardial effusion. There are no echocardiographic signs of tamponade. [MASKED] [MASKED] IMPRESSION: No acute intracranial hemorrhage. Stable findings when compared to the CT scan of the head performed yesterday. Brief Hospital Course: Ms. [MASKED] was brought to the emergency room at [MASKED] [MASKED] due to acute onset of severe left leg pain. She was found to have a mottled left lower extremity 3cm distal to left knee, decreased sensation, delayed capillary refill and pain on her calf. She was not taking her home Warfarin (indication: Afib) due to a fall complicated by SAH. A CTA of aorta/bifem/iliac runoff revealed complete occlusion of left lower extremity arteries from the popliteal to the DP. Noncon. head CT conducted preop showed resolution of SAH and therefore allowed for heparinization during the re-profusion procedure and postop. She was taken for an emergent left arterial cut down with embolectomy/thrombectomy. She tolerated the procedure well without complication (op details below): LEFT POPLITEAL CUT DOWN WITH LEFT FEMORAL EMBOLECTOMY & THROMBECTOMY: DETAILS OF PROCEDURE: The patient was brought to the Operating Room and placed supine on the OR table. She underwent general anesthesia and endotracheal intubation. Preoperative antibiotics were dosed prior to incision. The patient's abdomen and bilateral groins were prepped and draped in the usual sterile fashion. The left lower extremity was also prepped out and a bag was placed in the foot. We performed a preprocedural timeout. We began by making a longitudinal incision in the left groin. Dissection was carried down through the subcutaneous tissues with cautery. We carefully dissected out the femoral arteries inclusive of the superficial femoral and profunda femoris distally. Silastic vessel loops were encircled around each of these. Once inflow and outflow control had been obtained, we asked the anesthesia to give another bolus of heparin. The patient had notably already been on heparin drip, which had not been stopped during the beginning of the case. Few minutes after the bolus of heparin, a transverse arteriotomy was made in the distal common femoral artery after clamping proximal inflow. There was brisk backbleeding surprisingly. A [MASKED] [MASKED] balloon passed down the profunda femoris and a large amount of fresh thrombus was extracted. Once several passes had been made and a negative pass had been obtained, the lumen was irrigated with heparinized saline. The vessel loop around the profunda was then tightened and we then performed embolectomy of the superficial femoral artery and the popliteal artery. Again, a large amount of thrombus was extracted. The balloon was passed down to approximately 60 cm, which allowed it to go well into the tibialis. Again, small amounts of thrombus were extracted. Once the negative pass had been obtained, there was improved backbleeding from the superficial femoral artery. We thus decided to close the arteriotomy and assess the circulation to the foot. Therefore, using [MASKED] Prolene, the arteriotomy was closed in a running fashion. Once flow had been restored, we noticed that the left foot looked to be a little bit pinker. Using Doppler evaluation, we were able to get flow signals in the peroneal artery. We, therefore, decided against performing a left lower extremity angiogram at this time reasoning that the arteries below the knee would likely be in severe vasospasm and we would not get a good overall indication of the revascularization anyway. We, therefore, closed the groin in three layers of running Vicryl and the skin was stapled shut. By the time the patient's dressing had been applied and she was well on her way to being awakened from anesthesia, repeat Doppler evaluation of foot demonstrated a pretty decent left posterior tibial signal as well as the peroneal signal. There was no dorsalis pedis signal appreciated. The patient was then extubated successfully and transferred to the Post Anesthesia Care Unit in good condition. Dr. [MASKED] was present for all key portions of the procedure. Postoperative, she had dopplerable [MASKED]. She was maintained on heparin and Warfarin was restarted at 1mg and by day of discharged advanced to 3mg daily. She had some mild postop bleeding from the left groin incision site. Stiches were placed in this incision which greatly minimized the bleeding. By discharge minimal bleeding was observed and the wound was non-erythematous without discharge or induration. She has been hemodynamically stable during the entire postop course. Additionally, no neural deficits or concerning changes in mental status were ever appreciated. She was discharged to a rehab facility. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. amLODIPine 5 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Furosemide 20 mg PO DAILY 5. Levothyroxine Sodium 88 mcg PO DAILY 6. Losartan Potassium 25 mg PO BID 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Senna 17.2 mg PO HS 9. Alendronate Sodium 70 mg PO 1X/WEEK (SA) Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Aspirin EC 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 60 mg SC Q12 5. Senna 17.2 mg PO HS 6. Warfarin 5 mg PO DAILY16 7. Alendronate Sodium 70 mg PO 1X/WEEK (SA) 8. amLODIPine 5 mg PO DAILY 9. Furosemide 20 mg PO DAILY 10. Levothyroxine Sodium 88 mcg PO DAILY 11. Losartan Potassium 25 mg PO BID 12. Metoprolol Succinate XL 50 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Acute limb ischemia s/p left popliteal cute down with left femoral emolectomy & thrombectomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] because MEDICATION: Take Aspirin 325mg (enteric coated) once daily If instructed, take Plavix (Clopidogrel) 75mg once daily Continue all other medications you were taking before surgery, unless otherwise directed You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort WHAT TO EXPECT: It is normal to have slight swelling of the legs: Elevate your leg above the level of your heart with pillows every [MASKED] hours throughout the day and night Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time Drink plenty of fluids and eat small frequent meals It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication ACTIVITIES: When you go home, you may walk and use stairs You may shower (let the soapy water run over groin incision, rinse and pat dry) Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) After 1 week, you may resume sexual activity After 1 week, gradually increase your activities and distance walked as you can tolerate No driving until you are no longer taking pain medications CALL THE OFFICE FOR: [MASKED] Numbness, coldness or pain in lower extremities Temperature greater than 101.5F for 24 hours New or increased drainage from incision or white, yellow or green drainage from incisions Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office [MASKED]. If bleeding does not stop, call [MASKED] for transfer to closest Emergency Room. Followup Instructions: [MASKED]	[]	[ "I110", "I4891", "I5032", "Y92230", "D649", "E039", "F329", "J449", "Z87891" ]	[ "I743: Embolism and thrombosis of arteries of the lower extremities", "L7622: Postprocedural hemorrhage of skin and subcutaneous tissue following other procedure", "I110: Hypertensive heart disease with heart failure", "I4891: Unspecified atrial fibrillation", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "I5032: Chronic diastolic (congestive) heart failure", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Z87820: Personal history of traumatic brain injury", "D649: Anemia, unspecified", "E039: Hypothyroidism, unspecified", "M8580: Other specified disorders of bone density and structure, unspecified site", "R32: Unspecified urinary incontinence", "F329: Major depressive disorder, single episode, unspecified", "E559: Vitamin D deficiency, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "Z87891: Personal history of nicotine dependence", "Z96642: Presence of left artificial hip joint" ]
10,095,681	23,257,434	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: iodine strong / Morphine / potassium iodide Attending: ___ Chief Complaint: fell out of chair and hit head Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with history of dementia, atrial fibrillation on Coumadin, fell out of her chair and struck the left side of her face. She did not lose consciousness. Has a small right frontal Subarachnoid Hemorrhage. Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS ___ DYSPNEA DIABETIC RETINOPATHY Social History: ___ Family History: mother, brother with atrial fibrillation. Physical Exam: On Admission ============ O: T: 96 HR:88 BP: 154/96 RR:16 Sat:100% RA GCS at the scene: 15 GCS upon Neurosurgery Evaluation: 15 Airway: [x]Not intubated Eye Opening: [ ]1 Does not open eyes [ ]2 Opens eyes to painful stimuli [ ]3 Opens eyes to voice [x]4 Opens eyes spontaneously Verbal: [ ]1 Makes no sounds [ ]2 Incomprehensible sounds [ ]3 Inappropriate words [ ]4 Confused, disoriented [x]5 Oriented Motor: [ ]1 No movement [ ]2 Extension to painful stimuli (decerebrate response) [ ]3 Abnormal flexion to painful stimuli (decorticate response) [ ___ Flexion/ withdrawal to painful stimuli [ ]5 Localizes to painful stimuli [x]6 Obeys commands Exam: with Care attendant translating Gen: WD/WN, comfortable, NAD. HEENT: left periorbital ecchymosis and minimal edema Neck: supple, no midline tenderness Extrem: warm and well perfused Neuro: Mental Status: Awake, alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech is fluent with good comprehension. Cranial Nerves: I: Not tested II: Pupils briskly reactive to light, left 1mm larger than right. Visual fields not tested III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: decreased bulk and normal tone bilaterally. jaw tremor. Strength full power ___ throughout. No pronator drift c/o pain in left arm Sensation: Intact to light touch ============ At Discharge ============ General: VS: Tmax 98.1F, cur 97.5F, HR: 60-71, BP: 130/56, RR ___, SpO2 96-99% RA Bowel Regimen: [x]Yes [ ]No Last BM: PTA Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time - says ___ for year, daughter at bedside says that this is her baseline Follows commands: [ ]Simple [x]Complex [ ]None Pupils: Right 4-3mm Left 4-3mm EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]No - symmetric nasolabial flattening Tongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact: [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip LeftDoes not move because of pain IPQuadHamATEHLGast [x]Sensation intact to light touch Pertinent Results: Please see OMR for lab/imaging results. Brief Hospital Course: ___ with history of dementia, afib on Coumadin, s/p fall out of chair, struck the left side of her face, and has small right frontal SAH. #Traumatic Subarachnoid Hemorrhage She presented to the emergency department after falling and hitting her head as she was trying to sit down in a chair. In the ED, a ___ showed a small right frontal traumatic subarachnoid hemorrhage, and on exam she was neuro intact aside from baseline confusion regarding date. She had an area of ecchymosis over her left forehead/medial canthus. She was admitted to ___ for monitoring. Repeat NCHCT was stable. She was evaluated by ___, and was discharged home with existing services. #Left Arm Pain In the ED, she also complained of left arm pain. She was evaluated by ___ for a trauma workup, including XRays of left shoulder and left elbow were performed, which were negative for fracture. #UTI On ED presentation, her UA was positive for UTI, and she was started on ceftriaxone while in the ED. She was continued on Ciprofloxacin 250mg BID. Medications on Admission: ALENDRONATE - alendronate 70 mg tablet. 1 tablet(s) by mouth Once every week AMLODIPINE - amlodipine 5 mg tablet. 1 tablet(s) by mouth daily FUROSEMIDE - furosemide 20 mg tablet. 1 tablet(s) by mouth once a day LEVOTHYROXINE - levothyroxine 88 mcg tablet. 1 tablet(s) by mouth daily take 1 extra tablet on ___. Please take on empty stomach, 45min before breakfast without other medications. LOSARTAN - losartan 25 mg tablet. 1 tablet(s) by mouth twice a day METOPROLOL SUCCINATE - metoprolol succinate ER 50 mg tablet,extended release 24 hr. 1 (One) tablet(s) by mouth twice a day WARFARIN [COUMADIN] - Coumadin 5 mg tablet. one tablet(s) by mouth AS DIRECTED Medications - ___ CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) 400 unit chewable tablet. 2 tablet(s) by mouth daily - (OTC) CRANBERRY - Dosage uncertain - (OTC) Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Ciprofloxacin HCl 250 mg PO Q12H Duration: 3 Days RX ciprofloxacin HCl 250 mg 1 tablet(s) by mouth twice a day Disp #5 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID 4. Senna 17.2 mg PO HS 5. Alendronate Sodium 70 mg PO 1X/WEEK (SA) Please continue to take it the day you normally take it. 6. amLODIPine 5 mg PO DAILY 7. Furosemide 20 mg PO DAILY 8. Levothyroxine Sodium 88 mcg PO DAILY 9. Losartan Potassium 25 mg PO BID 10. Metoprolol Succinate XL 50 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Traumatic Subarachnoid Hemorrhage Urinary tract infection Hyponatremia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Discharge Instructions Brain Hemorrhage without Surgery Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted, you are NOT allowed to drive by law. No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. Again, please do not take Coumadin (Warfarin) for one month, and do not resume taking it without your neurosurgeon's approval. This will be restarted by your PCP after your neurosurgery follow-up appointment. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: You may have difficulty paying attention, concentrating, and remembering new information. Emotional and/or behavioral difficulties are common. Feeling more tired, restlessness, irritability, and mood swings are also common. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: Headache is one of the most common symptom after a brain bleed. Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit Nausea and/or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Followup Instructions: ___	[ "S066X0A", "W07XXXA", "Y929", "N390", "E871", "M79602", "E890", "I10" ]	Allergies: iodine strong / Morphine / potassium iodide Chief Complaint: fell out of chair and hit head Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old female with history of dementia, atrial fibrillation on Coumadin, fell out of her chair and struck the left side of her face. She did not lose consciousness. Has a small right frontal Subarachnoid Hemorrhage. Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS [MASKED] DYSPNEA DIABETIC RETINOPATHY Social History: [MASKED] Family History: mother, brother with atrial fibrillation. Physical Exam: On Admission ============ O: T: 96 HR:88 BP: 154/96 RR:16 Sat:100% RA GCS at the scene: 15 GCS upon Neurosurgery Evaluation: 15 Airway: [x]Not intubated Eye Opening: [ ]1 Does not open eyes [ ]2 Opens eyes to painful stimuli [ ]3 Opens eyes to voice [x]4 Opens eyes spontaneously Verbal: [ ]1 Makes no sounds [ ]2 Incomprehensible sounds [ ]3 Inappropriate words [ ]4 Confused, disoriented [x]5 Oriented Motor: [ ]1 No movement [ ]2 Extension to painful stimuli (decerebrate response) [ ]3 Abnormal flexion to painful stimuli (decorticate response) [ [MASKED] Flexion/ withdrawal to painful stimuli [ ]5 Localizes to painful stimuli [x]6 Obeys commands Exam: with Care attendant translating Gen: WD/WN, comfortable, NAD. HEENT: left periorbital ecchymosis and minimal edema Neck: supple, no midline tenderness Extrem: warm and well perfused Neuro: Mental Status: Awake, alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech is fluent with good comprehension. Cranial Nerves: I: Not tested II: Pupils briskly reactive to light, left 1mm larger than right. Visual fields not tested III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: decreased bulk and normal tone bilaterally. jaw tremor. Strength full power [MASKED] throughout. No pronator drift c/o pain in left arm Sensation: Intact to light touch ============ At Discharge ============ General: VS: Tmax 98.1F, cur 97.5F, HR: 60-71, BP: 130/56, RR [MASKED], SpO2 96-99% RA Bowel Regimen: [x]Yes [ ]No Last BM: PTA Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time - says [MASKED] for year, daughter at bedside says that this is her baseline Follows commands: [ ]Simple [x]Complex [ ]None Pupils: Right 4-3mm Left 4-3mm EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]No - symmetric nasolabial flattening Tongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact: [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip LeftDoes not move because of pain IPQuadHamATEHLGast [x]Sensation intact to light touch Pertinent Results: Please see OMR for lab/imaging results. Brief Hospital Course: [MASKED] with history of dementia, afib on Coumadin, s/p fall out of chair, struck the left side of her face, and has small right frontal SAH. #Traumatic Subarachnoid Hemorrhage She presented to the emergency department after falling and hitting her head as she was trying to sit down in a chair. In the ED, a [MASKED] showed a small right frontal traumatic subarachnoid hemorrhage, and on exam she was neuro intact aside from baseline confusion regarding date. She had an area of ecchymosis over her left forehead/medial canthus. She was admitted to [MASKED] for monitoring. Repeat NCHCT was stable. She was evaluated by [MASKED], and was discharged home with existing services. #Left Arm Pain In the ED, she also complained of left arm pain. She was evaluated by [MASKED] for a trauma workup, including XRays of left shoulder and left elbow were performed, which were negative for fracture. #UTI On ED presentation, her UA was positive for UTI, and she was started on ceftriaxone while in the ED. She was continued on Ciprofloxacin 250mg BID. Medications on Admission: ALENDRONATE - alendronate 70 mg tablet. 1 tablet(s) by mouth Once every week AMLODIPINE - amlodipine 5 mg tablet. 1 tablet(s) by mouth daily FUROSEMIDE - furosemide 20 mg tablet. 1 tablet(s) by mouth once a day LEVOTHYROXINE - levothyroxine 88 mcg tablet. 1 tablet(s) by mouth daily take 1 extra tablet on [MASKED]. Please take on empty stomach, 45min before breakfast without other medications. LOSARTAN - losartan 25 mg tablet. 1 tablet(s) by mouth twice a day METOPROLOL SUCCINATE - metoprolol succinate ER 50 mg tablet,extended release 24 hr. 1 (One) tablet(s) by mouth twice a day WARFARIN [COUMADIN] - Coumadin 5 mg tablet. one tablet(s) by mouth AS DIRECTED Medications - [MASKED] CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) 400 unit chewable tablet. 2 tablet(s) by mouth daily - (OTC) CRANBERRY - Dosage uncertain - (OTC) Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Ciprofloxacin HCl 250 mg PO Q12H Duration: 3 Days RX ciprofloxacin HCl 250 mg 1 tablet(s) by mouth twice a day Disp #5 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID 4. Senna 17.2 mg PO HS 5. Alendronate Sodium 70 mg PO 1X/WEEK (SA) Please continue to take it the day you normally take it. 6. amLODIPine 5 mg PO DAILY 7. Furosemide 20 mg PO DAILY 8. Levothyroxine Sodium 88 mcg PO DAILY 9. Losartan Potassium 25 mg PO BID 10. Metoprolol Succinate XL 50 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Traumatic Subarachnoid Hemorrhage Urinary tract infection Hyponatremia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Discharge Instructions Brain Hemorrhage without Surgery Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. [MASKED] try to do too much all at once. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted, you are NOT allowed to drive by law. No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. Again, please do not take Coumadin (Warfarin) for one month, and do not resume taking it without your neurosurgeon's approval. This will be restarted by your PCP after your neurosurgery follow-up appointment. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You [MASKED] Experience: You may have difficulty paying attention, concentrating, and remembering new information. Emotional and/or behavioral difficulties are common. Feeling more tired, restlessness, irritability, and mood swings are also common. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: Headache is one of the most common symptom after a brain bleed. Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at [MASKED] for: Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit Nausea and/or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face, arms, or leg Call [MASKED] and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Followup Instructions: [MASKED]	[]	[ "Y929", "N390", "E871", "I10" ]	[ "S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter", "W07XXXA: Fall from chair, initial encounter", "Y929: Unspecified place or not applicable", "N390: Urinary tract infection, site not specified", "E871: Hypo-osmolality and hyponatremia", "M79602: Pain in left arm", "E890: Postprocedural hypothyroidism", "I10: Essential (primary) hypertension" ]
10,095,681	23,380,001	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: iodine strong / Morphine / potassium iodide Attending: ___. Chief Complaint: R hand swelling Major Surgical or Invasive Procedure: None History of Present Illness: ___ female presents with PMH of cognitive impairment, afib on coumadin, CMC joint arthritis who presents with one week of Left wrist pain, swelling and redness. History is provided by the patient's daughter: the patient was recently admitted to ___ on ___ for zoster rash, mental status changes and hyponatremia. LP studies were negative and her Mental status resolved. She was discharged to rehab. Per daughter 1 day PTA the patient began to complain or L arm pain. The rehab staff did not notice any injury to the hand and did not report any preceding falls. On the day of admission the patient's daughter came to the rehab and found the L hand to be very swollen and red and she had a temperature of 100 at the rehab which was treated with Tylenol. They called her PCP who instructed them to come to the hospital. She has no other symptoms, including shortness of breath, chest pain, nausea, vomiting, diarrhea, or confusion. She is at her mental status baseline, per her daughter. From review of ___ discharge summary from ___, she was treated with valcyclovir, last day ___. Her Creatinine at discharge was reportedly 1.2 and she had a hyponatremia with c/f SIADH that was treated with salt tabs and improved to 137. Of note, she has history of cognitive impairment. She is a widow who lives alone in a supportive housing facility with daily services. She attends daycare daily. She is able to use the bathroom and partially to dress herself. She is unable to perform IADLs. In the ED her vitals were 98.4 60 148/74 20 100%. She was alert and was noted to have significant redness over the L hand with tenderness to palpation. No areas of fluctuance were noted. Wrist XR revealed severe osteoarthritis, no fractures. Labs notable for no leukocytosis, K 5.5 (hemolyzed), Crt 1.2 (baseline 0.8). She received Tylenol, 1 L LR, and was started on vancomycin. On the floor, she is alert and reports that her hand is too painful to use. She cannot use her walker because of the pain in her hand, so she is currently unable to ambulate. She denies other symptoms. Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS ___ DYSPNEA DIABETIC RETINOPATHY Social History: ___ Family History: mother, brother with atrial fibrillation. Physical Exam: ADMISSION EXAM Vitals: 98.9 126 / 70 93 20 96 ra General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear CV: Irregular 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 Lower extr: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema of the legs upper extr: L hand is swollen, erythematous over the dorsal surface with streaking over the forearm. No purulence or fluctuance. Patient with decreased wrist range of motion in L hand compared to R. Skin: Blistering rash over the L back wrapping around to L abdomen in dertmatomal distribution. Mostly healing with one open ulcerated lesion over the abdomen. DISCHARGE EXAM: Vitals: 97.4 170/80 72 21 98 RA General: Alert, no acute distress HEENT: Sclerae anicteric CV: Irregular 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 Lower extr: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema of the legs upper extr: L hand remains slightly discolored in areas of prior erythema, no longer swollen. No purulence or fluctuance. Skin: Blistering rash over the L back wrapping around to L abdomen in dertmatomal distribution. Mostly healing with one open ulcerated lesion over the abdomen. Pertinent Results: Admission labs: ___ 02:30PM BLOOD WBC-8.9 RBC-3.78 Hgb-11.5 Hct-34.4 MCV-91 MCH-30.4 MCHC-33.4 RDW-14.1 RDWSD-45.6 Plt ___ ___ 02:30PM BLOOD Neuts-69.6 Lymphs-18.3* Monos-10.9 Eos-0.1* Baso-0.5 Im ___ AbsNeut-6.17* AbsLymp-1.62 AbsMono-0.97* AbsEos-0.01* AbsBaso-0.04 ___ 02:30PM BLOOD ___ PTT-31.6 ___ ___ 07:35AM BLOOD Glucose-83 UreaN-18 Creat-0.8 Na-131* K-4.0 Cl-96 HCO3-22 AnGap-17 Micro: BCx ___: NGTD, pending at discharge x2 Imaging: ___ Wrist XR No acute fracture or dislocation seen. Severe osteoarthritic changes at the first carpometacarpal and triscaphe joints. Persistent slight widening of the scapholunate interval. Re- demonstrated calcification at the ___. Discharge labs: ___ 08:00AM BLOOD WBC-7.7 RBC-3.82* Hgb-11.4 Hct-34.8 MCV-91 MCH-29.8 MCHC-32.8 RDW-13.7 RDWSD-44.4 Plt ___ ___ 08:00AM BLOOD Glucose-82 UreaN-18 Creat-1.0 Na-133 K-4.4 Cl-96 HCO3-25 AnGap-16 ___ 08:00AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.3 Brief Hospital Course: Information for Outpatient Providers: ___ female presents with PMH of dementia, afib on coumadin, CMC joint arthritis who presents with L hand cellulitis. #L hand cellulitis: Patient's family reports redness, swelling and warmth of the L hand. She had a temp of 100 at her rehab and was brought to the ER for evaluation. There was no reported injury to the hand, and no hx of break in the skin. XR wrist was done in the ER and negative for fracture. No fluctuant areas for drainage on exam, but did have lymphangitic streaking. She was treated with Vancomycin (___) and then Keflex (___-) with rapid improvement in her cellulitis. She should continue on Keflex ___ Q8H for a total 14 day course given streaking (last day ___. ___: Cr 1.2 on admission. Per discharge summary her Cr on discharge from ___ on ___ was also 1.2. Per webOMR review, her baseline Cr is around 0.8. Unclear reason for ___ likely ___ poor PO intake. Should repeat BMP within 1 week to assess for resolution, if not would consider further workup. #Zoster infection: Started on valacyclovir at ___ during ___ admission. No signs of disseminated disease at that time. She has L back and stomach rash in dermatomal distribution, appears to be healing, though one open blister on abdomen. Her prescribed course of valacyclovir was continued at 1000mg BID, with last dose ___ per ___ discharge summary. She should finish out this course at home. #Afib on Coumadin: INR goal ___. No history of stroke. Continue warfarin 2.5mg daily. INR on discharge was 2.5. #Hyponatremia: Na 131 on admission. Per discharge summary from ___ on during ___ admission, she was noted to be hyponatremic and treated with salt tabs. Her Na on discharge on ___ was 137. Reason for hyponatremia is unclear; c/f SIADH. Na stable during hospitalization and 133 on discharge ___. Recheck sodium in one week; consider fluid restriction and further workup if not improving. #Hypothyroidism: Continued levothyroxine. #HTN: Pt with reported hx of hypertension, her meds were held on last admission at ___ ___ due to normotension. Her previous home regimen was metoprolol succinate 50mg daily. She was restarted on lower dose metoprolol 25 mg daily and additionally amlodipine 2.5 mg daily. #Dementia: Patient AAOx1-2. Lives alone with full-time supervision. Cannot perform IADLS. Has difficulty dressing herself, can toilet herself for the most part per family. TRANSITIONAL ISSUES =================== - Please monitor blood pressure and titrate anti-hypertensives as tolerated. - Please draw INR and BMP on ___ to assess her sodium and renal function. A script was provided to the patient. On discharge Na is 133 and Cr is 1.0. She may require further workup if hyponatremia and ___ not resolving. - Patient should finish her valacyclovir course on ___. - Metoprolol restarted at lower dose of 25 mg daily (previously discontinued at ___ hospitalization). - Keflex ___ q8h (renally-dosed) for total 14 day course (last day ___ for complicated L hand cellulitis. - Per documentation from prior hospitalizations, she had been made DNR/DNI though this hospitalization the family asked to defer discussion. Consider readdressing code status as an outpatient. # Emergency contact: ___ ___ (daughter) or ___ ___ (other daughter) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Polyethylene Glycol 17 g PO DAILY:PRN constipation 3. Ramelteon 8 mg PO QHS:PRN insomnia 4. Senna 17.2 mg PO QHS:PRN constipation 5. ValACYclovir 500 mg PO Q12H 6. Warfarin 2.5 mg PO DAILY16 7. Vitamin D 1000 UNIT PO DAILY 8. Levothyroxine Sodium 75 mcg PO DAILY The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Polyethylene Glycol 17 g PO DAILY:PRN constipation 3. Ramelteon 8 mg PO QHS:PRN insomnia 4. Senna 17.2 mg PO QHS:PRN constipation 5. ValACYclovir 500 mg PO Q12H 6. Warfarin 2.5 mg PO DAILY16 7. Vitamin D 1000 UNIT PO DAILY 8. Levothyroxine Sodium 75 mcg PO DAILY Discharge Medications: 1. amLODIPine 2.5 mg PO DAILY RX amlodipine 2.5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Cephalexin 500 mg PO Q8H RX cephalexin 500 mg 1 capsule(s) by mouth three times a day Disp #32 Capsule Refills:0 3. Metoprolol Succinate XL 25 mg PO DAILY RX metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 5. Levothyroxine Sodium 75 mcg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Ramelteon 8 mg PO QHS:PRN insomnia 8. Senna 17.2 mg PO QHS:PRN constipation 9. ValACYclovir 1000 mg PO Q12H 10. Vitamin D 1000 UNIT PO DAILY 11. Warfarin 2.5 mg PO DAILY16 12.Outpatient Lab Work Please draw INR and BMP on ___ to assess her sodium and renal function. Fax to Dr. ___ at ___. ICD-10: E87.1, I48. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Cellulitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you here at ___ ___. Why you were here: - You had cellulitis, an infection of the skin over the L hand What we did while you were here: - We did an Xray which did not show any broken bones or injuries to the hand. - We gave you antibiotics which quickly improved the infection and reduced the swelling and pain. - We restarted you on blood pressure medications (metoprolol succinate 25 mg daily and amlodipine 2.5 mg daily). What to do when you leave: - Please finish the entire course of antibiotics! - Your last dose of valacyclovir is this evening. You should stop this medication after tonight. - Call your doctor if you notice increased swelling of the hand, fevers or worsening pain. Sincerely, Your ___ Team Followup Instructions: ___	[ "L03114", "N179", "E875", "I4891", "B029", "E871", "F0390", "Z7901", "E039", "I10", "J449", "G4700", "F329", "E11319", "M19039", "Z23" ]	Allergies: iodine strong / Morphine / potassium iodide Chief Complaint: R hand swelling Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] female presents with PMH of cognitive impairment, afib on coumadin, CMC joint arthritis who presents with one week of Left wrist pain, swelling and redness. History is provided by the patient's daughter: the patient was recently admitted to [MASKED] on [MASKED] for zoster rash, mental status changes and hyponatremia. LP studies were negative and her Mental status resolved. She was discharged to rehab. Per daughter 1 day PTA the patient began to complain or L arm pain. The rehab staff did not notice any injury to the hand and did not report any preceding falls. On the day of admission the patient's daughter came to the rehab and found the L hand to be very swollen and red and she had a temperature of 100 at the rehab which was treated with Tylenol. They called her PCP who instructed them to come to the hospital. She has no other symptoms, including shortness of breath, chest pain, nausea, vomiting, diarrhea, or confusion. She is at her mental status baseline, per her daughter. From review of [MASKED] discharge summary from [MASKED], she was treated with valcyclovir, last day [MASKED]. Her Creatinine at discharge was reportedly 1.2 and she had a hyponatremia with c/f SIADH that was treated with salt tabs and improved to 137. Of note, she has history of cognitive impairment. She is a widow who lives alone in a supportive housing facility with daily services. She attends daycare daily. She is able to use the bathroom and partially to dress herself. She is unable to perform IADLs. In the ED her vitals were 98.4 60 148/74 20 100%. She was alert and was noted to have significant redness over the L hand with tenderness to palpation. No areas of fluctuance were noted. Wrist XR revealed severe osteoarthritis, no fractures. Labs notable for no leukocytosis, K 5.5 (hemolyzed), Crt 1.2 (baseline 0.8). She received Tylenol, 1 L LR, and was started on vancomycin. On the floor, she is alert and reports that her hand is too painful to use. She cannot use her walker because of the pain in her hand, so she is currently unable to ambulate. She denies other symptoms. Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS [MASKED] DYSPNEA DIABETIC RETINOPATHY Social History: [MASKED] Family History: mother, brother with atrial fibrillation. Physical Exam: ADMISSION EXAM Vitals: 98.9 126 / 70 93 20 96 ra General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear CV: Irregular 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 Lower extr: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema of the legs upper extr: L hand is swollen, erythematous over the dorsal surface with streaking over the forearm. No purulence or fluctuance. Patient with decreased wrist range of motion in L hand compared to R. Skin: Blistering rash over the L back wrapping around to L abdomen in dertmatomal distribution. Mostly healing with one open ulcerated lesion over the abdomen. DISCHARGE EXAM: Vitals: 97.4 170/80 72 21 98 RA General: Alert, no acute distress HEENT: Sclerae anicteric CV: Irregular 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 Lower extr: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema of the legs upper extr: L hand remains slightly discolored in areas of prior erythema, no longer swollen. No purulence or fluctuance. Skin: Blistering rash over the L back wrapping around to L abdomen in dertmatomal distribution. Mostly healing with one open ulcerated lesion over the abdomen. Pertinent Results: Admission labs: [MASKED] 02:30PM BLOOD WBC-8.9 RBC-3.78 Hgb-11.5 Hct-34.4 MCV-91 MCH-30.4 MCHC-33.4 RDW-14.1 RDWSD-45.6 Plt [MASKED] [MASKED] 02:30PM BLOOD Neuts-69.6 Lymphs-18.3* Monos-10.9 Eos-0.1* Baso-0.5 Im [MASKED] AbsNeut-6.17* AbsLymp-1.62 AbsMono-0.97* AbsEos-0.01* AbsBaso-0.04 [MASKED] 02:30PM BLOOD [MASKED] PTT-31.6 [MASKED] [MASKED] 07:35AM BLOOD Glucose-83 UreaN-18 Creat-0.8 Na-131* K-4.0 Cl-96 HCO3-22 AnGap-17 Micro: BCx [MASKED]: NGTD, pending at discharge x2 Imaging: [MASKED] Wrist XR No acute fracture or dislocation seen. Severe osteoarthritic changes at the first carpometacarpal and triscaphe joints. Persistent slight widening of the scapholunate interval. Re- demonstrated calcification at the [MASKED]. Discharge labs: [MASKED] 08:00AM BLOOD WBC-7.7 RBC-3.82* Hgb-11.4 Hct-34.8 MCV-91 MCH-29.8 MCHC-32.8 RDW-13.7 RDWSD-44.4 Plt [MASKED] [MASKED] 08:00AM BLOOD Glucose-82 UreaN-18 Creat-1.0 Na-133 K-4.4 Cl-96 HCO3-25 AnGap-16 [MASKED] 08:00AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.3 Brief Hospital Course: Information for Outpatient Providers: [MASKED] female presents with PMH of dementia, afib on coumadin, CMC joint arthritis who presents with L hand cellulitis. #L hand cellulitis: Patient's family reports redness, swelling and warmth of the L hand. She had a temp of 100 at her rehab and was brought to the ER for evaluation. There was no reported injury to the hand, and no hx of break in the skin. XR wrist was done in the ER and negative for fracture. No fluctuant areas for drainage on exam, but did have lymphangitic streaking. She was treated with Vancomycin ([MASKED]) and then Keflex ([MASKED]-) with rapid improvement in her cellulitis. She should continue on Keflex [MASKED] Q8H for a total 14 day course given streaking (last day [MASKED]. [MASKED]: Cr 1.2 on admission. Per discharge summary her Cr on discharge from [MASKED] on [MASKED] was also 1.2. Per webOMR review, her baseline Cr is around 0.8. Unclear reason for [MASKED] likely [MASKED] poor PO intake. Should repeat BMP within 1 week to assess for resolution, if not would consider further workup. #Zoster infection: Started on valacyclovir at [MASKED] during [MASKED] admission. No signs of disseminated disease at that time. She has L back and stomach rash in dermatomal distribution, appears to be healing, though one open blister on abdomen. Her prescribed course of valacyclovir was continued at 1000mg BID, with last dose [MASKED] per [MASKED] discharge summary. She should finish out this course at home. #Afib on Coumadin: INR goal [MASKED]. No history of stroke. Continue warfarin 2.5mg daily. INR on discharge was 2.5. #Hyponatremia: Na 131 on admission. Per discharge summary from [MASKED] on during [MASKED] admission, she was noted to be hyponatremic and treated with salt tabs. Her Na on discharge on [MASKED] was 137. Reason for hyponatremia is unclear; c/f SIADH. Na stable during hospitalization and 133 on discharge [MASKED]. Recheck sodium in one week; consider fluid restriction and further workup if not improving. #Hypothyroidism: Continued levothyroxine. #HTN: Pt with reported hx of hypertension, her meds were held on last admission at [MASKED] [MASKED] due to normotension. Her previous home regimen was metoprolol succinate 50mg daily. She was restarted on lower dose metoprolol 25 mg daily and additionally amlodipine 2.5 mg daily. #Dementia: Patient AAOx1-2. Lives alone with full-time supervision. Cannot perform IADLS. Has difficulty dressing herself, can toilet herself for the most part per family. TRANSITIONAL ISSUES =================== - Please monitor blood pressure and titrate anti-hypertensives as tolerated. - Please draw INR and BMP on [MASKED] to assess her sodium and renal function. A script was provided to the patient. On discharge Na is 133 and Cr is 1.0. She may require further workup if hyponatremia and [MASKED] not resolving. - Patient should finish her valacyclovir course on [MASKED]. - Metoprolol restarted at lower dose of 25 mg daily (previously discontinued at [MASKED] hospitalization). - Keflex [MASKED] q8h (renally-dosed) for total 14 day course (last day [MASKED] for complicated L hand cellulitis. - Per documentation from prior hospitalizations, she had been made DNR/DNI though this hospitalization the family asked to defer discussion. Consider readdressing code status as an outpatient. # Emergency contact: [MASKED] [MASKED] (daughter) or [MASKED] [MASKED] (other daughter) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Polyethylene Glycol 17 g PO DAILY:PRN constipation 3. Ramelteon 8 mg PO QHS:PRN insomnia 4. Senna 17.2 mg PO QHS:PRN constipation 5. ValACYclovir 500 mg PO Q12H 6. Warfarin 2.5 mg PO DAILY16 7. Vitamin D 1000 UNIT PO DAILY 8. Levothyroxine Sodium 75 mcg PO DAILY The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Polyethylene Glycol 17 g PO DAILY:PRN constipation 3. Ramelteon 8 mg PO QHS:PRN insomnia 4. Senna 17.2 mg PO QHS:PRN constipation 5. ValACYclovir 500 mg PO Q12H 6. Warfarin 2.5 mg PO DAILY16 7. Vitamin D 1000 UNIT PO DAILY 8. Levothyroxine Sodium 75 mcg PO DAILY Discharge Medications: 1. amLODIPine 2.5 mg PO DAILY RX amlodipine 2.5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Cephalexin 500 mg PO Q8H RX cephalexin 500 mg 1 capsule(s) by mouth three times a day Disp #32 Capsule Refills:0 3. Metoprolol Succinate XL 25 mg PO DAILY RX metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 5. Levothyroxine Sodium 75 mcg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Ramelteon 8 mg PO QHS:PRN insomnia 8. Senna 17.2 mg PO QHS:PRN constipation 9. ValACYclovir 1000 mg PO Q12H 10. Vitamin D 1000 UNIT PO DAILY 11. Warfarin 2.5 mg PO DAILY16 12.Outpatient Lab Work Please draw INR and BMP on [MASKED] to assess her sodium and renal function. Fax to Dr. [MASKED] at [MASKED]. ICD-10: E87.1, I48. Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: Cellulitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you here at [MASKED] [MASKED]. Why you were here: - You had cellulitis, an infection of the skin over the L hand What we did while you were here: - We did an Xray which did not show any broken bones or injuries to the hand. - We gave you antibiotics which quickly improved the infection and reduced the swelling and pain. - We restarted you on blood pressure medications (metoprolol succinate 25 mg daily and amlodipine 2.5 mg daily). What to do when you leave: - Please finish the entire course of antibiotics! - Your last dose of valacyclovir is this evening. You should stop this medication after tonight. - Call your doctor if you notice increased swelling of the hand, fevers or worsening pain. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "N179", "I4891", "E871", "Z7901", "E039", "I10", "J449", "G4700", "F329" ]	[ "L03114: Cellulitis of left upper limb", "N179: Acute kidney failure, unspecified", "E875: Hyperkalemia", "I4891: Unspecified atrial fibrillation", "B029: Zoster without complications", "E871: Hypo-osmolality and hyponatremia", "F0390: Unspecified dementia without behavioral disturbance", "Z7901: Long term (current) use of anticoagulants", "E039: Hypothyroidism, unspecified", "I10: Essential (primary) hypertension", "J449: Chronic obstructive pulmonary disease, unspecified", "G4700: Insomnia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "M19039: Primary osteoarthritis, unspecified wrist", "Z23: Encounter for immunization" ]
10,095,681	24,483,621	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: iodine strong / Morphine / potassium iodide Attending: ___. Chief Complaint: Lower extremity edema Major Surgical or Invasive Procedure: None History of Present Illness: ___ female past medical history of dementia, COPD and atrial fibrillation presenting complaining of several days of bilateral lower tibia edema and dyspnea on exertion. Patient also endorses orthopnea. She denies any chest pain. She denies any fever or cough. She denies any symptoms at rest. Number state that they feel that her face has been more swollen as well. She denies any throat or tongue swelling. She was recently seen in the CDAC on ___ for atrial firbilatiion where her metoprolol was increased to 50mg BID for improved rate control. TSH was 16 at the time; she is supposed to have FT4 checked as outpatient, but this has not been done yet. Was also hospitalized at ___ (Shingles) and ___ (left hand cellulitis) in ___ and ___ respectively. In the ED, initial vitals were: T97.5, HR 80, BP 126/68, RR18, SpO2 99% RA. Labs were notable for hemoglobin 9.9, INR 2.2, Na 131, K 4.9, bicarb 20, Cr 0.9, proBNP 2554 (no priors), troponin negative x1. CXR showed: 1. Severe cardiomegaly and mild pulmonary vascular congestion. 2. Small left pleural effusion. ECG showed: AFib 76 NA, NI, No ST T changes She was given furosemide 40mg IV x1. On the floor, she reports that she is feeling better. History is limited due to patient's underlying dementia. Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS ___ DYSPNEA DIABETIC RETINOPATHY Social History: ___ Family History: mother, brother with atrial fibrillation. Physical Exam: ADMISSION PHYSICAL EXAM ======================== Vital Signs: T97.2, BP 158/89, HR 82, RR 18, SpO2 99% RA. General: Sleeping comfortably, awakens to voice, interactive HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, JVP not significantly elevated CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Decreased at the left base with slight crackles Abdomen: Soft, non-tender, non-distended, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema noted Neuro: CNII-XII intact, moves all extremities equally in bed DISCHARGE PHYSICAL EXAM ======================== Vitals: Tmax= 98.8 HR= 66-102 BP= ___ RR= 18 O2= 92-97% on RA General: Sleeping comfortably, awakens to voice, interactive HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, JVP not significantly elevated CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Refuses full lung exam; clear in upper in mid fields Abdomen: Soft, non-tender, non-distended, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema noted Neuro: CNII-XII intact, moves all extremities equally in bed Pertinent Results: ADMISSION LABS =========================== ___ 09:10PM BLOOD WBC-7.5 RBC-3.31 Hgb-9.9* Hct-30.6* MCV-92 MCH-29.9 MCHC-32.4 RDW-14.2 RDWSD-48.0* Plt ___ ___ 09:10PM BLOOD Neuts-70.0 Lymphs-18.4* Monos-9.2 Eos-1.2 Baso-0.5 Im ___ AbsNeut-5.22 AbsLymp-1.37 AbsMono-0.69 AbsEos-0.09 AbsBaso-0.04 ___ 12:22AM BLOOD ___ PTT-37.2* ___ ___ 09:10PM BLOOD Glucose-97 UreaN-33* Creat-0.9 Na-131* K-5.9* Cl-96 HCO3-20* AnGap-21* ___ 09:10PM BLOOD cTropnT-<0.01 proBNP-2554* ___ 04:55AM BLOOD cTropnT-<0.01 ___ 09:10PM BLOOD Iron-28* ___ 04:55AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.1 ___ 09:10PM BLOOD calTIBC-346 Ferritn-184* TRF-266 ___ 04:55AM BLOOD TSH-22* DISCHARGE LABS ============================= ___ 05:00AM BLOOD WBC-6.1 RBC-3.70* Hgb-10.9* Hct-33.7* MCV-91 MCH-29.5 MCHC-32.3 RDW-13.9 RDWSD-46.5* Plt ___ ___ 05:00AM BLOOD Glucose-83 UreaN-28* Creat-0.8 Na-131* K-5.0 Cl-95* HCO3-25 AnGap-16 ___ 05:00AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.2 MICROBIOLOGY ============================== ___ 3:50 pm URINE Source: ___. *FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING ============================== CXR ___ IMPRESSION: 1. Severe cardiomegaly and mild pulmonary vascular congestion. 2. Small left pleural effusion. Transthoracic ECHO ___ IMPRESSION: EF 55-60% 1) Grade II diastolic dysfunction with at least moderate pulmonary systolic hypertension due to left heart disease. 2) Severe tricuspid regurgitation due to annular dilation in setting of elevation of RV pre and afterload. 3) Normal biventricular regional/global systolic function. 4) Very prominent Eustachian valve. In some views appears to be attached to the intraatrial septum suggestive of Cor tiatriatum however doppler flow more consistent with prominent Eustachian valve. Compared with the prior study (images reviewed) of ___, findings are similar using the retrospectoscope prominent Eustachian valve present on prior images. Tricuspid regurgitation severity increased. The patient is now in atrial fibrillation. Brief Hospital Course: ___ with history of dementia, COPD, hypothyroidism, and atrial fibrillation on Coumadin, presenting with lower extremity edema and DOE, found to have elevated BNP and pulmonary edema on CXR consistent with HFpEF exacerbation. Previous ECHO in ___ showing normal EF and significant TR and PR. Patient received 40 mg IV Lasix x1 and subsequently appeared euvolemic on exam, further diuresis was held. TSH was found to be 22, up from 16 in ___, and Levothyroxine was increased from 75 mcg to 88 mcg daily. # Acute decompensated HFpEF: patient with new onset leg swelling, orthopnea, elevated BNP and cardiopulmonary congestion seen on CXR, suspicious for CHF. However, appeared euvolemic on exam this AM after 40 mg IV Lasix x1. Last TTE was in ___ showing preserved EF, 2+ and 3+ TR and significant pulmonic regurgitation. TTE during admission showed preserved EF (55-60%) and increased TR. Precipitant of presentation may hvae been undertreated hypothyroidism (___ this admission 22). Also with positive UA; though UCX only with mixed flora. Patient was not given additional diuresis and was not discharged on diuretics. Amlodipine and metoprolol were continued. Synthroid was increased to 88 mcg. # Hyponatremia: Na 131 on admission, has remained stable. Could be secondary to hypervolemia given clinical picture of heart failure, though patient appears euvolemic, or to undertreated hypothyroidism. Na remained stable during admission. # Hypothyroidism: TSH was 16 when checked in ___ 22 this admission. Likely contributing to symptoms of progressive fatigue and lower extremity edema. Synthroid was increased to 88 mcg daily; patient should have repeat TSH drawn in 6 weeks for further med titration. # Normocytic Anemia: Normocytic anemia likely secondary to anemia of chronic disease. No obvious source of bleeding. Last colonoscopy ___ showed grade 1 internal hemorrhoids amd polyps in the proximal ascending colon (s/p polypectomy, endoclip). Low iron, high ferritin consistent with anemia of chronic disease, possibly in the setting of untreated hypothyroidism. H/H remained stable during admission. # Atrial fibrillation: Metoprolol recently increased to 50 BID, which was continued. HR controlled during admission (60s-70s). Warfarin home regimen was continued; INR 2.0 on DC; should be repeated on ___. # Dementia: Patient AAOx1-2. Lives alone with full-time supervision. Cannot perform IADLS. Has difficulty dressing herself, can toilet herself for the most part per family. # History of RML lung mass/pulmonary tuberculosis: patient underwent CT guided biopsy of PET-avid lesion in ___. Pathology results were inconclusive. Follow-up of this problem is unclear based on records as there has been no additional imaging and this is not noted on primary care notes moving forward, but per daughter's report this admission, this episode was actually pulmonary tuberculosis, which has been treated. Transitional issues: [] Levothyroxine was increased from 75 mcg to 88 mcg daily on ___. Please repeat TSH 6 weeks after discharge and further titrate as indicated. [] INR was 2.0 at discharge, please draw INR on ___ or sooner and adjust warfarin dose as appropriate. [] Patient was discharged without oral diuretics. Please trend weight and fluid status, and consider initiating oral furosemide as appropriate. [] UA during admission was positive for WBC and leuks. Urine culture was pending on discharge, but final results showing mixed bacterial flora inconsitent with UTI. No dysuria/abdominal pain, leukocytosis, or fever. [] TTE was performed during admission; final read was pending on discharge. ECHO showed increased TR but no decreased EF. Final read included in this summary. [] Losartan was decreased during admission from 50 mg PO BID to 25 mg PO BID. [] Consider initiation of novel oral anticoagulant for atrial fibrillation instead of warfarin. Discharge weight: 60.8 kg Discharge Cr: 0.8 Discharge Hgb: 10.9 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Polyethylene Glycol 17 g PO DAILY:PRN constipation 4. Ramelteon 8 mg PO QHS:PRN insomnia 5. Senna 17.2 mg PO QHS:PRN constipation 6. Vitamin D 1000 UNIT PO DAILY 7. Warfarin 2.5 mg PO 1X/WEEK (SA) 8. Metoprolol Succinate XL 50 mg PO BID 9. amLODIPine 5 mg PO DAILY 10. Warfarin 5 mg PO 6X/WEEK (___) 11. Losartan Potassium 50 mg PO BID 12. Alendronate Sodium 70 mg PO QMON Discharge Medications: 1. Levothyroxine Sodium 88 mcg PO DAILY RX levothyroxine 88 mcg 1 tablet(s) by mouth qAM Disp #30 Tablet Refills:0 2. Losartan Potassium 25 mg PO BID RX losartan 25 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 4. Alendronate Sodium 70 mg PO QMON 5. amLODIPine 5 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO BID 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Ramelteon 8 mg PO QHS:PRN insomnia 9. Senna 17.2 mg PO QHS:PRN constipation 10. Vitamin D 1000 UNIT PO DAILY 11. Warfarin 2.5 mg PO 1X/WEEK (SA) 12. Warfarin 5 mg PO 6X/WEEK (___) 13.Outpatient Lab Work Please draw ___ on ___ and fax to ___ ___ at ___. I48.1 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hypothyroidism Exacerbation of heart failure with preserved ejection fraction Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, It was a pleasure treating you at ___! Why was I admitted to the hospital? -You were admitted because you had swelling in your legs and increased fatigue. What happened while I was admitted? -We gave you medicine to help get fluid off of your body. -We found that your thyroid was not as active as it should be, so we increased your dose of thyroid medication. What should I do when I go home? -Please weigh yourself every day and call your physician if your weight goes up by more than 3 pounds in 2 days. We wish you the best! Your ___ care providers ___: ___	[ "I110", "E871", "F0390", "I482", "I5031", "E890", "Z7901", "J449", "M8580", "E559", "I071", "I371", "D638", "E11319", "Z8611", "R8299", "E7800", "R918", "F329" ]	Allergies: iodine strong / Morphine / potassium iodide Chief Complaint: Lower extremity edema Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] female past medical history of dementia, COPD and atrial fibrillation presenting complaining of several days of bilateral lower tibia edema and dyspnea on exertion. Patient also endorses orthopnea. She denies any chest pain. She denies any fever or cough. She denies any symptoms at rest. Number state that they feel that her face has been more swollen as well. She denies any throat or tongue swelling. She was recently seen in the CDAC on [MASKED] for atrial firbilatiion where her metoprolol was increased to 50mg BID for improved rate control. TSH was 16 at the time; she is supposed to have FT4 checked as outpatient, but this has not been done yet. Was also hospitalized at [MASKED] (Shingles) and [MASKED] (left hand cellulitis) in [MASKED] and [MASKED] respectively. In the ED, initial vitals were: T97.5, HR 80, BP 126/68, RR18, SpO2 99% RA. Labs were notable for hemoglobin 9.9, INR 2.2, Na 131, K 4.9, bicarb 20, Cr 0.9, proBNP 2554 (no priors), troponin negative x1. CXR showed: 1. Severe cardiomegaly and mild pulmonary vascular congestion. 2. Small left pleural effusion. ECG showed: AFib 76 NA, NI, No ST T changes She was given furosemide 40mg IV x1. On the floor, she reports that she is feeling better. History is limited due to patient's underlying dementia. Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS [MASKED] DYSPNEA DIABETIC RETINOPATHY Social History: [MASKED] Family History: mother, brother with atrial fibrillation. Physical Exam: ADMISSION PHYSICAL EXAM ======================== Vital Signs: T97.2, BP 158/89, HR 82, RR 18, SpO2 99% RA. General: Sleeping comfortably, awakens to voice, interactive HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, JVP not significantly elevated CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Decreased at the left base with slight crackles Abdomen: Soft, non-tender, non-distended, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema noted Neuro: CNII-XII intact, moves all extremities equally in bed DISCHARGE PHYSICAL EXAM ======================== Vitals: Tmax= 98.8 HR= 66-102 BP= [MASKED] RR= 18 O2= 92-97% on RA General: Sleeping comfortably, awakens to voice, interactive HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, JVP not significantly elevated CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Refuses full lung exam; clear in upper in mid fields Abdomen: Soft, non-tender, non-distended, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema noted Neuro: CNII-XII intact, moves all extremities equally in bed Pertinent Results: ADMISSION LABS =========================== [MASKED] 09:10PM BLOOD WBC-7.5 RBC-3.31 Hgb-9.9* Hct-30.6* MCV-92 MCH-29.9 MCHC-32.4 RDW-14.2 RDWSD-48.0* Plt [MASKED] [MASKED] 09:10PM BLOOD Neuts-70.0 Lymphs-18.4* Monos-9.2 Eos-1.2 Baso-0.5 Im [MASKED] AbsNeut-5.22 AbsLymp-1.37 AbsMono-0.69 AbsEos-0.09 AbsBaso-0.04 [MASKED] 12:22AM BLOOD [MASKED] PTT-37.2* [MASKED] [MASKED] 09:10PM BLOOD Glucose-97 UreaN-33* Creat-0.9 Na-131* K-5.9* Cl-96 HCO3-20* AnGap-21* [MASKED] 09:10PM BLOOD cTropnT-<0.01 proBNP-2554* [MASKED] 04:55AM BLOOD cTropnT-<0.01 [MASKED] 09:10PM BLOOD Iron-28* [MASKED] 04:55AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.1 [MASKED] 09:10PM BLOOD calTIBC-346 Ferritn-184* TRF-266 [MASKED] 04:55AM BLOOD TSH-22* DISCHARGE LABS ============================= [MASKED] 05:00AM BLOOD WBC-6.1 RBC-3.70* Hgb-10.9* Hct-33.7* MCV-91 MCH-29.5 MCHC-32.3 RDW-13.9 RDWSD-46.5* Plt [MASKED] [MASKED] 05:00AM BLOOD Glucose-83 UreaN-28* Creat-0.8 Na-131* K-5.0 Cl-95* HCO3-25 AnGap-16 [MASKED] 05:00AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.2 MICROBIOLOGY ============================== [MASKED] 3:50 pm URINE Source: [MASKED]. *FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING ============================== CXR [MASKED] IMPRESSION: 1. Severe cardiomegaly and mild pulmonary vascular congestion. 2. Small left pleural effusion. Transthoracic ECHO [MASKED] IMPRESSION: EF 55-60% 1) Grade II diastolic dysfunction with at least moderate pulmonary systolic hypertension due to left heart disease. 2) Severe tricuspid regurgitation due to annular dilation in setting of elevation of RV pre and afterload. 3) Normal biventricular regional/global systolic function. 4) Very prominent Eustachian valve. In some views appears to be attached to the intraatrial septum suggestive of Cor tiatriatum however doppler flow more consistent with prominent Eustachian valve. Compared with the prior study (images reviewed) of [MASKED], findings are similar using the retrospectoscope prominent Eustachian valve present on prior images. Tricuspid regurgitation severity increased. The patient is now in atrial fibrillation. Brief Hospital Course: [MASKED] with history of dementia, COPD, hypothyroidism, and atrial fibrillation on Coumadin, presenting with lower extremity edema and DOE, found to have elevated BNP and pulmonary edema on CXR consistent with HFpEF exacerbation. Previous ECHO in [MASKED] showing normal EF and significant TR and PR. Patient received 40 mg IV Lasix x1 and subsequently appeared euvolemic on exam, further diuresis was held. TSH was found to be 22, up from 16 in [MASKED], and Levothyroxine was increased from 75 mcg to 88 mcg daily. # Acute decompensated HFpEF: patient with new onset leg swelling, orthopnea, elevated BNP and cardiopulmonary congestion seen on CXR, suspicious for CHF. However, appeared euvolemic on exam this AM after 40 mg IV Lasix x1. Last TTE was in [MASKED] showing preserved EF, 2+ and 3+ TR and significant pulmonic regurgitation. TTE during admission showed preserved EF (55-60%) and increased TR. Precipitant of presentation may hvae been undertreated hypothyroidism ([MASKED] this admission 22). Also with positive UA; though UCX only with mixed flora. Patient was not given additional diuresis and was not discharged on diuretics. Amlodipine and metoprolol were continued. Synthroid was increased to 88 mcg. # Hyponatremia: Na 131 on admission, has remained stable. Could be secondary to hypervolemia given clinical picture of heart failure, though patient appears euvolemic, or to undertreated hypothyroidism. Na remained stable during admission. # Hypothyroidism: TSH was 16 when checked in [MASKED] 22 this admission. Likely contributing to symptoms of progressive fatigue and lower extremity edema. Synthroid was increased to 88 mcg daily; patient should have repeat TSH drawn in 6 weeks for further med titration. # Normocytic Anemia: Normocytic anemia likely secondary to anemia of chronic disease. No obvious source of bleeding. Last colonoscopy [MASKED] showed grade 1 internal hemorrhoids amd polyps in the proximal ascending colon (s/p polypectomy, endoclip). Low iron, high ferritin consistent with anemia of chronic disease, possibly in the setting of untreated hypothyroidism. H/H remained stable during admission. # Atrial fibrillation: Metoprolol recently increased to 50 BID, which was continued. HR controlled during admission (60s-70s). Warfarin home regimen was continued; INR 2.0 on DC; should be repeated on [MASKED]. # Dementia: Patient AAOx1-2. Lives alone with full-time supervision. Cannot perform IADLS. Has difficulty dressing herself, can toilet herself for the most part per family. # History of RML lung mass/pulmonary tuberculosis: patient underwent CT guided biopsy of PET-avid lesion in [MASKED]. Pathology results were inconclusive. Follow-up of this problem is unclear based on records as there has been no additional imaging and this is not noted on primary care notes moving forward, but per daughter's report this admission, this episode was actually pulmonary tuberculosis, which has been treated. Transitional issues: [] Levothyroxine was increased from 75 mcg to 88 mcg daily on [MASKED]. Please repeat TSH 6 weeks after discharge and further titrate as indicated. [] INR was 2.0 at discharge, please draw INR on [MASKED] or sooner and adjust warfarin dose as appropriate. [] Patient was discharged without oral diuretics. Please trend weight and fluid status, and consider initiating oral furosemide as appropriate. [] UA during admission was positive for WBC and leuks. Urine culture was pending on discharge, but final results showing mixed bacterial flora inconsitent with UTI. No dysuria/abdominal pain, leukocytosis, or fever. [] TTE was performed during admission; final read was pending on discharge. ECHO showed increased TR but no decreased EF. Final read included in this summary. [] Losartan was decreased during admission from 50 mg PO BID to 25 mg PO BID. [] Consider initiation of novel oral anticoagulant for atrial fibrillation instead of warfarin. Discharge weight: 60.8 kg Discharge Cr: 0.8 Discharge Hgb: 10.9 Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Polyethylene Glycol 17 g PO DAILY:PRN constipation 4. Ramelteon 8 mg PO QHS:PRN insomnia 5. Senna 17.2 mg PO QHS:PRN constipation 6. Vitamin D 1000 UNIT PO DAILY 7. Warfarin 2.5 mg PO 1X/WEEK (SA) 8. Metoprolol Succinate XL 50 mg PO BID 9. amLODIPine 5 mg PO DAILY 10. Warfarin 5 mg PO 6X/WEEK ([MASKED]) 11. Losartan Potassium 50 mg PO BID 12. Alendronate Sodium 70 mg PO QMON Discharge Medications: 1. Levothyroxine Sodium 88 mcg PO DAILY RX levothyroxine 88 mcg 1 tablet(s) by mouth qAM Disp #30 Tablet Refills:0 2. Losartan Potassium 25 mg PO BID RX losartan 25 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 4. Alendronate Sodium 70 mg PO QMON 5. amLODIPine 5 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO BID 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Ramelteon 8 mg PO QHS:PRN insomnia 9. Senna 17.2 mg PO QHS:PRN constipation 10. Vitamin D 1000 UNIT PO DAILY 11. Warfarin 2.5 mg PO 1X/WEEK (SA) 12. Warfarin 5 mg PO 6X/WEEK ([MASKED]) 13.Outpatient Lab Work Please draw [MASKED] on [MASKED] and fax to [MASKED] [MASKED] at [MASKED]. I48.1 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Hypothyroidism Exacerbation of heart failure with preserved ejection fraction Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure treating you at [MASKED]! Why was I admitted to the hospital? -You were admitted because you had swelling in your legs and increased fatigue. What happened while I was admitted? -We gave you medicine to help get fluid off of your body. -We found that your thyroid was not as active as it should be, so we increased your dose of thyroid medication. What should I do when I go home? -Please weigh yourself every day and call your physician if your weight goes up by more than 3 pounds in 2 days. We wish you the best! Your [MASKED] care providers [MASKED]: [MASKED]	[]	[ "I110", "E871", "Z7901", "J449", "F329" ]	[ "I110: Hypertensive heart disease with heart failure", "E871: Hypo-osmolality and hyponatremia", "F0390: Unspecified dementia without behavioral disturbance", "I482: Chronic atrial fibrillation", "I5031: Acute diastolic (congestive) heart failure", "E890: Postprocedural hypothyroidism", "Z7901: Long term (current) use of anticoagulants", "J449: Chronic obstructive pulmonary disease, unspecified", "M8580: Other specified disorders of bone density and structure, unspecified site", "E559: Vitamin D deficiency, unspecified", "I071: Rheumatic tricuspid insufficiency", "I371: Nonrheumatic pulmonary valve insufficiency", "D638: Anemia in other chronic diseases classified elsewhere", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "Z8611: Personal history of tuberculosis", "R8299: Other abnormal findings in urine", "E7800: Pure hypercholesterolemia, unspecified", "R918: Other nonspecific abnormal finding of lung field", "F329: Major depressive disorder, single episode, unspecified" ]
10,095,681	25,225,196	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: iodine strong / Morphine / potassium iodide Attending: ___. Chief Complaint: Supratherapeutic INR Epigastric pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with CHF, afib on warfarin, hypothyroidism, dementia who presents with nausea, decreased PO intake and a supratherapeutic INR. Per patient's daughter, patient was in her usual state of health until this morning when she developed mild nausea that has persisted throughout the day. She denies vomiting. She has not eaten or had any fluids today. She denies diarrhea, last BM was two days ago and had normal appearance. Visting ___ drew an INR and found it to be 7.4 and told patient to present to the ED. Patient denies bleeding although has some bruising on arms, legs, and chest. Denies any recent changes to diet or medications. In the ED: Initial vital signs were notable for: 96.3 76 144/64 18 100% RA Exam notable for: Afebrile, VSS Appears comfortable Irregularly irregular rhythm, normal rate, normal S1 and S2, no m/r/g Breathing comfortably on room air, CTAB soft, non-distended, minimal epigastric tenderness without guarding or rebound No ___ edema Bruises present on arms and legs Labs were notable for: INR 6.2 AST 55, AlkP 138 Na 124 UA: large leuk esterase, positive nitrite, >182 WBCs EKG: atrial fibrillation, QTC 501 Patient was given: - Ceftriaxone - Metoprolol - IVF Consults: None Upon arrival to the floor, attempted to use the interpreter phone, but the patient was speaking over the phone. Spoke with the patient in ___ though the patient is hard of hearing and has baseline dementia making the interview difficult. She endorsed abdominal pain rating the pain a ___. Denies nausea or vomiting at this point. Reports having to urinate more frequently but unclear given she is incontinent at baseline. Spoke with her daughter, ___, who endorses the patient woke up with abdominal pain and generalized weakness. Reports have nausea but no emesis. Did not eat or drink during the day. Given the belly pain, they brought her into the ED. Reports that she has been having daily soft bowel movements but none in the last 2 days. Unclear though given ___ has documented diarrhea per nursing note? REVIEW OF SYSTEMS: ROS as above. Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS ___ DYSPNEA DIABETIC RETINOPATHY Social History: ___ Family History: mother - hx of afib, HTN, stomach cancer father - HTN, DM brother - hx of afib Physical Exam: ADMISSION PHYSICAL EXAM: ======================== 24 HR Data (last updated ___ @ 2258) Temp: 97.3 (Tm 97.3), BP: 158/83, HR: 86, RR: 19, O2 sat: 98%, O2 delivery: Ra, Wt: 139.11 lb/63.1 kg GENERAL: Alert and interactive. In no acute distress. ___ speaking but does not like the interpreter phone. Answers about 60% of questions appropriately HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. Mucus membranes dry. CARDIAC: Irregularly irregular. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally anteriorly. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, mild tenderness to palpation worse in the LUQ and epigastrium. No rebound or guarding. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. Mild tenderness to palpation in the L calf. SKIN: WWP. No rash. NEUROLOGIC: Alert and oriented person, to hospital (___), and not to time (year ___. CN2-12 intact. Moving all four extremities with purpose. DISCHARGE PHYSICAL EXAM: VS:97.6 PO \|118 / 63\| 67 \|18 \|97 Ra GENERAL: Alert and interactive. In no acute distress. HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. Mucus membranes dry. CARDIAC: Irregularly irregular. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normoactive bowel sounds, non distended, mild tenderness to palpation in epigastrium. No guarding or masses. BACK: TLSO brace in place. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. NEUROLOGIC: Alert and interaction. CN2-12 grossly intact. Moving all four extremities with purpose. Strength ___ with dorsi and plantarflexion of ___. SKIN: Warm, dry. No rashes. Pertinent Results: ADMISSION LABS: ================ ___ 04:20PM BLOOD WBC-8.7 RBC-4.11 Hgb-11.7 Hct-35.1 MCV-85 MCH-28.5 MCHC-33.3 RDW-14.6 RDWSD-45.4 Plt ___ ___ 04:20PM BLOOD Neuts-76.9 Lymphs-14.6* Monos-7.6 Eos-0.1* Baso-0.2 Im ___ AbsNeut-6.70* AbsLymp-1.27 AbsMono-0.66 AbsEos-0.01* AbsBaso-0.02 ___ 04:20PM BLOOD ___ PTT-43.6* ___ ___ 04:20PM BLOOD Glucose-107* UreaN-10 Creat-0.7 Na-124* K-6.8* Cl-89* HCO3-22 AnGap-13 ___ 04:20PM BLOOD ALT-15 AST-55* AlkPhos-138* TotBili-1.1 ___ 07:30AM BLOOD Albumin-3.2* Calcium-8.2* Phos-3.3 Mg-1.9 ___ 04:34PM BLOOD Lactate-1.2 Na-126* K-5.1 MICROBIOLOGY: ___ 5:51 pm URINE *FINAL REPORT ___ URINE CULTURE (Final ___: KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- 8 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-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S URINE STUDIES: Urine Color Straw YELLOW Urine Appearance Hazy Specific Gravity 1.008 DIPSTICK URINALYSIS Blood SM* Nitrite POS* Protein 100* Glucose NEG Ketone TR* Bilirubin NEG Urobilinogen NEG pH 7.5 Leukocytes LG* MICROSCOPIC URINE EXAMINATION RBC 5* WBC >182* Bacteria MOD* Yeast NONE Epithelial Cells 4 IMAGING: ========== ___ MRI L SPINE IMPRESSION: 1. Acute transverse fracture through the superior L2 vertebral body extending into the left L2 pedicle with surrounding marrow edema. No buckling/discontinuity of the posterior cortex or bony retropulsion into the spinal canal. Ligamentum flavum and posterior longitudinal ligament appear continuous. The anterior longitudinal ligament also appears mostly continuous. 2. No spinal cord signal abnormality. 3. Left psoas intramuscular hematoma and edema. 4. Reactive soft tissue edema surrounding the L2 fracture. 5. Moderate multilevel lumbar spondylosis, notably causing severe right L5-S1 neural foraminal stenosis likely with impingement on the exiting right L5 nerve root. Further details, as above. ___ CT ABD & PELVIS W/O CONTRAST IMPRESSION: 1. Acute comminuted fracture through the L2 vertebral body with extension into the left pedicle. No retropulsion of fracture fragments. 2. New left psoas intramuscular hematoma. 3. No evidence of acute pancreatitis. 4. Cardiomegaly. Small pericardial effusion. 5. Small bilateral pleural effusions. DISCHARGE LABS: ___ 08:03AM BLOOD WBC-9.4 RBC-4.36 Hgb-12.4 Hct-38.0 MCV-87 MCH-28.4 MCHC-32.6 RDW-14.4 RDWSD-45.4 Plt ___ ___ 08:03AM BLOOD Glucose-82 UreaN-19 Creat-0.9 Na-132* K-4.9 Cl-94* HCO3-23 AnGap-15 ___ 07:35AM BLOOD ALT-10 AST-16 LD(LDH)-213 AlkPhos-131* TotBili-0.6 ___ 08:03AM BLOOD Calcium-9.0 Phos-3.6 Brief Hospital Course: Ms. ___ is a ___ year old woman with CHF, afib on warfarin, hypothyroidism, dementia who presented with nausea, epigastric abdominal pain,decreased PO intake and a supratherapeutic INR found to have a urinary tract infection and acute lumbar fracture and psoas hematoma. ACUTE ISSUES: ============= #Acute unstable L1 fracture #Osteoporosis Incidentally found to have an acute L1 vertebral fracture with MRI concerning for unstable fracture given extension into the left pedicle. No history of trauma or fall, possibly ___ osteoporosis. Neurosurgery was consulted and recommended TLSO bracing for all awake hours for 1 month. She will need follow up with neurosurgery in one month for reimaging to determine duration of TLSO bracing. In terms of her osteoporosis, she is currently on a drug holiday from home alenodronate 70mg 1x/week, she has follow up with endocrinology. #Psoas hematoma This was found incidentally on imaging and likely in setting of supratherapeutic INR and given fracture as above may suggest fall or trauma. Her hemoglobin remained stable throughout admission without concern for ongoing bleed. #Abdominal Pain #Constipation #Nausea On admission, family reported constipation with no bowel movement in two days prior to admission. She is s/p appendectomy and cholescystectomy. Lipase on admission was 38. Abdominal pain though potentially from baseline constipation. KUB without evidence of obstruction. Alternatively, thought that she may have some component of gastritis and was empirically started on a PPI and given bowel regimen with eventual alleviation of pain. There was no evidence of GI bleed. Work up overall unremarkable and likely multifactorial and possible with some referred pain from vertebral fracture. #UTI #Nausea U/A in the ED showed large ___, nitrates +, and WBC >182. Has been having UTI almost every ___ months and baseline incontinence. Urine culture grew Klebsiella. She was empirically started on ceftriaxone, whcih was switched to Bactrim to complete 7 day course. #Supratherapeutic INR #Atrial fibrillation She takes warfarin for atrial fibrillation at home. She had no reported bleeding. INR elevation may have been in setting of increased acetaminophen use at home. Eventually down-trended to 1.8 from 2.6 without any reversal. Her CHADSVASC score is 5. The decision was made to continue patient on warfarin given concern for threatened ischemic limb in past although risks of bleeding due to fall were also considered. Patient was started on reduced dose of warfarin with 2.5mg daily. She was continued on metoprolol. #Hypovolemic hyponatremia Chronic over last several months. Consistent with hypovolemic hyponatremia. Improved and stable. 132 at time of discharge. Continued to hold home lasix. CHRONIC ISSUES: =============== #Hypothyroidism s/p thyroidictomy in ___ (papillary thyroid microcarcinoma) - continued home levothyroxine 88mcg daily; extra dose each ___. #Hypertension BP stable this admission. - continued amlodipine 5mg daily - metoprolol as above - held home losartan 25mg BID #HFpEF #CAD Last echo in ___ with severe LAE. Moderate LV hypertrophy. LVEF of 70%. RV hypertrophy. Moderate AR and MR, Severe TR. - Continued home aspirin - held home Lasix 20mg daily given hyponatremia 36 min was spent seeing, examining, and coordinating discharge. TRANSITIONAL ISSUES: ======================= [ ] Patient was resumed on redosed dose of home warfarin 2.5mg daily, INR should be rechecked on ___. Goal INR ___. Ongoing discussion should be had on risks and benefits of continuing anticoagulation. [ ] Patient will need repeat CT L spine in ~1 month from discharge with follow up appoinment with Dr. ___ neurosurgery. The number for the office to schedule the appointment and the CT scan is ___. [ ] A PPI was started this admission for epigastric abdominal pain. Please continue to evaluate ongoing need for this medication and consider discontinuation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. amLODIPine 5 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Furosemide 20 mg PO DAILY 5. Levothyroxine Sodium 88 mcg PO DAILY 6. Losartan Potassium 25 mg PO BID 7. Senna 17.2 mg PO QHS 8. Metoprolol Succinate XL 50 mg PO BID 9. Warfarin 5 mg PO DAILY 10. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN abdominal pain/nausea 2. Bisacodyl ___AILY 3. Pantoprazole 40 mg PO Q12H 4. Levothyroxine Sodium 88 mcg PO 6X/WEEK (___) 5. Levothyroxine Sodium 176 mcg PO 1X/WEEK (___) 6. ___ MD to order daily dose PO DAILY16 7. Warfarin 2.5 mg PO DAILY16 Duration: 1 Dose 8. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 9. amLODIPine 5 mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. Docusate Sodium 100 mg PO BID 12. Losartan Potassium 25 mg PO BID 13. Metoprolol Succinate XL 50 mg PO BID 14. Senna 17.2 mg PO QHS 15. HELD- Furosemide 20 mg PO DAILY This medication was held. Do not restart Furosemide until you speak with your doctor. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Supratherapeutic INR Urinary tract infection Acute lumbar vertebral fracture Psoas hematoma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___: You were admitted to the hospital because you had an elevated INR and you were experiencing abdominal pain. At the hospital, you were found to have a urinary tract infection and you were given antibiotics. You were experiencing abdominal pain so you had a CT scan which showed a fracture in your spine and a small hematoma in your psoas muscle. You were seen by the neurosurgeon who recommended that you wear a brace. Your warfarin was held and your INR improved. You were then restarted on warfarin. When you leave the hospital you will go to rehab. Please follow up with all of your doctors. It was a pleasure caring for you! Sincerely, Your ___ Treatment Team Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___	[ "N390", "K6812", "M8008XA", "E871", "I5032", "B961", "K5900", "I4891", "R791", "E861", "E890", "I110", "E11319", "J449", "F0390", "I2510", "H9190", "Z7982", "Z7901", "Z87891" ]	Allergies: iodine strong / Morphine / potassium iodide Chief Complaint: Supratherapeutic INR Epigastric pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] with CHF, afib on warfarin, hypothyroidism, dementia who presents with nausea, decreased PO intake and a supratherapeutic INR. Per patient's daughter, patient was in her usual state of health until this morning when she developed mild nausea that has persisted throughout the day. She denies vomiting. She has not eaten or had any fluids today. She denies diarrhea, last BM was two days ago and had normal appearance. Visting [MASKED] drew an INR and found it to be 7.4 and told patient to present to the ED. Patient denies bleeding although has some bruising on arms, legs, and chest. Denies any recent changes to diet or medications. In the ED: Initial vital signs were notable for: 96.3 76 144/64 18 100% RA Exam notable for: Afebrile, VSS Appears comfortable Irregularly irregular rhythm, normal rate, normal S1 and S2, no m/r/g Breathing comfortably on room air, CTAB soft, non-distended, minimal epigastric tenderness without guarding or rebound No [MASKED] edema Bruises present on arms and legs Labs were notable for: INR 6.2 AST 55, AlkP 138 Na 124 UA: large leuk esterase, positive nitrite, >182 WBCs EKG: atrial fibrillation, QTC 501 Patient was given: - Ceftriaxone - Metoprolol - IVF Consults: None Upon arrival to the floor, attempted to use the interpreter phone, but the patient was speaking over the phone. Spoke with the patient in [MASKED] though the patient is hard of hearing and has baseline dementia making the interview difficult. She endorsed abdominal pain rating the pain a [MASKED]. Denies nausea or vomiting at this point. Reports having to urinate more frequently but unclear given she is incontinent at baseline. Spoke with her daughter, [MASKED], who endorses the patient woke up with abdominal pain and generalized weakness. Reports have nausea but no emesis. Did not eat or drink during the day. Given the belly pain, they brought her into the ED. Reports that she has been having daily soft bowel movements but none in the last 2 days. Unclear though given [MASKED] has documented diarrhea per nursing note? REVIEW OF SYSTEMS: ROS as above. Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS [MASKED] DYSPNEA DIABETIC RETINOPATHY Social History: [MASKED] Family History: mother - hx of afib, HTN, stomach cancer father - HTN, DM brother - hx of afib Physical Exam: ADMISSION PHYSICAL EXAM: ======================== 24 HR Data (last updated [MASKED] @ 2258) Temp: 97.3 (Tm 97.3), BP: 158/83, HR: 86, RR: 19, O2 sat: 98%, O2 delivery: Ra, Wt: 139.11 lb/63.1 kg GENERAL: Alert and interactive. In no acute distress. [MASKED] speaking but does not like the interpreter phone. Answers about 60% of questions appropriately HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. Mucus membranes dry. CARDIAC: Irregularly irregular. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally anteriorly. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, mild tenderness to palpation worse in the LUQ and epigastrium. No rebound or guarding. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. Mild tenderness to palpation in the L calf. SKIN: WWP. No rash. NEUROLOGIC: Alert and oriented person, to hospital ([MASKED]), and not to time (year [MASKED]. CN2-12 intact. Moving all four extremities with purpose. DISCHARGE PHYSICAL EXAM: VS:97.6 PO \|118 / 63\| 67 \|18 \|97 Ra GENERAL: Alert and interactive. In no acute distress. HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. Mucus membranes dry. CARDIAC: Irregularly irregular. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normoactive bowel sounds, non distended, mild tenderness to palpation in epigastrium. No guarding or masses. BACK: TLSO brace in place. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. NEUROLOGIC: Alert and interaction. CN2-12 grossly intact. Moving all four extremities with purpose. Strength [MASKED] with dorsi and plantarflexion of [MASKED]. SKIN: Warm, dry. No rashes. Pertinent Results: ADMISSION LABS: ================ [MASKED] 04:20PM BLOOD WBC-8.7 RBC-4.11 Hgb-11.7 Hct-35.1 MCV-85 MCH-28.5 MCHC-33.3 RDW-14.6 RDWSD-45.4 Plt [MASKED] [MASKED] 04:20PM BLOOD Neuts-76.9 Lymphs-14.6* Monos-7.6 Eos-0.1* Baso-0.2 Im [MASKED] AbsNeut-6.70* AbsLymp-1.27 AbsMono-0.66 AbsEos-0.01* AbsBaso-0.02 [MASKED] 04:20PM BLOOD [MASKED] PTT-43.6* [MASKED] [MASKED] 04:20PM BLOOD Glucose-107* UreaN-10 Creat-0.7 Na-124* K-6.8* Cl-89* HCO3-22 AnGap-13 [MASKED] 04:20PM BLOOD ALT-15 AST-55* AlkPhos-138* TotBili-1.1 [MASKED] 07:30AM BLOOD Albumin-3.2* Calcium-8.2* Phos-3.3 Mg-1.9 [MASKED] 04:34PM BLOOD Lactate-1.2 Na-126* K-5.1 MICROBIOLOGY: [MASKED] 5:51 pm URINE *FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- 8 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-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S URINE STUDIES: Urine Color Straw YELLOW Urine Appearance Hazy Specific Gravity 1.008 DIPSTICK URINALYSIS Blood SM* Nitrite POS* Protein 100* Glucose NEG Ketone TR* Bilirubin NEG Urobilinogen NEG pH 7.5 Leukocytes LG* MICROSCOPIC URINE EXAMINATION RBC 5* WBC >182* Bacteria MOD* Yeast NONE Epithelial Cells 4 IMAGING: ========== [MASKED] MRI L SPINE IMPRESSION: 1. Acute transverse fracture through the superior L2 vertebral body extending into the left L2 pedicle with surrounding marrow edema. No buckling/discontinuity of the posterior cortex or bony retropulsion into the spinal canal. Ligamentum flavum and posterior longitudinal ligament appear continuous. The anterior longitudinal ligament also appears mostly continuous. 2. No spinal cord signal abnormality. 3. Left psoas intramuscular hematoma and edema. 4. Reactive soft tissue edema surrounding the L2 fracture. 5. Moderate multilevel lumbar spondylosis, notably causing severe right L5-S1 neural foraminal stenosis likely with impingement on the exiting right L5 nerve root. Further details, as above. [MASKED] CT ABD & PELVIS W/O CONTRAST IMPRESSION: 1. Acute comminuted fracture through the L2 vertebral body with extension into the left pedicle. No retropulsion of fracture fragments. 2. New left psoas intramuscular hematoma. 3. No evidence of acute pancreatitis. 4. Cardiomegaly. Small pericardial effusion. 5. Small bilateral pleural effusions. DISCHARGE LABS: [MASKED] 08:03AM BLOOD WBC-9.4 RBC-4.36 Hgb-12.4 Hct-38.0 MCV-87 MCH-28.4 MCHC-32.6 RDW-14.4 RDWSD-45.4 Plt [MASKED] [MASKED] 08:03AM BLOOD Glucose-82 UreaN-19 Creat-0.9 Na-132* K-4.9 Cl-94* HCO3-23 AnGap-15 [MASKED] 07:35AM BLOOD ALT-10 AST-16 LD(LDH)-213 AlkPhos-131* TotBili-0.6 [MASKED] 08:03AM BLOOD Calcium-9.0 Phos-3.6 Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old woman with CHF, afib on warfarin, hypothyroidism, dementia who presented with nausea, epigastric abdominal pain,decreased PO intake and a supratherapeutic INR found to have a urinary tract infection and acute lumbar fracture and psoas hematoma. ACUTE ISSUES: ============= #Acute unstable L1 fracture #Osteoporosis Incidentally found to have an acute L1 vertebral fracture with MRI concerning for unstable fracture given extension into the left pedicle. No history of trauma or fall, possibly [MASKED] osteoporosis. Neurosurgery was consulted and recommended TLSO bracing for all awake hours for 1 month. She will need follow up with neurosurgery in one month for reimaging to determine duration of TLSO bracing. In terms of her osteoporosis, she is currently on a drug holiday from home alenodronate 70mg 1x/week, she has follow up with endocrinology. #Psoas hematoma This was found incidentally on imaging and likely in setting of supratherapeutic INR and given fracture as above may suggest fall or trauma. Her hemoglobin remained stable throughout admission without concern for ongoing bleed. #Abdominal Pain #Constipation #Nausea On admission, family reported constipation with no bowel movement in two days prior to admission. She is s/p appendectomy and cholescystectomy. Lipase on admission was 38. Abdominal pain though potentially from baseline constipation. KUB without evidence of obstruction. Alternatively, thought that she may have some component of gastritis and was empirically started on a PPI and given bowel regimen with eventual alleviation of pain. There was no evidence of GI bleed. Work up overall unremarkable and likely multifactorial and possible with some referred pain from vertebral fracture. #UTI #Nausea U/A in the ED showed large [MASKED], nitrates +, and WBC >182. Has been having UTI almost every [MASKED] months and baseline incontinence. Urine culture grew Klebsiella. She was empirically started on ceftriaxone, whcih was switched to Bactrim to complete 7 day course. #Supratherapeutic INR #Atrial fibrillation She takes warfarin for atrial fibrillation at home. She had no reported bleeding. INR elevation may have been in setting of increased acetaminophen use at home. Eventually down-trended to 1.8 from 2.6 without any reversal. Her CHADSVASC score is 5. The decision was made to continue patient on warfarin given concern for threatened ischemic limb in past although risks of bleeding due to fall were also considered. Patient was started on reduced dose of warfarin with 2.5mg daily. She was continued on metoprolol. #Hypovolemic hyponatremia Chronic over last several months. Consistent with hypovolemic hyponatremia. Improved and stable. 132 at time of discharge. Continued to hold home lasix. CHRONIC ISSUES: =============== #Hypothyroidism s/p thyroidictomy in [MASKED] (papillary thyroid microcarcinoma) - continued home levothyroxine 88mcg daily; extra dose each [MASKED]. #Hypertension BP stable this admission. - continued amlodipine 5mg daily - metoprolol as above - held home losartan 25mg BID #HFpEF #CAD Last echo in [MASKED] with severe LAE. Moderate LV hypertrophy. LVEF of 70%. RV hypertrophy. Moderate AR and MR, Severe TR. - Continued home aspirin - held home Lasix 20mg daily given hyponatremia 36 min was spent seeing, examining, and coordinating discharge. TRANSITIONAL ISSUES: ======================= [ ] Patient was resumed on redosed dose of home warfarin 2.5mg daily, INR should be rechecked on [MASKED]. Goal INR [MASKED]. Ongoing discussion should be had on risks and benefits of continuing anticoagulation. [ ] Patient will need repeat CT L spine in ~1 month from discharge with follow up appoinment with Dr. [MASKED] neurosurgery. The number for the office to schedule the appointment and the CT scan is [MASKED]. [ ] A PPI was started this admission for epigastric abdominal pain. Please continue to evaluate ongoing need for this medication and consider discontinuation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. amLODIPine 5 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Furosemide 20 mg PO DAILY 5. Levothyroxine Sodium 88 mcg PO DAILY 6. Losartan Potassium 25 mg PO BID 7. Senna 17.2 mg PO QHS 8. Metoprolol Succinate XL 50 mg PO BID 9. Warfarin 5 mg PO DAILY 10. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aluminum-Magnesium Hydrox.-Simethicone [MASKED] mL PO QID:PRN abdominal pain/nausea 2. Bisacodyl AILY 3. Pantoprazole 40 mg PO Q12H 4. Levothyroxine Sodium 88 mcg PO 6X/WEEK ([MASKED]) 5. Levothyroxine Sodium 176 mcg PO 1X/WEEK ([MASKED]) 6. [MASKED] MD to order daily dose PO DAILY16 7. Warfarin 2.5 mg PO DAILY16 Duration: 1 Dose 8. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 9. amLODIPine 5 mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. Docusate Sodium 100 mg PO BID 12. Losartan Potassium 25 mg PO BID 13. Metoprolol Succinate XL 50 mg PO BID 14. Senna 17.2 mg PO QHS 15. HELD- Furosemide 20 mg PO DAILY This medication was held. Do not restart Furosemide until you speak with your doctor. Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Supratherapeutic INR Urinary tract infection Acute lumbar vertebral fracture Psoas hematoma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED]: You were admitted to the hospital because you had an elevated INR and you were experiencing abdominal pain. At the hospital, you were found to have a urinary tract infection and you were given antibiotics. You were experiencing abdominal pain so you had a CT scan which showed a fracture in your spine and a small hematoma in your psoas muscle. You were seen by the neurosurgeon who recommended that you wear a brace. Your warfarin was held and your INR improved. You were then restarted on warfarin. When you leave the hospital you will go to rehab. Please follow up with all of your doctors. It was a pleasure caring for you! Sincerely, Your [MASKED] Treatment Team Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: [MASKED]	[]	[ "N390", "E871", "I5032", "K5900", "I4891", "I110", "J449", "I2510", "Z7901", "Z87891" ]	[ "N390: Urinary tract infection, site not specified", "K6812: Psoas muscle abscess", "M8008XA: Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture", "E871: Hypo-osmolality and hyponatremia", "I5032: Chronic diastolic (congestive) heart failure", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "K5900: Constipation, unspecified", "I4891: Unspecified atrial fibrillation", "R791: Abnormal coagulation profile", "E861: Hypovolemia", "E890: Postprocedural hypothyroidism", "I110: Hypertensive heart disease with heart failure", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "J449: Chronic obstructive pulmonary disease, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "H9190: Unspecified hearing loss, unspecified ear", "Z7982: Long term (current) use of aspirin", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence" ]
10,095,681	25,394,784	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: iodine strong / Morphine / potassium iodide Attending: ___ Chief Complaint: swollen legs, abdomen and face noted by family Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENTING ILLNESS: Ms. ___ is a ___ year-old ___ speaking female with history of HFpEF (EF 58%), CAD, atrial fibrillation (on Xarelto), HTN, COPD (not on home O2), and CVA while on warfarin (BI-N ___ who presents as a transfer from the ___ for weight gain, edema, and fatigue. Notably, she was recently admitted to the ___ heart failure service from ___ for dyspnea in the setting of an acute diastolic heart failure exacerbation, felt secondary to a reduction in her home diuretic dose vs. infection (found to have an E.coli UTI, completed treatment on ___. She received IV Lasix and was transitioned to PO Lasix 40mg daily (increased from 20mg daily) on discharge. Discharge weight ___ was 122.3lbs. On ___, patient's daughter ___ called in to report that the patient has been steadily gaining weight since ___. She reports a ___ lbs. weight gain with worsening lower extremity edema, abdominal distension, and fatigue. She has been compliant with her home Lasix. The patient was referred to the ___, at which time labs were notable for pro-BNP 1594, Na 127 (from 132 on discharge), INR 3.4. She she received IV Lasix 40mg x1 and was transferred to ___ 3. Upon arrival to ___ 3, patient is accompanied by her daughter, ___, who endorses the above history. She adds that they have been encouraging the patient to drink 2L of water daily, per the recommendations they were given on discharge. She has also been having soup and tea daily. Patient denies fevers, chills, chest pain, dyspnea, abdominal pain, nausea, vomiting, diarrhea, dysuria, or frequency. ___ feels the patient has had increased swelling in her abdomen, though the patient denies this. REVIEW OF SYSTEMS: 10-pt ROS reviewed; pertinent positives/negatives as above, otherwise negative Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS ___ DYSPNEA DIABETIC RETINOPATHY Social History: ___ Family History: mother - hx of afib, HTN, stomach cancer father - HTN, DM, CVA brother - hx of afib Physical Exam: ADMISSION PHYSICAL EXAM ========================= VS: 97.4 153/84 68 18 98 RA Dry weight: 122.3 lbs Admission weight: 154.3 lbs. GENERAL: Well-appearing elderly woman, laying in bed at 45 degree angle, in NAD HEENT: NC/AT, EOMI, PERRL, anicteric sclera, MMM, maxillary dentures present, no oropharyngeal erythema/exudate NECK: Supple, JVP 15cm CARDIAC: Irregularly irregular, normal S1/S2, no m/r/g LUNGS: Mildly tachypneic but breathing comfortably on RA without use of accessory mm. respiration, decreased breath sounds in bilateral bases, no wheezes or crackles ABDOMEN: Non-distended, active bowel sounds, soft, non-tender to palpation in all quadrants, no appreciable hepatosplenomegaly, mildly edematous abdominal wall EXTREMITIES: Warm, well-perfused, 2+ pitting edema in b/l lower extremities extending into mid thigh SKIN: No significant skin lesions or rashes PULSES: Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAM ========================= 24 HR Data (last updated ___ @ 805) Temp: 97.6 (Tm 98.4), BP: 124/58 (106-144/49-76), HR: 70 (63-73), RR: 17 (___), O2 sat: 97% (97-99), O2 delivery: Ra, Wt: 139.33 lb/63.2 kg GENERAL: Well-appearing elderly woman, laying in bed in NAD NECK: Supple, no JVD CARDIAC: Irregularly irregular, normal S1/S2, no m/r/g LUNGS: Breathing comfortably on RA without use of accessory mm. respiration, decreased breath sounds in bilateral bases, no wheezes or crackles ABDOMEN: Non-distended, active bowel sounds, soft, non-tender to palpation in all quadrants, no appreciable hepatosplenomegaly, mildly edematous abdominal wall EXTREMITIES: Warm, well-perfused, 1+ edema in b/l lower extremities to right above the ankle; eerythema on the R extremity is improved but now with a 4cm slightly movable nodular mass in the R medial thigh Pertinent Results: ADMISSION LABS: ======================= ___ 05:59PM URINE HOURS-RANDOM UREA N-133 CREAT-12 SODIUM-100 ___ 02:30PM LACTATE-1.1 ___ 01:38PM GLUCOSE-125 UREA N-23* CREAT-1.0 SODIUM-127* POTASSIUM-4.9 CHLORIDE-92* TOTAL CO2-23 ANION GAP-12 ___ 01:38PM estGFR-Using this ___ 01:38PM ALT(SGPT)-11 AST(SGOT)-17 ALK PHOS-114* TOT BILI-0.6 ___ 01:38PM cTropnT-<0.01 proBNP-1594* ___ 01:38PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-2.0 ___ 01:38PM WBC-7.4 RBC-3.46* HGB-9.5* HCT-30.1* MCV-87 MCH-27.5 MCHC-31.6* RDW-15.3 RDWSD-49.1* ___ 01:38PM NEUTS-75.3* LYMPHS-13.9* MONOS-9.4 EOS-0.4* BASOS-0.5 IM ___ AbsNeut-5.57 AbsLymp-1.03* AbsMono-0.70 AbsEos-0.03* AbsBaso-0.04 ___ 01:38PM PLT COUNT-276 ___ 01:38PM ___ PTT-43.8* ___ IMAGING ======================= UNILATERAL LOWER EXTREMITY ULTRASOUND ___ IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins DISCHARGE LABS: ======================= ___ 05:29AM BLOOD WBC-7.3 RBC-3.93 Hgb-10.8* Hct-33.5* MCV-85 MCH-27.5 MCHC-32.2 RDW-15.6* RDWSD-48.2* Plt ___ ___ 05:29AM BLOOD Plt ___ ___ 03:30PM BLOOD Glucose-116* UreaN-32* Creat-1.1 Na-135 K-4.0 Cl-95* HCO3-28 AnGap-12 ___ 03:30PM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0 Brief Hospital Course: PATIENT SUMMARY STATEMENT ====================================== Ms. ___ is a ___ year-old ___ speaking female with history of HFpEF (EF 58%), CAD, atrial fibrillation (on Xarelto), HTN, and CVA while on warfarin (BI-N ___ who presented as a transfer from the ___ for weight gain, edema, and fatigue concerning for acute diastolic HF exacerbation. # CORONARIES: Unknown # PUMP: EF 58% (___) # RHYTHM: Atrial fibrillation ACTIVE ISSUES: ============== # Acute diastolic heart failure exacerbation Patient brought in by family due to concern for ~20 lb weight gain. Per patient's daughter, her legs, abdomen and face were very edematous. Dry weight was reported as 122.6 lbs and weight on admission at 154.32 lbs. Her volume exam was inconsistent with this weight gain as she did not appear floridly overloaded. She had no JVD, no crackles other than lower extremity edema. Her pro-BNP on admission was 1594. She diuresed very well with 40mg Iv Lasix and was transitioned to Po torsemide at 30mg daily. Etiology of this exacerbation likely secondary to confusion regarding fluid restriction as family was reporting that they were encouring patient to drink at least 2L of fluids daily. Has otherwise been compliant with home diuretic dosing, though notably, may have inadequate absorption due to mild abdominal edema. There was no evidence of active infection, no chest pain/ECG changes to suggest ACS and Atrial fib with well-controlled rates. It was ultimately felt that patient may have a new dry weight as she appeared euvolemic on discharge. Her discharge weight was 139.33 lbs. She was discharged on torsemide 30mg QD, metoprolol 50mg XL BID, amlodipine 10mg daily and losartan 25mg daily. # RLE rash Patient had an erythematous patch on the RLE which improved overnight and now with a 4cm nodular mass in the area. Initially suspected cellulitis. However given improvement without antibiotics, no fever, leukocytosis and development of nodular lesion, suspected phlebitis. Lower extremity ultrasound was negative. Encouraged patient to apply warm compress to the area upon discharge. # Hyponatremia Patient presented with hyponatremia to 127. Etiology felt to be hypervolemic hyponatremia in setting of volume overload, as above. Her sodium improved with diuresis. She was also placed on a 2L fluid restriction. # Coagulopathy Elevated INR to 3.4 on arrival. Suspect nutritional component and pt also on xarelto which can affect INR. No evidence of active bleeding. INR was 2.4 on discharge. Patient sent home with ___ who will continue to check INR. CHRONIC ISSUES: ====================================== # Atrial fibrillation CHADS2-VASc 9 Continued home metoprolol fractionated to 25mg Q6h and home rivaroxaban 20mg qpm. # Hypertension Continued home amlodipine 10mg daily and losartan 25mg daily # CVA Admitted to BI-N in ___ with CVA while on warfarin. Transitioned to rivaroxaban at this time and ASA 81mg daily discontinued. # PAD # CAD Previously on ASA 81mg daily; discontinued upon initiation of rivaroxaban in ___. Continued home atorvastatin 20mg qpm and metoprolol as above. # Medullary thyroid carcinoma s/p thyroidectomy # Post-surgical hypothyroidism Continued home levothyroxine 112mcg daily. TRANSITIONAL ISSUES: ====================================== Cr: 1.1 INR: 2.4 Weight: 139.33 lb New meds ----------- -Torsemide 30mg QD Discontinued meds ----------- Lasix 40mg QD [] Discharged home with torsemide 30mg. Please repeat BMP within the week [] Suspect patient has new dry weight. Discharge weight was 139.33 lb and appeared euvolemic [] INR elevated on admission. Suspected nutritional and small contribution from ___. Going home with ___. Consider repeat INR in a week [] New RLE phlebitis. Please monitor for interval change. Lower extremity ultrasound was negative for DVT ====================================== #LANGUAGE: ___ #CODE STATUS: DNR/DNI, OK for BIPAP #CONTACT: ___ (Daughter) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 25 mg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. amLODIPine 10 mg PO DAILY 4. Rivaroxaban 20 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Furosemide 40 mg PO DAILY 7. Levothyroxine Sodium 112 mcg PO DAILY 8. Vitamin D 800 UNIT PO DAILY Discharge Medications: 1. Metoprolol Succinate XL 50 mg PO BID 2. Torsemide 30 mg PO DAILY 3. amLODIPine 10 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Levothyroxine Sodium 112 mcg PO DAILY 6. Losartan Potassium 25 mg PO DAILY 7. Rivaroxaban 20 mg PO DAILY 8. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute diastolic Heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you had a heart failure exacerbation. You family noticed that you had gained extra weight and your legs and face were puffier. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - We gave you IV diuretics - We discontinued your home Lasix and started you on a medication called torsemide. - We also noticed a rash on your right leg and a lump near the rash. We think this is due to inflammation in one of your blood vessels. Please put a warm compress to the area for 15 mins 3 times a day. WHAT SHOULD I DO WHEN I GO HOME? - You should continue to take your medications as prescribed. - You should attend the appointments listed below. - Weigh yourself every morning, call your doctor if your weight goes up more than 3 lbs. - Please do not take in more than 2L of fluids in a day. - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, or shortness of breath at night. - Your discharge weight: 139.33 lb. You should use this as your baseline after you leave the hospital. We wish you the best! Your ___ Care Team Followup Instructions: ___	[ "I110", "D688", "E871", "I5033", "I4891", "E890", "I2510", "E11319", "M810", "E1151", "R21", "J449", "F0390", "Z66", "Z85850", "Z7901", "Z8673" ]	Allergies: iodine strong / Morphine / potassium iodide Chief Complaint: swollen legs, abdomen and face noted by family Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENTING ILLNESS: Ms. [MASKED] is a [MASKED] year-old [MASKED] speaking female with history of HFpEF (EF 58%), CAD, atrial fibrillation (on Xarelto), HTN, COPD (not on home O2), and CVA while on warfarin (BI-N [MASKED] who presents as a transfer from the [MASKED] for weight gain, edema, and fatigue. Notably, she was recently admitted to the [MASKED] heart failure service from [MASKED] for dyspnea in the setting of an acute diastolic heart failure exacerbation, felt secondary to a reduction in her home diuretic dose vs. infection (found to have an E.coli UTI, completed treatment on [MASKED]. She received IV Lasix and was transitioned to PO Lasix 40mg daily (increased from 20mg daily) on discharge. Discharge weight [MASKED] was 122.3lbs. On [MASKED], patient's daughter [MASKED] called in to report that the patient has been steadily gaining weight since [MASKED]. She reports a [MASKED] lbs. weight gain with worsening lower extremity edema, abdominal distension, and fatigue. She has been compliant with her home Lasix. The patient was referred to the [MASKED], at which time labs were notable for pro-BNP 1594, Na 127 (from 132 on discharge), INR 3.4. She she received IV Lasix 40mg x1 and was transferred to [MASKED] 3. Upon arrival to [MASKED] 3, patient is accompanied by her daughter, [MASKED], who endorses the above history. She adds that they have been encouraging the patient to drink 2L of water daily, per the recommendations they were given on discharge. She has also been having soup and tea daily. Patient denies fevers, chills, chest pain, dyspnea, abdominal pain, nausea, vomiting, diarrhea, dysuria, or frequency. [MASKED] feels the patient has had increased swelling in her abdomen, though the patient denies this. REVIEW OF SYSTEMS: 10-pt ROS reviewed; pertinent positives/negatives as above, otherwise negative Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS [MASKED] DYSPNEA DIABETIC RETINOPATHY Social History: [MASKED] Family History: mother - hx of afib, HTN, stomach cancer father - HTN, DM, CVA brother - hx of afib Physical Exam: ADMISSION PHYSICAL EXAM ========================= VS: 97.4 153/84 68 18 98 RA Dry weight: 122.3 lbs Admission weight: 154.3 lbs. GENERAL: Well-appearing elderly woman, laying in bed at 45 degree angle, in NAD HEENT: NC/AT, EOMI, PERRL, anicteric sclera, MMM, maxillary dentures present, no oropharyngeal erythema/exudate NECK: Supple, JVP 15cm CARDIAC: Irregularly irregular, normal S1/S2, no m/r/g LUNGS: Mildly tachypneic but breathing comfortably on RA without use of accessory mm. respiration, decreased breath sounds in bilateral bases, no wheezes or crackles ABDOMEN: Non-distended, active bowel sounds, soft, non-tender to palpation in all quadrants, no appreciable hepatosplenomegaly, mildly edematous abdominal wall EXTREMITIES: Warm, well-perfused, 2+ pitting edema in b/l lower extremities extending into mid thigh SKIN: No significant skin lesions or rashes PULSES: Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAM ========================= 24 HR Data (last updated [MASKED] @ 805) Temp: 97.6 (Tm 98.4), BP: 124/58 (106-144/49-76), HR: 70 (63-73), RR: 17 ([MASKED]), O2 sat: 97% (97-99), O2 delivery: Ra, Wt: 139.33 lb/63.2 kg GENERAL: Well-appearing elderly woman, laying in bed in NAD NECK: Supple, no JVD CARDIAC: Irregularly irregular, normal S1/S2, no m/r/g LUNGS: Breathing comfortably on RA without use of accessory mm. respiration, decreased breath sounds in bilateral bases, no wheezes or crackles ABDOMEN: Non-distended, active bowel sounds, soft, non-tender to palpation in all quadrants, no appreciable hepatosplenomegaly, mildly edematous abdominal wall EXTREMITIES: Warm, well-perfused, 1+ edema in b/l lower extremities to right above the ankle; eerythema on the R extremity is improved but now with a 4cm slightly movable nodular mass in the R medial thigh Pertinent Results: ADMISSION LABS: ======================= [MASKED] 05:59PM URINE HOURS-RANDOM UREA N-133 CREAT-12 SODIUM-100 [MASKED] 02:30PM LACTATE-1.1 [MASKED] 01:38PM GLUCOSE-125 UREA N-23* CREAT-1.0 SODIUM-127* POTASSIUM-4.9 CHLORIDE-92* TOTAL CO2-23 ANION GAP-12 [MASKED] 01:38PM estGFR-Using this [MASKED] 01:38PM ALT(SGPT)-11 AST(SGOT)-17 ALK PHOS-114* TOT BILI-0.6 [MASKED] 01:38PM cTropnT-<0.01 proBNP-1594* [MASKED] 01:38PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-2.0 [MASKED] 01:38PM WBC-7.4 RBC-3.46* HGB-9.5* HCT-30.1* MCV-87 MCH-27.5 MCHC-31.6* RDW-15.3 RDWSD-49.1* [MASKED] 01:38PM NEUTS-75.3* LYMPHS-13.9* MONOS-9.4 EOS-0.4* BASOS-0.5 IM [MASKED] AbsNeut-5.57 AbsLymp-1.03* AbsMono-0.70 AbsEos-0.03* AbsBaso-0.04 [MASKED] 01:38PM PLT COUNT-276 [MASKED] 01:38PM [MASKED] PTT-43.8* [MASKED] IMAGING ======================= UNILATERAL LOWER EXTREMITY ULTRASOUND [MASKED] IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins DISCHARGE LABS: ======================= [MASKED] 05:29AM BLOOD WBC-7.3 RBC-3.93 Hgb-10.8* Hct-33.5* MCV-85 MCH-27.5 MCHC-32.2 RDW-15.6* RDWSD-48.2* Plt [MASKED] [MASKED] 05:29AM BLOOD Plt [MASKED] [MASKED] 03:30PM BLOOD Glucose-116* UreaN-32* Creat-1.1 Na-135 K-4.0 Cl-95* HCO3-28 AnGap-12 [MASKED] 03:30PM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0 Brief Hospital Course: PATIENT SUMMARY STATEMENT ====================================== Ms. [MASKED] is a [MASKED] year-old [MASKED] speaking female with history of HFpEF (EF 58%), CAD, atrial fibrillation (on Xarelto), HTN, and CVA while on warfarin (BI-N [MASKED] who presented as a transfer from the [MASKED] for weight gain, edema, and fatigue concerning for acute diastolic HF exacerbation. # CORONARIES: Unknown # PUMP: EF 58% ([MASKED]) # RHYTHM: Atrial fibrillation ACTIVE ISSUES: ============== # Acute diastolic heart failure exacerbation Patient brought in by family due to concern for ~20 lb weight gain. Per patient's daughter, her legs, abdomen and face were very edematous. Dry weight was reported as 122.6 lbs and weight on admission at 154.32 lbs. Her volume exam was inconsistent with this weight gain as she did not appear floridly overloaded. She had no JVD, no crackles other than lower extremity edema. Her pro-BNP on admission was 1594. She diuresed very well with 40mg Iv Lasix and was transitioned to Po torsemide at 30mg daily. Etiology of this exacerbation likely secondary to confusion regarding fluid restriction as family was reporting that they were encouring patient to drink at least 2L of fluids daily. Has otherwise been compliant with home diuretic dosing, though notably, may have inadequate absorption due to mild abdominal edema. There was no evidence of active infection, no chest pain/ECG changes to suggest ACS and Atrial fib with well-controlled rates. It was ultimately felt that patient may have a new dry weight as she appeared euvolemic on discharge. Her discharge weight was 139.33 lbs. She was discharged on torsemide 30mg QD, metoprolol 50mg XL BID, amlodipine 10mg daily and losartan 25mg daily. # RLE rash Patient had an erythematous patch on the RLE which improved overnight and now with a 4cm nodular mass in the area. Initially suspected cellulitis. However given improvement without antibiotics, no fever, leukocytosis and development of nodular lesion, suspected phlebitis. Lower extremity ultrasound was negative. Encouraged patient to apply warm compress to the area upon discharge. # Hyponatremia Patient presented with hyponatremia to 127. Etiology felt to be hypervolemic hyponatremia in setting of volume overload, as above. Her sodium improved with diuresis. She was also placed on a 2L fluid restriction. # Coagulopathy Elevated INR to 3.4 on arrival. Suspect nutritional component and pt also on xarelto which can affect INR. No evidence of active bleeding. INR was 2.4 on discharge. Patient sent home with [MASKED] who will continue to check INR. CHRONIC ISSUES: ====================================== # Atrial fibrillation CHADS2-VASc 9 Continued home metoprolol fractionated to 25mg Q6h and home rivaroxaban 20mg qpm. # Hypertension Continued home amlodipine 10mg daily and losartan 25mg daily # CVA Admitted to BI-N in [MASKED] with CVA while on warfarin. Transitioned to rivaroxaban at this time and ASA 81mg daily discontinued. # PAD # CAD Previously on ASA 81mg daily; discontinued upon initiation of rivaroxaban in [MASKED]. Continued home atorvastatin 20mg qpm and metoprolol as above. # Medullary thyroid carcinoma s/p thyroidectomy # Post-surgical hypothyroidism Continued home levothyroxine 112mcg daily. TRANSITIONAL ISSUES: ====================================== Cr: 1.1 INR: 2.4 Weight: 139.33 lb New meds ----------- -Torsemide 30mg QD Discontinued meds ----------- Lasix 40mg QD [] Discharged home with torsemide 30mg. Please repeat BMP within the week [] Suspect patient has new dry weight. Discharge weight was 139.33 lb and appeared euvolemic [] INR elevated on admission. Suspected nutritional and small contribution from [MASKED]. Going home with [MASKED]. Consider repeat INR in a week [] New RLE phlebitis. Please monitor for interval change. Lower extremity ultrasound was negative for DVT ====================================== #LANGUAGE: [MASKED] #CODE STATUS: DNR/DNI, OK for BIPAP #CONTACT: [MASKED] (Daughter) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 25 mg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. amLODIPine 10 mg PO DAILY 4. Rivaroxaban 20 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Furosemide 40 mg PO DAILY 7. Levothyroxine Sodium 112 mcg PO DAILY 8. Vitamin D 800 UNIT PO DAILY Discharge Medications: 1. Metoprolol Succinate XL 50 mg PO BID 2. Torsemide 30 mg PO DAILY 3. amLODIPine 10 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Levothyroxine Sodium 112 mcg PO DAILY 6. Losartan Potassium 25 mg PO DAILY 7. Rivaroxaban 20 mg PO DAILY 8. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Acute diastolic Heart failure 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] [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you had a heart failure exacerbation. You family noticed that you had gained extra weight and your legs and face were puffier. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - We gave you IV diuretics - We discontinued your home Lasix and started you on a medication called torsemide. - We also noticed a rash on your right leg and a lump near the rash. We think this is due to inflammation in one of your blood vessels. Please put a warm compress to the area for 15 mins 3 times a day. WHAT SHOULD I DO WHEN I GO HOME? - You should continue to take your medications as prescribed. - You should attend the appointments listed below. - Weigh yourself every morning, call your doctor if your weight goes up more than 3 lbs. - Please do not take in more than 2L of fluids in a day. - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, or shortness of breath at night. - Your discharge weight: 139.33 lb. You should use this as your baseline after you leave the hospital. We wish you the best! Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "I110", "E871", "I4891", "I2510", "J449", "Z66", "Z7901", "Z8673" ]	[ "I110: Hypertensive heart disease with heart failure", "D688: Other specified coagulation defects", "E871: Hypo-osmolality and hyponatremia", "I5033: Acute on chronic diastolic (congestive) heart failure", "I4891: Unspecified atrial fibrillation", "E890: Postprocedural hypothyroidism", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "M810: Age-related osteoporosis without current pathological fracture", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "R21: Rash and other nonspecific skin eruption", "J449: Chronic obstructive pulmonary disease, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "Z66: Do not resuscitate", "Z85850: Personal history of malignant neoplasm of thyroid", "Z7901: Long term (current) use of anticoagulants", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]
10,095,681	26,415,777	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: iodine strong / Morphine / potassium iodide Attending: ___. Chief Complaint: dyspnea and leg swelling Major Surgical or Invasive Procedure: none History of Present Illness: ___ ___ female with history of HFpEF, COPD, A. fib on xarelto, recent CVA, dementia, hypertension, hypothyroidism, prior subarachnoid hemorrhage, who presents with increasing shortness of breath. History obtained from daughter ___ by phone. They noted bilateral leg swelling and left hand swelling starting yesterday, which worsened today. The day of presentation she also found the patient to appear much more short of breath than usual, tachypneic. She called EMS and pt was brought in to ED. Of note, patient's Lasix dosing was recently decreased, though daughter is unclear on the details of this as her sister usually manages the patient's medications. Per OMR, she was seen by PCP ___ ___ and Lasix 20 daily was decreased to once weekly iso hypovolemic Hyponatremia. Per ED report family had been holding Lasix for the past month because they were unclear on the dosing. No recent f/c, CP, cough, sputum, abd pain, N/V, report of dysuria. In the ED initial vitals were: 98.3, 80, 170/74, 36, 97% RA - patient triggered for tachypnea was breathing in the ___ Labs/studies notable for: 10.0 10.3 232 >-----< 33.2 127 94 19 129 AGap=13 ------------< 5.0 20 0.9 Trop-T: <0.01 proBNP: 1675 VBG 7.36 / 44 INR: 2.2 UA with large leuk, pos nitrite, WBC >182, mod bacteria LUE Doppler: negative CXR: Lungs are clear. There is moderate cardiomegaly. There is a small left pleural effusion. No pneumothorax. EKG: afib, rate 97 Patient was given: - SL Nitroglycerin SL .4 mg, then started on IV nitro gtt - IV Furosemide 40 mg - IV CefTRIAXone 1 g - PO Rivaroxaban 20 mg Vitals on transfer: 73, 122/71, 18, 95% 2L NC On the floor, patient is pleasant but confused. AAOX3, but speaking to interpreter on the phone as though the interpreter is her daughter. She denies any current SOB, CP, or pain anywhere else, no urinary symptoms. Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS ___ DYSPNEA DIABETIC RETINOPATHY Social History: ___ Family History: mother - hx of afib, HTN, stomach cancer father - HTN, DM, CVA brother - hx of afib Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VS: ___ Temp: 98.3 PO BP: 158/71 HR: 83 RR: 20 O2 sat: 98% O2 delivery: 2 L GENERAL: Well developed elderly woman in NAD. AAOX3, confused and talking to interpreter on phone as thought she were her daughter. ___ atraumatic. Sclera anicteric. PERRL. EOMI. NECK: pt not cooperating with JVP exam, possible mid neck at 45 deg CARDIAC: sounding regular. Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use, on 2L NC. bibasilar crackles R>L on anterior exam. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. 1+ ___ bilaterally. slight LUE soft tissue edema compared to RUE. SKIN: scattered ecchymosis DISCHARGE PHYSICAL EXAM: ====================== 24 HR Data (last updated ___ @ 1450) Temp: 97.7 (Tm 98.2), BP: 130/54 (108-144/54-67), HR: 77 (56-77), RR: 18 (___), O2 sat: 99% (94-99), O2 delivery: RA, Wt: 122.3 lb/55.48 kg (122.3-140.43) GENERAL: Well developed elderly woman in NAD. confused intermittently. ___: Sclera anicteric. PERRL. EOMI. NECK: JVP not elevated CARDIAC: RRR. Normal S1, S2. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. CTAB. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. trace to 1+ edema in bilateral lower extremities. SKIN: scattered ecchymosis Pertinent Results: ADMISSION LABS: ============= ___ 01:00PM NEUTS-73.4 LYMPHS-14.6* MONOS-10.9 EOS-0.4* BASOS-0.3 IM ___ AbsNeut-7.31* AbsLymp-1.45 AbsMono-1.08* AbsEos-0.04 AbsBaso-0.03 ___ 01:00PM WBC-10.0 RBC-3.74* HGB-10.3* HCT-33.2* MCV-89 MCH-27.5 MCHC-31.0* RDW-15.1 RDWSD-49.2* ___ 01:00PM CALCIUM-8.9 PHOSPHATE-3.1 MAGNESIUM-2.0 ___ 01:00PM proBNP-1675* ___ 01:00PM cTropnT-<0.01 ___ 01:00PM GLUCOSE-129* UREA N-19 CREAT-0.9 SODIUM-127* POTASSIUM-5.0 CHLORIDE-94* TOTAL CO2-20* ANION GAP-13 ___ 02:00PM URINE BLOOD-SM* NITRITE-POS* PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG* MICROBIO: ======== URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING: ======= No evidence of deep vein thrombosis in the left upper extremity. Lungs are clear. There is moderate cardiomegaly. There is a small left pleural effusion. No pneumothorax. DISCHARGE LABS: ============= ___ 08:22AM BLOOD WBC-9.0 RBC-3.93 Hgb-10.7* Hct-34.0 MCV-87 MCH-27.2 MCHC-31.5* RDW-15.0 RDWSD-47.7* Plt ___ ___ 08:22AM BLOOD Glucose-89 UreaN-25* Creat-0.8 Na-132* K-4.3 Cl-94* HCO3-24 AnGap-14 ___ 07:57AM BLOOD ALT-10 AST-13 AlkPhos-103 TotBili-0.7 ___ 08:22AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.___ ___ female with history of HFpEF, COPD, A. fib on xarelto, recent CVA ___, dementia, hypertension, hypothyroidism, prior subarachnoid hemorrhage, who presented with increasing shortness of breath consistent with an acute on chronic diastolic heart failure exacerbation. TRANSITIONAL ISSUES: ================== [] Patient presented with volume overload. She will be discharged on 40mg PO furosemide daily. Please monitor the patient's volume status. [] The patient's dry weight is likely ~120lbs. [] Amlodipine was increased to 10mg daily. Please reassess PRN. [] Patient had an E. coli UTI on admission. She was treated with ceftriaxone and then changed to nitrofurantoin on discharge to complete a total of 6 days of treatment. =============== ACTIVE ISSUES: =============== # HFpEF Presented with lower extremity edema and dyspnea. Appeared overloaded on exam, also has elevated BNP. Trigger of exacerbation likely underdiuresis at home, with recent change in Lasix regimen and family may have been holding the Lasix. Also possible infection as below. S/p IV Lasix x 2 with adequate output. She was transitioned to 40mg PO furosemide daily. This may require adjustment based on her PO intake and weight trends over time. # Hypertension The patient required a nitroglycerine drip in ED initially for elevated BPs. She was transitioned to home antihypertensives: amlodipine 5mg , losartan 25mg. Hydralazine 10mg TID was also added to help reduce BP further, but was stopped in favor of increasing amlodipine to 10mg daily. # UTI growing E coli Pt denies urinary symptoms though poor historian. UA concerning for infection. Given unreliable history and concurrent CHF exacerbation, she was treated with ceftriaxone ___. The culture came back as E. coli sensitive to ceftriaxone and nitrofurantoin. She was narrowed to nitrofurantoin on discharge. # Hyponatremia Patient was mildly hyponatremic to 127 on admission, but uptrended to 132. She has intermittently had hyponatremia in the past, most recently attributed to some overdiuresis with Lasix use. On presentation she was volume up and hyponatremic, possibly reflecting hypervolemic hyponatremia. Urine lytes were consistent with SIADH. She should be maintained on a 2 liter fluid restriction. ================ CHRONIC ISSUES: ================ # recent CVA Admitted to ___ in ___ with CVA despite anticoagulation with warfarin at the time. Transitioned to rivaroxaban. She continued rivaroxaban 20mg daily. # history of subarachnoid hemorrhage Suffered fall in ___ c/b SAH, subsequently stopped taking warfarin. F/u CT head showed no acute hemorrhage and she was restarted on warfarin subsequently stopped as above. She should continue rivaroxaban 20mg daily for AC. # CAD - Patient's metoprolol succinate 50mg BID was fractionated to tartrate 25mg Q6H while admitted and then resumed on discharge - recently D/C'd ASA when initiated on rivaroxaban # Afib - continue rivaroxaban 20mg daily. - Patient's metoprolol succinate 50mg BID was fractionated to tartrate 25mg Q6H while admitted and then resumed on discharge # HTN - continue amlodipine 5, losartan 25. She was started on hydralazine 10mg TID in the hospital, but was stopped in favor of increasing amlodipine to 10mg daily. # Hypothyroidism s/p thyroidectomy in ___ (papillary thyroid microcarcinoma) - She continued home levothyroxine. # LANGUAGE: ___ # CODE STATUS: DNR/DNI, OK for BIPAP # CONTACT: ___: Daughter Phone number: ___ Cell phone: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Furosemide 20 mg PO DAILY 4. Levothyroxine Sodium 112 mcg PO DAILY 5. Losartan Potassium 25 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO BID 7. Rivaroxaban 20 mg PO DAILY Discharge Medications: 1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO BID Duration: 2 Days RX nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth twice a day Disp #4 Capsule Refills:0 2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line RX polyethylene glycol 3350 17 gram 1 packet(s) by mouth once a day Disp #30 Packet Refills:0 3. amLODIPine 10 mg PO DAILY RX amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. Furosemide 40 mg PO DAILY RX furosemide 40 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 5. Atorvastatin 20 mg PO QPM 6. Levothyroxine Sodium 112 mcg PO DAILY 7. Losartan Potassium 25 mg PO DAILY 8. Metoprolol Succinate XL 50 mg PO BID 9. Rivaroxaban 20 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS acute on chronic diastolic heart failure hyponatremia SECONDARY DIAGNOSES urinary tract infection hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were admitted to the hospital because you were having trouble breathing and your legs were swollen. WHAT HAPPENED TO ME IN THE HOSPITAL? - In the hospital we gave you diuretic medicine to remove the extra fluid in your body. This makes it easier for your heart to pump efficiently. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Weigh yourself every morning, call MD if weight goes up more than 3 pounds or down by more than 5 pounds. - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___	[ "I110", "N390", "E871", "I5033", "I4891", "Z7901", "F0390", "J449", "E890", "Z8673", "Z85850", "Z66", "B9620", "T501X6A", "Y92009" ]	Allergies: iodine strong / Morphine / potassium iodide Chief Complaint: dyspnea and leg swelling Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] [MASKED] female with history of HFpEF, COPD, A. fib on xarelto, recent CVA, dementia, hypertension, hypothyroidism, prior subarachnoid hemorrhage, who presents with increasing shortness of breath. History obtained from daughter [MASKED] by phone. They noted bilateral leg swelling and left hand swelling starting yesterday, which worsened today. The day of presentation she also found the patient to appear much more short of breath than usual, tachypneic. She called EMS and pt was brought in to ED. Of note, patient's Lasix dosing was recently decreased, though daughter is unclear on the details of this as her sister usually manages the patient's medications. Per OMR, she was seen by PCP [MASKED] [MASKED] and Lasix 20 daily was decreased to once weekly iso hypovolemic Hyponatremia. Per ED report family had been holding Lasix for the past month because they were unclear on the dosing. No recent f/c, CP, cough, sputum, abd pain, N/V, report of dysuria. In the ED initial vitals were: 98.3, 80, 170/74, 36, 97% RA - patient triggered for tachypnea was breathing in the [MASKED] Labs/studies notable for: 10.0 10.3 232 >-----< 33.2 127 94 19 129 AGap=13 ------------< 5.0 20 0.9 Trop-T: <0.01 proBNP: 1675 VBG 7.36 / 44 INR: 2.2 UA with large leuk, pos nitrite, WBC >182, mod bacteria LUE Doppler: negative CXR: Lungs are clear. There is moderate cardiomegaly. There is a small left pleural effusion. No pneumothorax. EKG: afib, rate 97 Patient was given: - SL Nitroglycerin SL .4 mg, then started on IV nitro gtt - IV Furosemide 40 mg - IV CefTRIAXone 1 g - PO Rivaroxaban 20 mg Vitals on transfer: 73, 122/71, 18, 95% 2L NC On the floor, patient is pleasant but confused. AAOX3, but speaking to interpreter on the phone as though the interpreter is her daughter. She denies any current SOB, CP, or pain anywhere else, no urinary symptoms. Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS [MASKED] DYSPNEA DIABETIC RETINOPATHY Social History: [MASKED] Family History: mother - hx of afib, HTN, stomach cancer father - HTN, DM, CVA brother - hx of afib Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VS: [MASKED] Temp: 98.3 PO BP: 158/71 HR: 83 RR: 20 O2 sat: 98% O2 delivery: 2 L GENERAL: Well developed elderly woman in NAD. AAOX3, confused and talking to interpreter on phone as thought she were her daughter. [MASKED] atraumatic. Sclera anicteric. PERRL. EOMI. NECK: pt not cooperating with JVP exam, possible mid neck at 45 deg CARDIAC: sounding regular. Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use, on 2L NC. bibasilar crackles R>L on anterior exam. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. 1+ [MASKED] bilaterally. slight LUE soft tissue edema compared to RUE. SKIN: scattered ecchymosis DISCHARGE PHYSICAL EXAM: ====================== 24 HR Data (last updated [MASKED] @ 1450) Temp: 97.7 (Tm 98.2), BP: 130/54 (108-144/54-67), HR: 77 (56-77), RR: 18 ([MASKED]), O2 sat: 99% (94-99), O2 delivery: RA, Wt: 122.3 lb/55.48 kg (122.3-140.43) GENERAL: Well developed elderly woman in NAD. confused intermittently. [MASKED]: Sclera anicteric. PERRL. EOMI. NECK: JVP not elevated CARDIAC: RRR. Normal S1, S2. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. CTAB. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. trace to 1+ edema in bilateral lower extremities. SKIN: scattered ecchymosis Pertinent Results: ADMISSION LABS: ============= [MASKED] 01:00PM NEUTS-73.4 LYMPHS-14.6* MONOS-10.9 EOS-0.4* BASOS-0.3 IM [MASKED] AbsNeut-7.31* AbsLymp-1.45 AbsMono-1.08* AbsEos-0.04 AbsBaso-0.03 [MASKED] 01:00PM WBC-10.0 RBC-3.74* HGB-10.3* HCT-33.2* MCV-89 MCH-27.5 MCHC-31.0* RDW-15.1 RDWSD-49.2* [MASKED] 01:00PM CALCIUM-8.9 PHOSPHATE-3.1 MAGNESIUM-2.0 [MASKED] 01:00PM proBNP-1675* [MASKED] 01:00PM cTropnT-<0.01 [MASKED] 01:00PM GLUCOSE-129* UREA N-19 CREAT-0.9 SODIUM-127* POTASSIUM-5.0 CHLORIDE-94* TOTAL CO2-20* ANION GAP-13 [MASKED] 02:00PM URINE BLOOD-SM* NITRITE-POS* PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG* MICROBIO: ======== URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING: ======= No evidence of deep vein thrombosis in the left upper extremity. Lungs are clear. There is moderate cardiomegaly. There is a small left pleural effusion. No pneumothorax. DISCHARGE LABS: ============= [MASKED] 08:22AM BLOOD WBC-9.0 RBC-3.93 Hgb-10.7* Hct-34.0 MCV-87 MCH-27.2 MCHC-31.5* RDW-15.0 RDWSD-47.7* Plt [MASKED] [MASKED] 08:22AM BLOOD Glucose-89 UreaN-25* Creat-0.8 Na-132* K-4.3 Cl-94* HCO3-24 AnGap-14 [MASKED] 07:57AM BLOOD ALT-10 AST-13 AlkPhos-103 TotBili-0.7 [MASKED] 08:22AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.[MASKED] [MASKED] female with history of HFpEF, COPD, A. fib on xarelto, recent CVA [MASKED], dementia, hypertension, hypothyroidism, prior subarachnoid hemorrhage, who presented with increasing shortness of breath consistent with an acute on chronic diastolic heart failure exacerbation. TRANSITIONAL ISSUES: ================== [] Patient presented with volume overload. She will be discharged on 40mg PO furosemide daily. Please monitor the patient's volume status. [] The patient's dry weight is likely ~120lbs. [] Amlodipine was increased to 10mg daily. Please reassess PRN. [] Patient had an E. coli UTI on admission. She was treated with ceftriaxone and then changed to nitrofurantoin on discharge to complete a total of 6 days of treatment. =============== ACTIVE ISSUES: =============== # HFpEF Presented with lower extremity edema and dyspnea. Appeared overloaded on exam, also has elevated BNP. Trigger of exacerbation likely underdiuresis at home, with recent change in Lasix regimen and family may have been holding the Lasix. Also possible infection as below. S/p IV Lasix x 2 with adequate output. She was transitioned to 40mg PO furosemide daily. This may require adjustment based on her PO intake and weight trends over time. # Hypertension The patient required a nitroglycerine drip in ED initially for elevated BPs. She was transitioned to home antihypertensives: amlodipine 5mg , losartan 25mg. Hydralazine 10mg TID was also added to help reduce BP further, but was stopped in favor of increasing amlodipine to 10mg daily. # UTI growing E coli Pt denies urinary symptoms though poor historian. UA concerning for infection. Given unreliable history and concurrent CHF exacerbation, she was treated with ceftriaxone [MASKED]. The culture came back as E. coli sensitive to ceftriaxone and nitrofurantoin. She was narrowed to nitrofurantoin on discharge. # Hyponatremia Patient was mildly hyponatremic to 127 on admission, but uptrended to 132. She has intermittently had hyponatremia in the past, most recently attributed to some overdiuresis with Lasix use. On presentation she was volume up and hyponatremic, possibly reflecting hypervolemic hyponatremia. Urine lytes were consistent with SIADH. She should be maintained on a 2 liter fluid restriction. ================ CHRONIC ISSUES: ================ # recent CVA Admitted to [MASKED] in [MASKED] with CVA despite anticoagulation with warfarin at the time. Transitioned to rivaroxaban. She continued rivaroxaban 20mg daily. # history of subarachnoid hemorrhage Suffered fall in [MASKED] c/b SAH, subsequently stopped taking warfarin. F/u CT head showed no acute hemorrhage and she was restarted on warfarin subsequently stopped as above. She should continue rivaroxaban 20mg daily for AC. # CAD - Patient's metoprolol succinate 50mg BID was fractionated to tartrate 25mg Q6H while admitted and then resumed on discharge - recently D/C'd ASA when initiated on rivaroxaban # Afib - continue rivaroxaban 20mg daily. - Patient's metoprolol succinate 50mg BID was fractionated to tartrate 25mg Q6H while admitted and then resumed on discharge # HTN - continue amlodipine 5, losartan 25. She was started on hydralazine 10mg TID in the hospital, but was stopped in favor of increasing amlodipine to 10mg daily. # Hypothyroidism s/p thyroidectomy in [MASKED] (papillary thyroid microcarcinoma) - She continued home levothyroxine. # LANGUAGE: [MASKED] # CODE STATUS: DNR/DNI, OK for BIPAP # CONTACT: [MASKED]: Daughter Phone number: [MASKED] Cell phone: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Furosemide 20 mg PO DAILY 4. Levothyroxine Sodium 112 mcg PO DAILY 5. Losartan Potassium 25 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO BID 7. Rivaroxaban 20 mg PO DAILY Discharge Medications: 1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO BID Duration: 2 Days RX nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth twice a day Disp #4 Capsule Refills:0 2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line RX polyethylene glycol 3350 17 gram 1 packet(s) by mouth once a day Disp #30 Packet Refills:0 3. amLODIPine 10 mg PO DAILY RX amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. Furosemide 40 mg PO DAILY RX furosemide 40 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 5. Atorvastatin 20 mg PO QPM 6. Levothyroxine Sodium 112 mcg PO DAILY 7. Losartan Potassium 25 mg PO DAILY 8. Metoprolol Succinate XL 50 mg PO BID 9. Rivaroxaban 20 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS acute on chronic diastolic heart failure hyponatremia SECONDARY DIAGNOSES urinary tract infection hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear [MASKED], It was a privilege caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? - You were admitted to the hospital because you were having trouble breathing and your legs were swollen. WHAT HAPPENED TO ME IN THE HOSPITAL? - In the hospital we gave you diuretic medicine to remove the extra fluid in your body. This makes it easier for your heart to pump efficiently. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Weigh yourself every morning, call MD if weight goes up more than 3 pounds or down by more than 5 pounds. - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "I110", "N390", "E871", "I4891", "Z7901", "J449", "Z8673", "Z66" ]	[ "I110: Hypertensive heart disease with heart failure", "N390: Urinary tract infection, site not specified", "E871: Hypo-osmolality and hyponatremia", "I5033: Acute on chronic diastolic (congestive) heart failure", "I4891: Unspecified atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "F0390: Unspecified dementia without behavioral disturbance", "J449: Chronic obstructive pulmonary disease, unspecified", "E890: Postprocedural hypothyroidism", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z85850: Personal history of malignant neoplasm of thyroid", "Z66: Do not resuscitate", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "T501X6A: Underdosing of loop [high-ceiling] diuretics, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]
10,095,681	27,503,137	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: iodine strong / Morphine / potassium iodide Attending: ___. Chief Complaint: Leg Pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ female with history of atrial fibrillation who was taken off her anticoagulation in the setting of developing a ___ s/p fall last year who then presented with acute left leg ischemia and underwent left cutdown, femoral/popliteal embolectomy on ___ ___. Her post-operative course was uncomplicated and she was discharged to rehab on ___. She was seen in clinic on ___ ___ noted to be doing well without complaints. She was discharged home from rehab yesterday and is brought into the ER today by her caregiver at her daughter's request. Per the daughter, the patient has been reporting posterior left calf pain with walking since being discharged from the hospital. The pain has been stable. The patient denies current pain at the time of evaluation but is unable to provide any further history. Per her caregiver, she has been otherwise doing well and is ambulating without difficulty. Denies fevers or chills. She has been taking her coumadin daily at rehab but did not take it today. Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS ___ DYSPNEA DIABETIC RETINOPATHY Social History: ___ Family History: mother - hx of afib, HTN, stomach cancer father - HTN, DM brother - hx of afib Physical Exam: Gen: NAD, Alert, responsive and conversant HEENT: no neck masses, no cervical LAD< Pulm: unlabored breathing, normal chest excursion CV: irregularly irregular Abd: soft, non-tender, no masses Ext: feet warm bilaterally, lateral deviation of LLE digits, intact LLE sensation bilateral ___ Pulse exam: R: P/P/P/D L:P/D/D(monophasic)/D (monophasic) Pertinent Results: ___ 07:15AM BLOOD WBC-5.6 RBC-3.34 Hgb-9.9* Hct-31.2* MCV-93 MCH-29.6 MCHC-31.7* RDW-15.4 RDWSD-52.5* Plt ___ ___ 06:55AM BLOOD WBC-6.3 RBC-3.34* Hgb-9.9* Hct-30.8* MCV-92 MCH-29.6 MCHC-32.1 RDW-15.5 RDWSD-52.6* Plt ___ ___ 01:50AM BLOOD WBC-6.6 RBC-3.23* Hgb-9.5* Hct-29.6* MCV-92 MCH-29.4 MCHC-32.1 RDW-15.4 RDWSD-51.8* Plt ___ ___ 09:50AM BLOOD WBC-5.8 RBC-3.30* Hgb-9.6* Hct-30.5* MCV-92 MCH-29.1 MCHC-31.5* RDW-15.5 RDWSD-53.2* Plt ___ ___ 02:10PM BLOOD WBC-7.1 RBC-3.31* Hgb-9.9* Hct-30.9* MCV-93 MCH-29.9 MCHC-32.0 RDW-15.8* RDWSD-54.1* Plt ___ ___ 07:15AM BLOOD Plt ___ ___ 07:15AM BLOOD ___ ___ 06:55AM BLOOD ___ PTT-30.4 ___ ___ 09:50AM BLOOD ___ PTT-117.7* ___ ___ 05:29PM URINE Blood-SM* Nitrite-POS* Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG* Brief Hospital Course: ___ hx afib recently underwent femoral/popliteal embolectomy ___ acute limb ischemia, and now presented this admission with subacute left leg pain, subtherapeutic INR. She was managed non-operatively with anticoagulation. She was started on a heparin drip and titrated to a goal of 60-90. She was restarted on Coumadin with INR goal of ___. She was switched from heparin drip to lovenox to bridge her Coumadin. Her discharge INR was 1.4. She will continue daily dosing of warfarin 5mg, with a 90mg lovenox bridge until warfarin is therapeutic. Outpatient Coumadin management for her is being done the ___ clinic here at ___. She was also noted to have urinary frequency and UA was positive. She was started on Bactrim and will complete a 5 day course of cefpodixime on discharge. She was evaluated by physical therapy while admitted. She was deemed her okay to discharge home given she was ambulating at baseline levels, and the level of support (24hour caretaker) she has at home. She was discharged home with ___ services on ___. ___ will administer her lovenox 90mg once daily dosing, and draw INR labs as required. She will follow up with ___ clinic for outpatient warfarin management. These instructions were conveyed to patient and daughter who verbalized understanding. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Senna 17.2 mg PO QHS 3. Warfarin 5 mg PO DAILY 4. Alendronate Sodium 70 mg PO 1X/WEEK (FR) 5. Losartan Potassium 25 mg PO BID 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Furosemide 20 mg PO DAILY 8. Levothyroxine Sodium 88 mcg PO DAILY 9. amLODIPine 5 mg PO DAILY 10. Enoxaparin Sodium 60 mg SC Q12H Start: Tomorrow - ___, First Dose: First Routine Administration Time 11. Docusate Sodium 100 mg PO BID 12. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 5 Days RX cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #10 Tablet Refills:0 2. Enoxaparin Sodium 90 mg SC Q24H Start: Tomorrow - ___, First Dose: First Routine Administration Time Please administer 1st dose within 24 hours of last dose. RX enoxaparin [Lovenox] ___ mg/mL 90 MG sc Q24H Disp #21 Syringe Refills:0 3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 4. Alendronate Sodium 70 mg PO 1X/WEEK (FR) 5. amLODIPine 5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Furosemide 20 mg PO DAILY 9. Levothyroxine Sodium 88 mcg PO DAILY 10. Losartan Potassium 25 mg PO BID 11. Metoprolol Succinate XL 50 mg PO DAILY 12. Senna 17.2 mg PO QHS 13. Warfarin 5 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: - leg pain likely secondary to Left femoral arterial thrombus - urinary tract infection Discharge Condition: Mental Status: coherent most times Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - at baseline level. Discharge Instructions: Dear ___, ___ were admitted for persistent subacute leg pain and urinary tract infection. ___ were treated with anti-coagulation and antibiotics. ___ will need to remain on anticoagulation going forward. Medications: 1. ___ will continue to take warfarin. ___ are being discharged home on 5mg Coumadin daily. Take as recommended. Follow up with your ___ clinic for adjustments to your Coumadin levels as appriopriate 2. Because your Coumadin level (measured with INR) is still not at goal, ___ are being discharged home on lovenox 90mg once daily. This will be administered by visiting nurses that will come to your house. 3. ___ will complete a 5 day course of antibiotics for Urinary tract infection that ___ were found to have. 4. Except told otherwise, please resume other medications ___ were on ACTIVITY: - we encourage ___ to get out of bed, walk and be as active as ___ can tolerate. Followup Instructions: ___	[ "I743", "N390", "J449", "I4891", "F0390", "Z7901", "I10", "E890", "M8580", "F329" ]	Allergies: iodine strong / Morphine / potassium iodide Chief Complaint: Leg Pain Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] female with history of atrial fibrillation who was taken off her anticoagulation in the setting of developing a [MASKED] s/p fall last year who then presented with acute left leg ischemia and underwent left cutdown, femoral/popliteal embolectomy on [MASKED] [MASKED]. Her post-operative course was uncomplicated and she was discharged to rehab on [MASKED]. She was seen in clinic on [MASKED] [MASKED] noted to be doing well without complaints. She was discharged home from rehab yesterday and is brought into the ER today by her caregiver at her daughter's request. Per the daughter, the patient has been reporting posterior left calf pain with walking since being discharged from the hospital. The pain has been stable. The patient denies current pain at the time of evaluation but is unable to provide any further history. Per her caregiver, she has been otherwise doing well and is ambulating without difficulty. Denies fevers or chills. She has been taking her coumadin daily at rehab but did not take it today. Past Medical History: DEMENTIA S/P ORIF RIGHT HIP ANEMIA APPENDECTOMY ATRIAL FIBRILLATION ON COUMADIN CHOLECYSTECTOMY CHRONIC OBSTRUCTIVE PULMONARY DISEASE HEADACHES HYPERTENSION HYPOTHYROIDISM s/p subtotal thyroidectomy HYSTERECTOMY INSOMNIA OSTEOPENIA URINARY INCONTINENCE CMC JOINT OSTEOARTHRITIS DEPRESSION VITAMIN D DEFICIENCY URINARY FREQUENCY HEARING LOSS [MASKED] DYSPNEA DIABETIC RETINOPATHY Social History: [MASKED] Family History: mother - hx of afib, HTN, stomach cancer father - HTN, DM brother - hx of afib Physical Exam: Gen: NAD, Alert, responsive and conversant HEENT: no neck masses, no cervical LAD< Pulm: unlabored breathing, normal chest excursion CV: irregularly irregular Abd: soft, non-tender, no masses Ext: feet warm bilaterally, lateral deviation of LLE digits, intact LLE sensation bilateral [MASKED] Pulse exam: R: P/P/P/D L:P/D/D(monophasic)/D (monophasic) Pertinent Results: [MASKED] 07:15AM BLOOD WBC-5.6 RBC-3.34 Hgb-9.9* Hct-31.2* MCV-93 MCH-29.6 MCHC-31.7* RDW-15.4 RDWSD-52.5* Plt [MASKED] [MASKED] 06:55AM BLOOD WBC-6.3 RBC-3.34* Hgb-9.9* Hct-30.8* MCV-92 MCH-29.6 MCHC-32.1 RDW-15.5 RDWSD-52.6* Plt [MASKED] [MASKED] 01:50AM BLOOD WBC-6.6 RBC-3.23* Hgb-9.5* Hct-29.6* MCV-92 MCH-29.4 MCHC-32.1 RDW-15.4 RDWSD-51.8* Plt [MASKED] [MASKED] 09:50AM BLOOD WBC-5.8 RBC-3.30* Hgb-9.6* Hct-30.5* MCV-92 MCH-29.1 MCHC-31.5* RDW-15.5 RDWSD-53.2* Plt [MASKED] [MASKED] 02:10PM BLOOD WBC-7.1 RBC-3.31* Hgb-9.9* Hct-30.9* MCV-93 MCH-29.9 MCHC-32.0 RDW-15.8* RDWSD-54.1* Plt [MASKED] [MASKED] 07:15AM BLOOD Plt [MASKED] [MASKED] 07:15AM BLOOD [MASKED] [MASKED] 06:55AM BLOOD [MASKED] PTT-30.4 [MASKED] [MASKED] 09:50AM BLOOD [MASKED] PTT-117.7* [MASKED] [MASKED] 05:29PM URINE Blood-SM* Nitrite-POS* Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG* Brief Hospital Course: [MASKED] hx afib recently underwent femoral/popliteal embolectomy [MASKED] acute limb ischemia, and now presented this admission with subacute left leg pain, subtherapeutic INR. She was managed non-operatively with anticoagulation. She was started on a heparin drip and titrated to a goal of 60-90. She was restarted on Coumadin with INR goal of [MASKED]. She was switched from heparin drip to lovenox to bridge her Coumadin. Her discharge INR was 1.4. She will continue daily dosing of warfarin 5mg, with a 90mg lovenox bridge until warfarin is therapeutic. Outpatient Coumadin management for her is being done the [MASKED] clinic here at [MASKED]. She was also noted to have urinary frequency and UA was positive. She was started on Bactrim and will complete a 5 day course of cefpodixime on discharge. She was evaluated by physical therapy while admitted. She was deemed her okay to discharge home given she was ambulating at baseline levels, and the level of support (24hour caretaker) she has at home. She was discharged home with [MASKED] services on [MASKED]. [MASKED] will administer her lovenox 90mg once daily dosing, and draw INR labs as required. She will follow up with [MASKED] clinic for outpatient warfarin management. These instructions were conveyed to patient and daughter who verbalized understanding. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Senna 17.2 mg PO QHS 3. Warfarin 5 mg PO DAILY 4. Alendronate Sodium 70 mg PO 1X/WEEK (FR) 5. Losartan Potassium 25 mg PO BID 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Furosemide 20 mg PO DAILY 8. Levothyroxine Sodium 88 mcg PO DAILY 9. amLODIPine 5 mg PO DAILY 10. Enoxaparin Sodium 60 mg SC Q12H Start: Tomorrow - [MASKED], First Dose: First Routine Administration Time 11. Docusate Sodium 100 mg PO BID 12. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 5 Days RX cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #10 Tablet Refills:0 2. Enoxaparin Sodium 90 mg SC Q24H Start: Tomorrow - [MASKED], First Dose: First Routine Administration Time Please administer 1st dose within 24 hours of last dose. RX enoxaparin [Lovenox] [MASKED] mg/mL 90 MG sc Q24H Disp #21 Syringe Refills:0 3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 4. Alendronate Sodium 70 mg PO 1X/WEEK (FR) 5. amLODIPine 5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Furosemide 20 mg PO DAILY 9. Levothyroxine Sodium 88 mcg PO DAILY 10. Losartan Potassium 25 mg PO BID 11. Metoprolol Succinate XL 50 mg PO DAILY 12. Senna 17.2 mg PO QHS 13. Warfarin 5 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: - leg pain likely secondary to Left femoral arterial thrombus - urinary tract infection Discharge Condition: Mental Status: coherent most times Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - at baseline level. Discharge Instructions: Dear [MASKED], [MASKED] were admitted for persistent subacute leg pain and urinary tract infection. [MASKED] were treated with anti-coagulation and antibiotics. [MASKED] will need to remain on anticoagulation going forward. Medications: 1. [MASKED] will continue to take warfarin. [MASKED] are being discharged home on 5mg Coumadin daily. Take as recommended. Follow up with your [MASKED] clinic for adjustments to your Coumadin levels as appriopriate 2. Because your Coumadin level (measured with INR) is still not at goal, [MASKED] are being discharged home on lovenox 90mg once daily. This will be administered by visiting nurses that will come to your house. 3. [MASKED] will complete a 5 day course of antibiotics for Urinary tract infection that [MASKED] were found to have. 4. Except told otherwise, please resume other medications [MASKED] were on ACTIVITY: - we encourage [MASKED] to get out of bed, walk and be as active as [MASKED] can tolerate. Followup Instructions: [MASKED]	[]	[ "N390", "J449", "I4891", "Z7901", "I10", "F329" ]	[ "I743: Embolism and thrombosis of arteries of the lower extremities", "N390: Urinary tract infection, site not specified", "J449: Chronic obstructive pulmonary disease, unspecified", "I4891: Unspecified atrial fibrillation", "F0390: Unspecified dementia without behavioral disturbance", "Z7901: Long term (current) use of anticoagulants", "I10: Essential (primary) hypertension", "E890: Postprocedural hypothyroidism", "M8580: Other specified disorders of bone density and structure, unspecified site", "F329: Major depressive disorder, single episode, unspecified" ]
10,095,796	20,232,434	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Fever, rigors, urinary discomfort Major Surgical or Invasive Procedure: no major procedures (Midline insertion) History of Present Illness: Per Dr. ___: "Mr. ___ is a ___ oncologist with past medical history significant for recurrent episodes of self-diagnosed and treated prostatitis, with ~ 6 episodes in his adult life, all treated successfully with quinolones. He now presents with ~ 36 hrs of his usual prostatitis symptoms, including dysuria, hesitancy, perineal discomfort, and fevers, except now, with more marked systemic symptoms and rigors. On arrival, VSS except for fever to 102.7, which spiked to 103 after Urology performed a DRE. Initial plan was to send him home on Bactrim, but given high fever and systemic symptoms, it was decided to admit for parenteral therapy and closer observation. ROS positive for malaise, rigors, fevers, dysuria, frontal headache, and mild constipation. He also has mild chronic BPH symptoms and intermittent dysphagia, which he attributes to esophageal spasm. ROS: Pertinent positives and negatives as noted in the HPI; review of systems otherwise negative." Past Medical History: - Mild hypomagnesemia - Mild BPH Social History: ___ Family History: - Father with BPH, breast cancer. Physical Exam: GENERAL: No apparent distress. EYES: Anicteric and without injection. ENT: Ears, nose, and oropharynx without erythema or exudate. CV: Regular, S1 and S2, no murmurs or gallops. RESP: Lungs clear to auscultation bilaterally without rales, rhonchi, or wheezes. GI: Abdomen soft, non-distended, non-tender to palpation. GU: Deferred as already performed by Urology in the ED. MSK: BLE warm, without edema. SKIN: Warm and well perfused, no lesions, rashes, or ulcerations noted. NEURO: Awake, alert, oriented to self, place, time and situation. Able to relate history without difficulty. Speech is fluent, verbal comprehension is intact. Face symmetric, gaze conjugate and EOMI, gross motor function intact and symmetric in all four extremities. Pertinent Results: ___ 03:25AM BLOOD WBC-8.0 RBC-4.05* Hgb-12.2* Hct-36.8* MCV-91 MCH-30.1 MCHC-33.2 RDW-12.5 RDWSD-41.1 Plt ___ ___ 06:30AM BLOOD WBC-6.7 RBC-3.95* Hgb-11.6* Hct-36.3* MCV-92 MCH-29.4 MCHC-32.0 RDW-12.4 RDWSD-42.1 Plt ___ ___ 06:30AM BLOOD WBC-4.7 RBC-3.78* Hgb-11.2* Hct-33.8* MCV-89 MCH-29.6 MCHC-33.1 RDW-12.4 RDWSD-41.1 Plt ___ ___ 03:25AM BLOOD Glucose-121* UreaN-13 Creat-1.1 Na-134* K-4.3 Cl-97 HCO3-23 AnGap-14 ___ 06:30AM BLOOD Glucose-127* UreaN-7 Creat-1.0 Na-135 K-3.9 Cl-100 HCO3-22 AnGap-13 ___ 06:30AM BLOOD Glucose-116* UreaN-9 Creat-0.8 Na-136 K-3.9 Cl-102 HCO3-22 AnGap-12 ___ 06:30AM BLOOD Mg-1.5* ___ 03:34AM BLOOD Lactate-1.2 MICROBIOLOGY: ___ 3:25 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: ___. FINAL SENSITIVITIES. DOXYCYCLINE Susceptibility testing requested per ___ ___ ___ (___) ___. RESISTANT TO DOXYCYCLINE test result performed by ___ ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ___ \| AMIKACIN-------------- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). Reported to and read back by ___ ON ___ @ 2110. Anaerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). ___ 3:10 am URINE FINAL REPORT ___ URINE CULTURE (Final ___: ___. 10,000-100,000 CFU/mL. DOXYCYCLINE AND MINOCYCLINE Susceptibility testing requested per ___ (___)- ___. DOXYCYCLINE = RESISTANT. MINOCYCLINE = RESISTANT. DOXYCYCLINE AND MINOCYCLINE test result performed by ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ___ \| AMIKACIN-------------- 4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: Mr. ___ is a ___ male with acute, recurrent prostatitis. #Acute bacterial prostatitis with systemic symptoms #Morganella UTI and bacteremia He presented with sepsis and systemic and urinary symptoms. He was seen by urology in the ER and underwent DRE which was uncomfortable but without suspicion for prostatic abscess. He was started on ceftriaxone in the ED, and although reported initial interval improvement in constitutional symptoms, he later again developed rigors and low grade temperatures. Infectious disease consulted. His antibiotics were changed from Ceftriaxone to Cefepime. His BP were found to run a little soft at ~ 110/70. Admission lactate was 1.2. After antibiotics, he appeared non-toxic, with warm extremities, mentating well, and made urine. His blood and urine cultures grew Morganella ___ which was unfortunately resistant to several oral antibiotics including fluoroquinolones, Bactrim, Doxycycline. Due to inducible resistance to beta lactam antibiotics in Morganella, it was felt that IV antibiotics with once daily Ertapenem would be the best option. He was set up with home infusion and ___ to receive Ertapenem 1g q24h via midline (inserted ___. End date of antibiotics is ___. OPAT has been set up by ID (Dr. ___. He should get weekly CBC with differential, BUN, Creatinine, AST, ALT, Total Bilirubin and results to be sent to Dr. ___ ___ CLINIC - FAX: ___. The ___ will schedule follow up and contact the patient. He will be discharged on Flomax for urinary relief. He is advised to follow up with outpatient urology after his infection is controlled. TRANSITION OF CARE: - Weekly labs per OPAT (see OPAT note) - Follow up with Urology after infection has resolved/been treated Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Ertapenem Sodium 1 g IV ONCE GNR bacteremia Duration: 1 Dose Patient to be given 1g Ertapenem every 24 hours. Last date ___. 2. Tamsulosin 0.4 mg PO QHS RX tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #30 Capsule Refills:*5 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Bacteremia with Morganella Urinary tract infection with Morganella Acute bacterial prosatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You presented with fever, rigors and urinary symptoms and were diagnosed with a urinary tract infection, inflammation of the prostate and a bloodstream infection. You were seen by the urologist and the infectious disease specialist. You were treated with IV antibiotics after which your symptoms seemed to improve. Due to the bacteria growing in the urine and blood being resistant to several antibiotics, you are being treated with Intravenous antibiotics for a period of 4 weeks. You will be set up with home ___ to assist you with home infusions. You are advised to follow up with your PCP, ID specialist and urologist as an outpatient. Yours ___ Team Followup Instructions: ___	[ "A4159", "N410", "N390", "N401", "K224", "Z1624", "R350", "R3914" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Fever, rigors, urinary discomfort Major Surgical or Invasive Procedure: no major procedures (Midline insertion) History of Present Illness: Per Dr. [MASKED]: "Mr. [MASKED] is a [MASKED] oncologist with past medical history significant for recurrent episodes of self-diagnosed and treated prostatitis, with ~ 6 episodes in his adult life, all treated successfully with quinolones. He now presents with ~ 36 hrs of his usual prostatitis symptoms, including dysuria, hesitancy, perineal discomfort, and fevers, except now, with more marked systemic symptoms and rigors. On arrival, VSS except for fever to 102.7, which spiked to 103 after Urology performed a DRE. Initial plan was to send him home on Bactrim, but given high fever and systemic symptoms, it was decided to admit for parenteral therapy and closer observation. ROS positive for malaise, rigors, fevers, dysuria, frontal headache, and mild constipation. He also has mild chronic BPH symptoms and intermittent dysphagia, which he attributes to esophageal spasm. ROS: Pertinent positives and negatives as noted in the HPI; review of systems otherwise negative." Past Medical History: - Mild hypomagnesemia - Mild BPH Social History: [MASKED] Family History: - Father with BPH, breast cancer. Physical Exam: GENERAL: No apparent distress. EYES: Anicteric and without injection. ENT: Ears, nose, and oropharynx without erythema or exudate. CV: Regular, S1 and S2, no murmurs or gallops. RESP: Lungs clear to auscultation bilaterally without rales, rhonchi, or wheezes. GI: Abdomen soft, non-distended, non-tender to palpation. GU: Deferred as already performed by Urology in the ED. MSK: BLE warm, without edema. SKIN: Warm and well perfused, no lesions, rashes, or ulcerations noted. NEURO: Awake, alert, oriented to self, place, time and situation. Able to relate history without difficulty. Speech is fluent, verbal comprehension is intact. Face symmetric, gaze conjugate and EOMI, gross motor function intact and symmetric in all four extremities. Pertinent Results: [MASKED] 03:25AM BLOOD WBC-8.0 RBC-4.05* Hgb-12.2* Hct-36.8* MCV-91 MCH-30.1 MCHC-33.2 RDW-12.5 RDWSD-41.1 Plt [MASKED] [MASKED] 06:30AM BLOOD WBC-6.7 RBC-3.95* Hgb-11.6* Hct-36.3* MCV-92 MCH-29.4 MCHC-32.0 RDW-12.4 RDWSD-42.1 Plt [MASKED] [MASKED] 06:30AM BLOOD WBC-4.7 RBC-3.78* Hgb-11.2* Hct-33.8* MCV-89 MCH-29.6 MCHC-33.1 RDW-12.4 RDWSD-41.1 Plt [MASKED] [MASKED] 03:25AM BLOOD Glucose-121* UreaN-13 Creat-1.1 Na-134* K-4.3 Cl-97 HCO3-23 AnGap-14 [MASKED] 06:30AM BLOOD Glucose-127* UreaN-7 Creat-1.0 Na-135 K-3.9 Cl-100 HCO3-22 AnGap-13 [MASKED] 06:30AM BLOOD Glucose-116* UreaN-9 Creat-0.8 Na-136 K-3.9 Cl-102 HCO3-22 AnGap-12 [MASKED] 06:30AM BLOOD Mg-1.5* [MASKED] 03:34AM BLOOD Lactate-1.2 MICROBIOLOGY: [MASKED] 3:25 am BLOOD CULTURE FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: [MASKED]. FINAL SENSITIVITIES. DOXYCYCLINE Susceptibility testing requested per [MASKED] [MASKED] [MASKED] ([MASKED]) [MASKED]. RESISTANT TO DOXYCYCLINE test result performed by [MASKED] [MASKED]. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] [MASKED] \| AMIKACIN-------------- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R Aerobic Bottle Gram Stain (Final [MASKED]: GRAM NEGATIVE ROD(S). Reported to and read back by [MASKED] ON [MASKED] @ 2110. Anaerobic Bottle Gram Stain (Final [MASKED]: GRAM NEGATIVE ROD(S). [MASKED] 3:10 am URINE FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: [MASKED]. 10,000-100,000 CFU/mL. DOXYCYCLINE AND MINOCYCLINE Susceptibility testing requested per [MASKED] ([MASKED])- [MASKED]. DOXYCYCLINE = RESISTANT. MINOCYCLINE = RESISTANT. DOXYCYCLINE AND MINOCYCLINE test result performed by [MASKED]. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] [MASKED] \| AMIKACIN-------------- 4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with acute, recurrent prostatitis. #Acute bacterial prostatitis with systemic symptoms #Morganella UTI and bacteremia He presented with sepsis and systemic and urinary symptoms. He was seen by urology in the ER and underwent DRE which was uncomfortable but without suspicion for prostatic abscess. He was started on ceftriaxone in the ED, and although reported initial interval improvement in constitutional symptoms, he later again developed rigors and low grade temperatures. Infectious disease consulted. His antibiotics were changed from Ceftriaxone to Cefepime. His BP were found to run a little soft at ~ 110/70. Admission lactate was 1.2. After antibiotics, he appeared non-toxic, with warm extremities, mentating well, and made urine. His blood and urine cultures grew Morganella [MASKED] which was unfortunately resistant to several oral antibiotics including fluoroquinolones, Bactrim, Doxycycline. Due to inducible resistance to beta lactam antibiotics in Morganella, it was felt that IV antibiotics with once daily Ertapenem would be the best option. He was set up with home infusion and [MASKED] to receive Ertapenem 1g q24h via midline (inserted [MASKED]. End date of antibiotics is [MASKED]. OPAT has been set up by ID (Dr. [MASKED]. He should get weekly CBC with differential, BUN, Creatinine, AST, ALT, Total Bilirubin and results to be sent to Dr. [MASKED] [MASKED] CLINIC - FAX: [MASKED]. The [MASKED] will schedule follow up and contact the patient. He will be discharged on Flomax for urinary relief. He is advised to follow up with outpatient urology after his infection is controlled. TRANSITION OF CARE: - Weekly labs per OPAT (see OPAT note) - Follow up with Urology after infection has resolved/been treated Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Ertapenem Sodium 1 g IV ONCE GNR bacteremia Duration: 1 Dose Patient to be given 1g Ertapenem every 24 hours. Last date [MASKED]. 2. Tamsulosin 0.4 mg PO QHS RX tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #30 Capsule Refills:*5 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Bacteremia with Morganella Urinary tract infection with Morganella Acute bacterial prosatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You presented with fever, rigors and urinary symptoms and were diagnosed with a urinary tract infection, inflammation of the prostate and a bloodstream infection. You were seen by the urologist and the infectious disease specialist. You were treated with IV antibiotics after which your symptoms seemed to improve. Due to the bacteria growing in the urine and blood being resistant to several antibiotics, you are being treated with Intravenous antibiotics for a period of 4 weeks. You will be set up with home [MASKED] to assist you with home infusions. You are advised to follow up with your PCP, ID specialist and urologist as an outpatient. Yours [MASKED] Team Followup Instructions: [MASKED]	[]	[ "N390" ]	[ "A4159: Other Gram-negative sepsis", "N410: Acute prostatitis", "N390: Urinary tract infection, site not specified", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "K224: Dyskinesia of esophagus", "Z1624: Resistance to multiple antibiotics", "R350: Frequency of micturition", "R3914: Feeling of incomplete bladder emptying" ]
10,096,046	27,093,118	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Bactrim Attending: ___ Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is an ___ year old woman with a history of HTN, hypothyroidism, parathyroid adenoma, afib/aflutter, scleroderma, who presents after an unwitnessed fall around 6:30pm on ___. Patient states that she was picking up a bag from her closet, which was too heavy, and she fell over. Her son came to assist shortly after but was unable to pick her up. She was lying down for 12 hours and then decided to call an ambulance for assistance. She denies any loss of consciousness and no preceding symptoms. She has right upper chest pain on inspiration. At baseline, patient is able to ambulate with a walker but has been unable to do so since falling. Patient lives with her son at home. She denies headache, dizziness, changes in vision, nausea/vomiting. On presentation to the ED, patient had a CT head which was negative, CT C spine which showed degenerative spondylolisthesis but no acute injury, CT Chest that showed mildly displaced fractures through anterior R ___ ribs. She also had bilateral knee x-rays that were negative for acute injury, and a pelvis AP film that showed no acute injury. Past Medical History: PMH: HTN, hypothyroidism, parathyroid adenoma, afib/aflutter, scleroderma, GERD, osteoporosis, cataracts PSH: T&A, open appendectomy, open cholecystectomy, TAH, partial colectomy Social History: ___ Family History: FH: Brother died in his sleep at age ___. Brother with AAA. Physical Exam: Physical Exam on Admission: Vitals - T 98.1; BP 154/72; HR 65; RR 18; SPO2 97% RA GEN - Well appearing, no acute distress HEENT - NCAT, EOMI, sclera anicteric CV - HDS PULM - No signs of respiratory distress. EXT - Warm, well-perfused NEURO - A&Ox3, no focal neurologic deficits Physical Exam on Discharge: 98.2, 136/81, 59, 18, 96% Ra Gen: [x] NAD, [] AAOx3 CV: [x] RRR, [] murmur Resp: [x] breaths unlabored, [x] CTAB, [] wheezing, [] rales Abdomen: [x] soft, [] distended, [] tender, [] rebound/guarding Wound: [] incisions clean, dry, intact Ext: [x] warm, [] tender, [] edema Pertinent Results: CT C-SPINE W/O CONTRAST Study Date of ___ 1. No acute fracture. 2. Multi level spondylolisthesis including anterolisthesis of C2/C3, C3/C4 and C4/C5 which is mild and most likely degenerative in nature. CT HEAD W/O CONTRAST Study Date of ___ No acute intracranial process. Mild small vessel disease. CT CHEST W/O CONTRAST Study Date of ___ 1. Mildly displaced fracture through the anterior right ___ ribs. No evidence of pneumothorax. 2. The ascending thoracic aorta is borderline aneurysmal, measuring up to 4 cm in the greatest diameter. PELVIS AP ___ VIEWS Study Date of ___ 1. No acute fracture or dislocation. 2. Status post left femoral neck fixation with heterotopic ossification. 3. Degenerative changes of the bilateral hips, left greater than right. KNEE (AP, LAT & OBLIQUE) BILAT Study Date of ___ 1. No fracture or dislocation. 2. Trace left knee joint effusion. 3. Features of chondrocalcinosis with calcification within the tibiofemoral joint space bilaterally. Labs: ___ 06:45AM BLOOD WBC-6.0 RBC-4.29 Hgb-12.9 Hct-40.2 MCV-94 MCH-30.1 MCHC-32.1 RDW-14.6 RDWSD-49.9* Plt ___ ___ 06:53AM BLOOD WBC-6.8 RBC-3.73* Hgb-11.3 Hct-35.0 MCV-94 MCH-30.3 MCHC-32.3 RDW-14.7 RDWSD-50.8* Plt ___ ___ 03:57AM BLOOD WBC-7.4 RBC-3.14* Hgb-9.5* Hct-29.9* MCV-95 MCH-30.3 MCHC-31.8* RDW-14.6 RDWSD-50.8* Plt ___ ___ 04:00PM BLOOD WBC-12.2* RBC-4.11 Hgb-12.6 Hct-38.4 MCV-93 MCH-30.7 MCHC-32.8 RDW-14.5 RDWSD-49.6* Plt ___ ___ 06:45AM BLOOD Glucose-94 UreaN-16 Creat-0.9 Na-140 K-4.7 Cl-102 HCO3-27 AnGap-11 ___ 06:53AM BLOOD Glucose-97 UreaN-19 Creat-0.9 Na-141 K-4.4 Cl-105 HCO3-25 AnGap-11 ___ 03:57AM BLOOD Glucose-81 UreaN-23* Creat-0.9 Na-143 K-3.4* Cl-105 HCO3-29 AnGap-9* ___ 06:53AM BLOOD ___ 09:30AM BLOOD CK(CPK)-4498* ___ 03:57AM BLOOD CK(CPK)-5479* ___ 10:28PM BLOOD CK(CPK)-6686* ___ 04:00PM BLOOD CK(CPK)-8718* Brief Hospital Course: Patient is a ___ year old female with pmh significant for hypertension, hypothyroid, a-fib/flutter not on anticoagulation. Patient presented to the emergency department for evaluation s/p fall at home with down time of approximately 12 hours. Imaging was completed which demonstrated displaced R ___ rib fractures. She also experienced rhabdomyelosis. Therefore acute care surgery was consulted for evaluation and management. She was transferred to the inpatient floor and her pain was managed. She was also evaluated by physical therapy who recommended short term rehab. Social work was also consulted given her prolonged down time while in the care of her son. As mandated reporters, a claim was filed with elder services and this was discussed with her son with reported understanding. Cardiac surgery was then consulted given incidental findings on chest CT which showed the ascending thoracic aorta to be borderline aneurysmal, measuring up to 4 cm in the greatest diameter. They recommended obtaining an echo which was completed on ___. Case management then worked for find rehab placement with patient and her son. During this hospitalization, the patient voided without difficulty. She was adherent with respiratory toilet and incentive spirometry and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well. She was afebrile and her vital signs were stable. The patient was tolerating a regular diet, ambulating, voiding with assistance, and her pain was well controlled. The patient was discharged to rehab. Discharge teaching was completed and follow-up instructions were reviewed with reported understanding and agreement. Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Losartan Potassium 100 mg PO DAILY 2. Magnesium Oxide 400 mg PO DAILY 3. amLODIPine 5 mg PO DAILY 4. Penicillamine 250 mg PO DAILY 5. Furosemide 10 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Levothyroxine Sodium 88 mcg PO 6X/WEEK (___) 10. Levothyroxine Sodium 44 mcg PO 1X/WEEK (___) Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H please limit to 3000mg in 24 hour period. 2. Docusate Sodium 100 mg PO BID please hold for loose stool. 3. Senna 8.6 mg PO BID:PRN Constipation - First Line please hold for loose stool 4. TraMADol 50 mg PO Q4H:PRN Pain - Moderate this medication may cause drowsiness. 5. amLODIPine 5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Furosemide 10 mg PO DAILY 8. Levothyroxine Sodium 88 mcg PO 6X/WEEK (___) 9. Levothyroxine Sodium 44 mcg PO 1X/WEEK (___) 10. Losartan Potassium 100 mg PO DAILY 11. Magnesium Oxide 400 mg PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. Omeprazole 20 mg PO DAILY 14. Penicillamine 250 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Displaced R ___ rib fracture Rhabdomyolysis 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 ___ for evaluation following a fall at home. As a result of your fall, you sustained right side ___ rib fractures. You worked with physical therapy and are recovering well. You are now ready for discharge. Please follow the instructions below to continue your recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: ___	[ "M6282", "S2241XA", "I5032", "I4892", "I712", "I959", "I4891", "M349", "S0990XA", "I110", "E039", "K219", "M810", "Z96642", "W010XXA", "Y92008" ]	Allergies: Bactrim Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is an [MASKED] year old woman with a history of HTN, hypothyroidism, parathyroid adenoma, afib/aflutter, scleroderma, who presents after an unwitnessed fall around 6:30pm on [MASKED]. Patient states that she was picking up a bag from her closet, which was too heavy, and she fell over. Her son came to assist shortly after but was unable to pick her up. She was lying down for 12 hours and then decided to call an ambulance for assistance. She denies any loss of consciousness and no preceding symptoms. She has right upper chest pain on inspiration. At baseline, patient is able to ambulate with a walker but has been unable to do so since falling. Patient lives with her son at home. She denies headache, dizziness, changes in vision, nausea/vomiting. On presentation to the ED, patient had a CT head which was negative, CT C spine which showed degenerative spondylolisthesis but no acute injury, CT Chest that showed mildly displaced fractures through anterior R [MASKED] ribs. She also had bilateral knee x-rays that were negative for acute injury, and a pelvis AP film that showed no acute injury. Past Medical History: PMH: HTN, hypothyroidism, parathyroid adenoma, afib/aflutter, scleroderma, GERD, osteoporosis, cataracts PSH: T&A, open appendectomy, open cholecystectomy, TAH, partial colectomy Social History: [MASKED] Family History: FH: Brother died in his sleep at age [MASKED]. Brother with AAA. Physical Exam: Physical Exam on Admission: Vitals - T 98.1; BP 154/72; HR 65; RR 18; SPO2 97% RA GEN - Well appearing, no acute distress HEENT - NCAT, EOMI, sclera anicteric CV - HDS PULM - No signs of respiratory distress. EXT - Warm, well-perfused NEURO - A&Ox3, no focal neurologic deficits Physical Exam on Discharge: 98.2, 136/81, 59, 18, 96% Ra Gen: [x] NAD, [] AAOx3 CV: [x] RRR, [] murmur Resp: [x] breaths unlabored, [x] CTAB, [] wheezing, [] rales Abdomen: [x] soft, [] distended, [] tender, [] rebound/guarding Wound: [] incisions clean, dry, intact Ext: [x] warm, [] tender, [] edema Pertinent Results: CT C-SPINE W/O CONTRAST Study Date of [MASKED] 1. No acute fracture. 2. Multi level spondylolisthesis including anterolisthesis of C2/C3, C3/C4 and C4/C5 which is mild and most likely degenerative in nature. CT HEAD W/O CONTRAST Study Date of [MASKED] No acute intracranial process. Mild small vessel disease. CT CHEST W/O CONTRAST Study Date of [MASKED] 1. Mildly displaced fracture through the anterior right [MASKED] ribs. No evidence of pneumothorax. 2. The ascending thoracic aorta is borderline aneurysmal, measuring up to 4 cm in the greatest diameter. PELVIS AP [MASKED] VIEWS Study Date of [MASKED] 1. No acute fracture or dislocation. 2. Status post left femoral neck fixation with heterotopic ossification. 3. Degenerative changes of the bilateral hips, left greater than right. KNEE (AP, LAT & OBLIQUE) BILAT Study Date of [MASKED] 1. No fracture or dislocation. 2. Trace left knee joint effusion. 3. Features of chondrocalcinosis with calcification within the tibiofemoral joint space bilaterally. Labs: [MASKED] 06:45AM BLOOD WBC-6.0 RBC-4.29 Hgb-12.9 Hct-40.2 MCV-94 MCH-30.1 MCHC-32.1 RDW-14.6 RDWSD-49.9* Plt [MASKED] [MASKED] 06:53AM BLOOD WBC-6.8 RBC-3.73* Hgb-11.3 Hct-35.0 MCV-94 MCH-30.3 MCHC-32.3 RDW-14.7 RDWSD-50.8* Plt [MASKED] [MASKED] 03:57AM BLOOD WBC-7.4 RBC-3.14* Hgb-9.5* Hct-29.9* MCV-95 MCH-30.3 MCHC-31.8* RDW-14.6 RDWSD-50.8* Plt [MASKED] [MASKED] 04:00PM BLOOD WBC-12.2* RBC-4.11 Hgb-12.6 Hct-38.4 MCV-93 MCH-30.7 MCHC-32.8 RDW-14.5 RDWSD-49.6* Plt [MASKED] [MASKED] 06:45AM BLOOD Glucose-94 UreaN-16 Creat-0.9 Na-140 K-4.7 Cl-102 HCO3-27 AnGap-11 [MASKED] 06:53AM BLOOD Glucose-97 UreaN-19 Creat-0.9 Na-141 K-4.4 Cl-105 HCO3-25 AnGap-11 [MASKED] 03:57AM BLOOD Glucose-81 UreaN-23* Creat-0.9 Na-143 K-3.4* Cl-105 HCO3-29 AnGap-9* [MASKED] 06:53AM BLOOD [MASKED] 09:30AM BLOOD CK(CPK)-4498* [MASKED] 03:57AM BLOOD CK(CPK)-5479* [MASKED] 10:28PM BLOOD CK(CPK)-6686* [MASKED] 04:00PM BLOOD CK(CPK)-8718* Brief Hospital Course: Patient is a [MASKED] year old female with pmh significant for hypertension, hypothyroid, a-fib/flutter not on anticoagulation. Patient presented to the emergency department for evaluation s/p fall at home with down time of approximately 12 hours. Imaging was completed which demonstrated displaced R [MASKED] rib fractures. She also experienced rhabdomyelosis. Therefore acute care surgery was consulted for evaluation and management. She was transferred to the inpatient floor and her pain was managed. She was also evaluated by physical therapy who recommended short term rehab. Social work was also consulted given her prolonged down time while in the care of her son. As mandated reporters, a claim was filed with elder services and this was discussed with her son with reported understanding. Cardiac surgery was then consulted given incidental findings on chest CT which showed the ascending thoracic aorta to be borderline aneurysmal, measuring up to 4 cm in the greatest diameter. They recommended obtaining an echo which was completed on [MASKED]. Case management then worked for find rehab placement with patient and her son. During this hospitalization, the patient voided without difficulty. She was adherent with respiratory toilet and incentive spirometry and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well. She was afebrile and her vital signs were stable. The patient was tolerating a regular diet, ambulating, voiding with assistance, and her pain was well controlled. The patient was discharged to rehab. Discharge teaching was completed and follow-up instructions were reviewed with reported understanding and agreement. Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Losartan Potassium 100 mg PO DAILY 2. Magnesium Oxide 400 mg PO DAILY 3. amLODIPine 5 mg PO DAILY 4. Penicillamine 250 mg PO DAILY 5. Furosemide 10 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Levothyroxine Sodium 88 mcg PO 6X/WEEK ([MASKED]) 10. Levothyroxine Sodium 44 mcg PO 1X/WEEK ([MASKED]) Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H please limit to 3000mg in 24 hour period. 2. Docusate Sodium 100 mg PO BID please hold for loose stool. 3. Senna 8.6 mg PO BID:PRN Constipation - First Line please hold for loose stool 4. TraMADol 50 mg PO Q4H:PRN Pain - Moderate this medication may cause drowsiness. 5. amLODIPine 5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Furosemide 10 mg PO DAILY 8. Levothyroxine Sodium 88 mcg PO 6X/WEEK ([MASKED]) 9. Levothyroxine Sodium 44 mcg PO 1X/WEEK ([MASKED]) 10. Losartan Potassium 100 mg PO DAILY 11. Magnesium Oxide 400 mg PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. Omeprazole 20 mg PO DAILY 14. Penicillamine 250 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Displaced R [MASKED] rib fracture Rhabdomyolysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] for evaluation following a fall at home. As a result of your fall, you sustained right side [MASKED] rib fractures. You worked with physical therapy and are recovering well. You are now ready for discharge. Please follow the instructions below to continue your recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: [MASKED]	[]	[ "I5032", "I4891", "I110", "E039", "K219" ]	[ "M6282: Rhabdomyolysis", "S2241XA: Multiple fractures of ribs, right side, initial encounter for closed fracture", "I5032: Chronic diastolic (congestive) heart failure", "I4892: Unspecified atrial flutter", "I712: Thoracic aortic aneurysm, without rupture", "I959: Hypotension, unspecified", "I4891: Unspecified atrial fibrillation", "M349: Systemic sclerosis, unspecified", "S0990XA: Unspecified injury of head, initial encounter", "I110: Hypertensive heart disease with heart failure", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "M810: Age-related osteoporosis without current pathological fracture", "Z96642: Presence of left artificial hip joint", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "Y92008: Other place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]
10,096,175	21,035,896	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: latex / amitriptyline / fluoxetine / morphine / piroxicam Attending: ___. Chief Complaint: L MCA aneurysm Major Surgical or Invasive Procedure: ___ L craniotomy for MCA aneurysm clipping History of Present Illness: ___ female previous smoker with no known family history of intracranial aneurysm who was being worked up for a couple of episodes of confusion, and speaking gibberish. In the process of evaluation a left middle cerebral artery aneurysms was identified. The lesion appears to be approximately 6-7 mm in diameter. The patient was seen in the ___ clinic and a long discussion was had with her and her son regarding the natural history of aneurysms as well as potential treatment options of endovascular and surgical management. She underwent angiogram and presents for elective clipping of the MCA aneurysm. Past Medical History: MCA aneurysm dyslipidemia PAF stable on beta blocker COPD HTN Lung mass OA Lumbar DJD with neurogenic claudication TIA epilepsy T2DM Social History: ___ Family History: No known family history of intracranial aneurysms. Physical Exam: On Admission: Opens eyes: [ ]spontaneous [x]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Required cues to focus on exam/questions. Follows commands: [ ]Simple [x]Complex [ ]None Pupils: Right 3-2mm Left 3-2mm EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip IPQuadHamATEHLGast [x]Sensation intact to light touch ============= ON DISCHARGE: ============= Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x] Place [x] Date Follows commands: [ ]Simple [x]Complex [ ]None Pupils: Right 3-2mm Left 3-2mm EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]No Tongue Midline: [x]Yes [ ]No Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip IPQuadHamATEHLGast [x]Sensation intact to light touch Wound: L crani: [x]Clean, dry, intact with sutures Pertinent Results: Please see OMR for pertinent lab and imaging results. Brief Hospital Course: Ms. ___ presents for elective clipping of the left MCA aneurysm. #L MCA aneurysm She was taken to the OR on ___ and underwent left craniotomy for aneurysm clipping with Dr. ___. The procedure was uncomplicated. Please see separately dictated operative report by Dr. ___ complete details of the procedure. She tolerated the procedure well. She was extubated in the OR and transferred to PACU for recovery. She remained neurologically stable and was transferred to the neuro step-down unit for close monitoring. She was cleared to resume home Aspirin on POD#7. Per discussion with her PCP's office, Plavix is no longer needed and can be discontinued. #Seizures/epilepsy She takes Lamotrigine at home for h/o seizures. On POD#2 (___) she had 3 episodes of unresponsiveness with oxygen desaturations to the ___, lasting about 1 minute. She received 0.5mg Ativan to break the seizure, however her exam remained altered with aphasia after unresponsiveness and oxygen improved with supplemental oxygen. Head CT was stable with postop changes but no acute complication. EEG was placed and captured seizure activity which correlated with unresponsiveness. She was loaded with 2g keppra then 1500mg bid and her lamictal 150mg BID was continued. Her mental status remained altered. Neurology consult was placed for additional AED recommendations and EEG was placed, which was positive for seizure activity. On ___, she became acutely agitated and received 0.5mg Ativan and 0.25mg Haldol, however this agitation was unrelated to seizure. On ___, EEG was read as generalized slowing with frequent epileptiform discharges in temporal region (L > R), without overt seizure activity. #COPD/Respiratory distress She was initially continued on her home COPD inhaler medications without issue. However, during the episode of agitation on ___, she was tachypneic and in respiratory distress, for which ___ was consulted. She was also febrile to 102 and her SpO2 was 92% on RA. A CXR showed mild-moderate pulmonary edema, ABG showed PaO2 of 60. She was started on face mask with 50% FiO2, given 20mg IV Lasix, and started on broad spectrum antibiotics to cover for pneumonia. She was transferred to Neuro ICU for complicated respiratory status. In the ICU, she was redosed with 20mg IV Lasix, which was continued BID, and she was weaned to 2L NC. #Fever She was initially started on vancomycin and zosyn when found to be febrile on ___, and it was determined that she should complete a 7 day course of antibiotics. She was transitioned to ___ugmentin on ___. #Hypertension Continue on home medications. She required nicardipine postoperatively but this was weaned off POD#1. She continued to be hypertensive despite IV hydralzine, and amlodipine was increased to 5mg daily. Medications on Admission: albuterol sulfate [Ventolin HFA] 2puffs PRN amlodipine 2.5mg daily atenolol 150 mg tablet daily atorvastatin 60mg daily buspirone 10 mg tablet BID PRN clopidogrel 75 mg tablet daily Flovent HFA 110 mcg 2 INH twice a day furosemide 20 mg tablet daily gabapentin 300 mg capsule TID lamotrigine 100 mg tablet BID paroxetine 20 mg tablet daily aspirin 325 mg tablet daily cholecalciferol (vitamin D3) 1,000 unit capsule daily Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Doses Please take at: ___ and 8pm ___ and 8pm 2. Bisacodyl 10 mg PR QHS 3. Docusate Sodium 100 mg PO BID 4. LevETIRAcetam 1500 mg PO BID 5. Ondansetron 4 mg IV Q8H:PRN nausea 6. Senna 17.2 mg PO QHS 7. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 8. amLODIPine 2.5 mg PO DAILY 9. Aspirin 325 mg PO DAILY 10. Atenolol 150 mg PO DAILY 11. Atorvastatin 60 mg PO QPM 12. BusPIRone 10 mg PO BID:PRN anxiety 13. Fluticasone Propionate 110mcg 2 PUFF IH BID 14. Furosemide 20 mg PO DAILY 15. Gabapentin 300 mg PO TID 16. LamoTRIgine 150 mg PO BID 17. PARoxetine 20 mg PO DAILY 18. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: L MCA aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Elective Aneurysm Clipping Call your neurosurgeons office and speak to the Nurse Practitioner if you experience: -Any neurological issues, such as change in vision, speech or movement -Swelling, drainage, or redness of your incision -Any problems with medications, such as nausea vomiting or lethargy -Fever greater than 101.5 degrees Fahrenheit -Headaches not relieved with prescribed medications Medications: -Because you had a seizure while you were in the hospital, you are now taking Keppra(Levetiracetam)and will be discharged home with a script to continue on this medication, along with your lamictal. Please follow the instructions to take this new medication. -You may resume your Aspirin 325mg, but please do NOT take your Plavix (clopidogrel)75mg any more. -You also will have a script for an antibiotic (amoxicillin clavulanate) to help with your pneumonia. You have three days remaining on this medication, please take this medication as well. Activity: -Start to resume all activities as you tolerate but start slowly and increase at your own pace. -Do not operate any motorized vehicle for at least 10 days after your surgery your Nurse Practitioner can give you more detail at the time of your suture removal. Incision Care: -Keep your wound clean and dry. -Do not use shampoo until your sutures are removed. -When you are allowed to shampoo your hair, let the shampoo run off the incision line. Gently pad the incision with a towel to dry. -Do not rub, scrub, scratch, or pick at any scabs on the incision line. -You need your sutures removed 7 to 10 days after surgery Post-Operative Experiences: Physical -Jaw pain on the same side as your surgery; this goes away after about a month -You may experience constipation. Constipation can be prevented by: oDrinking plenty of fluids oIncreasing fiber in your diet by eating vegetables, prunes, fiber rich breads and cereals, or fiber supplements oExercising oUsing over-the-counter bowel stimulants or laxatives as needed, stopping usage if you experience loose bowel movements or diarrhea -Fatigue which will slowly resolve over time -Numbness or tingling in the area of the incision; this can take weeks or months to fully resolve -Muffled hearing in the ear near the incision area -Low back pain or shooting pain down the leg which can resolve with increased activity Post-Operative Experiences: Emotional -You may experience depression. Symptoms of depression can include oFeeling down or sad oIrritability, frustration, and confusion oDistractibility oLower Self-Esteem/Relationship Challenges oInsomnia oLoneliness -If you experience these symptoms, you can contact your Primary Care Provider who can make a referral to a Psychologist or Psychiatrist -You can also seek out a local Brain Aneurysm Support Group in your area through the Brain Aneurysm Foundation oMore information can be found at ___ Followup Instructions: ___	[ "I671", "J690", "R4701", "F17210", "I10", "J449", "G40909", "Z8673", "F419", "F329", "M47816", "E785", "R339", "R451", "E119", "R0902", "E8770", "E669", "Z6834", "K5900" ]	Allergies: latex / amitriptyline / fluoxetine / morphine / piroxicam Chief Complaint: L MCA aneurysm Major Surgical or Invasive Procedure: [MASKED] L craniotomy for MCA aneurysm clipping History of Present Illness: [MASKED] female previous smoker with no known family history of intracranial aneurysm who was being worked up for a couple of episodes of confusion, and speaking gibberish. In the process of evaluation a left middle cerebral artery aneurysms was identified. The lesion appears to be approximately 6-7 mm in diameter. The patient was seen in the [MASKED] clinic and a long discussion was had with her and her son regarding the natural history of aneurysms as well as potential treatment options of endovascular and surgical management. She underwent angiogram and presents for elective clipping of the MCA aneurysm. Past Medical History: MCA aneurysm dyslipidemia PAF stable on beta blocker COPD HTN Lung mass OA Lumbar DJD with neurogenic claudication TIA epilepsy T2DM Social History: [MASKED] Family History: No known family history of intracranial aneurysms. Physical Exam: On Admission: Opens eyes: [ ]spontaneous [x]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Required cues to focus on exam/questions. Follows commands: [ ]Simple [x]Complex [ ]None Pupils: Right 3-2mm Left 3-2mm EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip IPQuadHamATEHLGast [x]Sensation intact to light touch ============= ON DISCHARGE: ============= Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x] Place [x] Date Follows commands: [ ]Simple [x]Complex [ ]None Pupils: Right 3-2mm Left 3-2mm EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]No Tongue Midline: [x]Yes [ ]No Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip IPQuadHamATEHLGast [x]Sensation intact to light touch Wound: L crani: [x]Clean, dry, intact with sutures Pertinent Results: Please see OMR for pertinent lab and imaging results. Brief Hospital Course: Ms. [MASKED] presents for elective clipping of the left MCA aneurysm. #L MCA aneurysm She was taken to the OR on [MASKED] and underwent left craniotomy for aneurysm clipping with Dr. [MASKED]. The procedure was uncomplicated. Please see separately dictated operative report by Dr. [MASKED] complete details of the procedure. She tolerated the procedure well. She was extubated in the OR and transferred to PACU for recovery. She remained neurologically stable and was transferred to the neuro step-down unit for close monitoring. She was cleared to resume home Aspirin on POD#7. Per discussion with her PCP's office, Plavix is no longer needed and can be discontinued. #Seizures/epilepsy She takes Lamotrigine at home for h/o seizures. On POD#2 ([MASKED]) she had 3 episodes of unresponsiveness with oxygen desaturations to the [MASKED], lasting about 1 minute. She received 0.5mg Ativan to break the seizure, however her exam remained altered with aphasia after unresponsiveness and oxygen improved with supplemental oxygen. Head CT was stable with postop changes but no acute complication. EEG was placed and captured seizure activity which correlated with unresponsiveness. She was loaded with 2g keppra then 1500mg bid and her lamictal 150mg BID was continued. Her mental status remained altered. Neurology consult was placed for additional AED recommendations and EEG was placed, which was positive for seizure activity. On [MASKED], she became acutely agitated and received 0.5mg Ativan and 0.25mg Haldol, however this agitation was unrelated to seizure. On [MASKED], EEG was read as generalized slowing with frequent epileptiform discharges in temporal region (L > R), without overt seizure activity. #COPD/Respiratory distress She was initially continued on her home COPD inhaler medications without issue. However, during the episode of agitation on [MASKED], she was tachypneic and in respiratory distress, for which [MASKED] was consulted. She was also febrile to 102 and her SpO2 was 92% on RA. A CXR showed mild-moderate pulmonary edema, ABG showed PaO2 of 60. She was started on face mask with 50% FiO2, given 20mg IV Lasix, and started on broad spectrum antibiotics to cover for pneumonia. She was transferred to Neuro ICU for complicated respiratory status. In the ICU, she was redosed with 20mg IV Lasix, which was continued BID, and she was weaned to 2L NC. #Fever She was initially started on vancomycin and zosyn when found to be febrile on [MASKED], and it was determined that she should complete a 7 day course of antibiotics. She was transitioned to ugmentin on [MASKED]. #Hypertension Continue on home medications. She required nicardipine postoperatively but this was weaned off POD#1. She continued to be hypertensive despite IV hydralzine, and amlodipine was increased to 5mg daily. Medications on Admission: albuterol sulfate [Ventolin HFA] 2puffs PRN amlodipine 2.5mg daily atenolol 150 mg tablet daily atorvastatin 60mg daily buspirone 10 mg tablet BID PRN clopidogrel 75 mg tablet daily Flovent HFA 110 mcg 2 INH twice a day furosemide 20 mg tablet daily gabapentin 300 mg capsule TID lamotrigine 100 mg tablet BID paroxetine 20 mg tablet daily aspirin 325 mg tablet daily cholecalciferol (vitamin D3) 1,000 unit capsule daily Discharge Medications: 1. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H Duration: 5 Doses Please take at: [MASKED] and 8pm [MASKED] and 8pm 2. Bisacodyl 10 mg PR QHS 3. Docusate Sodium 100 mg PO BID 4. LevETIRAcetam 1500 mg PO BID 5. Ondansetron 4 mg IV Q8H:PRN nausea 6. Senna 17.2 mg PO QHS 7. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 8. amLODIPine 2.5 mg PO DAILY 9. Aspirin 325 mg PO DAILY 10. Atenolol 150 mg PO DAILY 11. Atorvastatin 60 mg PO QPM 12. BusPIRone 10 mg PO BID:PRN anxiety 13. Fluticasone Propionate 110mcg 2 PUFF IH BID 14. Furosemide 20 mg PO DAILY 15. Gabapentin 300 mg PO TID 16. LamoTRIgine 150 mg PO BID 17. PARoxetine 20 mg PO DAILY 18. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: L MCA aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Elective Aneurysm Clipping Call your neurosurgeons office and speak to the Nurse Practitioner if you experience: -Any neurological issues, such as change in vision, speech or movement -Swelling, drainage, or redness of your incision -Any problems with medications, such as nausea vomiting or lethargy -Fever greater than 101.5 degrees Fahrenheit -Headaches not relieved with prescribed medications Medications: -Because you had a seizure while you were in the hospital, you are now taking Keppra(Levetiracetam)and will be discharged home with a script to continue on this medication, along with your lamictal. Please follow the instructions to take this new medication. -You may resume your Aspirin 325mg, but please do NOT take your Plavix (clopidogrel)75mg any more. -You also will have a script for an antibiotic (amoxicillin clavulanate) to help with your pneumonia. You have three days remaining on this medication, please take this medication as well. Activity: -Start to resume all activities as you tolerate but start slowly and increase at your own pace. -Do not operate any motorized vehicle for at least 10 days after your surgery your Nurse Practitioner can give you more detail at the time of your suture removal. Incision Care: -Keep your wound clean and dry. -Do not use shampoo until your sutures are removed. -When you are allowed to shampoo your hair, let the shampoo run off the incision line. Gently pad the incision with a towel to dry. -Do not rub, scrub, scratch, or pick at any scabs on the incision line. -You need your sutures removed 7 to 10 days after surgery Post-Operative Experiences: Physical -Jaw pain on the same side as your surgery; this goes away after about a month -You may experience constipation. Constipation can be prevented by: oDrinking plenty of fluids oIncreasing fiber in your diet by eating vegetables, prunes, fiber rich breads and cereals, or fiber supplements oExercising oUsing over-the-counter bowel stimulants or laxatives as needed, stopping usage if you experience loose bowel movements or diarrhea -Fatigue which will slowly resolve over time -Numbness or tingling in the area of the incision; this can take weeks or months to fully resolve -Muffled hearing in the ear near the incision area -Low back pain or shooting pain down the leg which can resolve with increased activity Post-Operative Experiences: Emotional -You may experience depression. Symptoms of depression can include oFeeling down or sad oIrritability, frustration, and confusion oDistractibility oLower Self-Esteem/Relationship Challenges oInsomnia oLoneliness -If you experience these symptoms, you can contact your Primary Care Provider who can make a referral to a Psychologist or Psychiatrist -You can also seek out a local Brain Aneurysm Support Group in your area through the Brain Aneurysm Foundation oMore information can be found at [MASKED] Followup Instructions: [MASKED]	[]	[ "F17210", "I10", "J449", "Z8673", "F419", "F329", "E785", "E119", "E669", "K5900" ]	[ "I671: Cerebral aneurysm, nonruptured", "J690: Pneumonitis due to inhalation of food and vomit", "R4701: Aphasia", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I10: Essential (primary) hypertension", "J449: Chronic obstructive pulmonary disease, unspecified", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "M47816: Spondylosis without myelopathy or radiculopathy, lumbar region", "E785: Hyperlipidemia, unspecified", "R339: Retention of urine, unspecified", "R451: Restlessness and agitation", "E119: Type 2 diabetes mellitus without complications", "R0902: Hypoxemia", "E8770: Fluid overload, unspecified", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult", "K5900: Constipation, unspecified" ]
10,096,381	29,951,795	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: penicillin G Attending: ___. Chief Complaint: BRBPR, transfer Major Surgical or Invasive Procedure: Flexible Sigmoidoscopy History of Present Illness: This is a ___ with PMHx HTN who presents with bright red blood per rectum x 1d, in the setting of recent colonoscopy with polypectomy on ___. Patient states he has had occasional small-volume bright red blood per rectum for several months. This blood was very slightly noted on the surface of stools, and particularly when wiping. He had a colonoscopy on ___ to better evaluate this, and was found to have two polyps (snared per his report) as well as internal hemorrhoids and diverticulitis. The patient felt well and had no complications during/after his procedure. On ___, the patient felt like he was going to have a diarrheal bowel movement. He got up and had what he describes as "pure blood" in the toilet bowl and running down his legs. Over the next few hours he had 8 more episodes of this bright red blood per rectum. He felt dizzy, had palpitations, and felt nauseous - but did not vomit or pass out. He presented to ___ ___ for evaluation of same, and was transferred subsequently here for further evaluation. At ___, the patient reports he got 2uPRBC. His hemoglobin prior to transfer was 13.9. In the ED, initial VS were: T 98 BP 141/69 HR 107 RR 16 O2 99% on RA Exam notable for: None documented ___ showed: -Hb 12.9 (no priors for comparison), WBC 8.9, Plt 168 -Lactate 1.1 -Coags pending Imaging showed: None performed Consults: GASTROENTEROLOGY: Keep NPO, will evaluate in the morning Patient received: 1uPRBC ordered, not given owing to pending crossmatch Transfer VS were: T 98 BP 138/68 HR 104 RR 17 O2 95% on RA On arrival to the floor, patient reports the above history. He does not have palpitations at the moment. He notes suprapubic ___ abdominal "discomfort" that is "annoying." Otherwise he denies recent fevers/chills. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: Hypertension Social History: ___ Family History: Mother with breast cancer diagnosed after ___ y/o. Otherwise no family history. No early malignancies or early heart disease in particular. Physical Exam: ADMISSION PHYSCIAL EXAM: ======================== VS: T 98.6 BP 138/81 HR 99 RR 16 O2 96% on RA GENERAL: Overweight gentleman sitting up in bed, appears mildly anxious. Pleasant and cooperative, in NAD. HEENT: Sclerae anicteric, MMM. HEART: Tachycardic with regular rhythm, normal S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi. ABDOMEN: Hyperactive bowel sounds. Abdomen is soft, nondistended. There is minimal LLQ tenderness to palpation without rebound/guarding. No hepatosplenomegaly. EXTREMITIES: Warm and well perfused. No cyanosis, clubbing or edema. PULSES: 2+ posterior tibialis pulses bilaterally NEURO: CN II-XII intact. Moving all four extremities with purpose. DISCHARGE PHYSCIAL EXAM: ======================== VS: 24 HR Data (last updated ___ @ 1130) Temp: 98.5 (Tm 98.6), BP: 121/78 (120-149/78-92), HR: 72 (72-87), RR: 18 (___), O2 sat: 98% (96-98), O2 delivery: Ra GENERAL: Sitting up in bed, no apparent distress HEENT: Sclerae anicteric, EOMI, PERRLA, MMM, OP Clear. HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi. ABDOMEN: Bowel sounds present. Abdomen is soft, nondistended, nontender EXTREMITIES: Warm and well perfused. No cyanosis, clubbing or edema. PULSES: 2+ posterior tibialis pulses bilaterally NEURO: AAOx3, CN II-XII grossly intact. Moving all four extremities with purpose. Pertinent Results: ADMISSION ___: =============== ___ 01:15AM BLOOD WBC-8.9 RBC-4.22* Hgb-12.9* Hct-38.8* MCV-92 MCH-30.6 MCHC-33.2 RDW-12.4 RDWSD-42.0 Plt ___ ___ 01:15AM BLOOD Neuts-82.5* Lymphs-12.2* Monos-4.4* Eos-0.1* Baso-0.5 Im ___ AbsNeut-7.30* AbsLymp-1.08* AbsMono-0.39 AbsEos-0.01* AbsBaso-0.04 ___ 02:04AM BLOOD ___ PTT-24.8* ___ ___ 01:15AM BLOOD Glucose-121* UreaN-14 Creat-1.0 Na-138 K-4.5 Cl-105 HCO3-22 AnGap-11 ___ 01:14PM BLOOD Calcium-8.6 Phos-3.2 Mg-2.0 ___ 01:19AM BLOOD Lactate-1.1 DISCHARGE ___: =============== ___ 05:40AM BLOOD WBC-4.1 RBC-3.75* Hgb-11.5* Hct-34.3* MCV-92 MCH-30.7 MCHC-33.5 RDW-12.6 RDWSD-41.8 Plt ___ ___ 05:40AM BLOOD Glucose-99 UreaN-9 Creat-0.9 Na-138 K-3.8 Cl-106 HCO3-24 AnGap-8* IMAGING/STUDIES: ================ Sigmoidoscopy ___: IMPRESSIONS: At 20cm the polypectomy site was encountered with the clip still in place. The stalk of the polyp had an ulcer at the top with adherent clot and active bleeding. One clip was palced across the top of the ulcer and two additional clips were palced at the base to control the presumed blood supply to the ulcer. Then 5cc of epinephrine was injected into the polyp stalk. Brief Hospital Course: SUMMARY: ======== Patient is a ___ year old man with PMHx of hypertension who presented with bright red blood per rectum after a colonoscopy with polypectomy performed on ___. Site of polypectomy determined to be sigmoid colon after discussion with outpatient GI doctor. Patient underwent flex sigmoidoscopy with 3 clips applied and epinephrine injected into bleeding site of polyp removal. He was monitored over the next ___ hours for further bleeding and was maintained on a clear liquid diet during this time. H/H remained stable with further clinical evidence of ongoing bleeding so patient was felt to be safe for discharge home ___. TRANSITIONAL ISSUES: ==================== -Follow Up Appintments: PCP -___: CBC within ___ weeks to ensure stable to uptrending Hgb -Discharge Hgb 11.5 Hct 34.3 -Follow up of polpy pathology per Atrius GI ACUTE ISSUES: ============== # GI Bleed On admission, felt to be most concerning for postprocedural bleed given recent polypectomy and subsequent development of frank blood per rectum. Patient reported hypotension at outside hospital, to a nadir of 70/40 however remained normotensive while admitted to ___. Received 2u pRBCs at outside hospital and 1u pRBCs on admission here. GI team discussed case with attending who performed prior colonoscopy and found polyps were removed from sigmoid colon. Decision made to perform flex sig instead of full colonoscopy based on likely site of bleeding. Flex sig performed ___ with visualized bleeding from polypectomy site. Clips and epinephrine were applied with achievement of hemostasis. Patient monitored over subsequent 24 hours without further evidence of bleeding. CHRONIC/STABLE ISSUES: #HTN: Home losartan was held on admission. Restarted at discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY Discharge Medications: 1. Losartan Potassium 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== GI bleed SECONDARY DIAGNOSIS: ==================== HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a privilege taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== - You were admitted to the hospital because you were having bloody bowel movements WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - You underwent a procedure called a flexible sigmoidoscopy to evaluate and treat the likely source of your bleeding which was felt to be the site of recent polyp removal during your outpatient colonoscopy. - Bleeding was found in this area and was stopped with clips and injection of a medication to help close off the blood vessels - You were monitored over the course of the next ___ hours to ensure that you were not experiencing any further bleeding WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your ___ appointments. We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___	[ "K922", "D62", "I10", "Z87891", "K635" ]	Allergies: penicillin G Chief Complaint: BRBPR, transfer Major Surgical or Invasive Procedure: Flexible Sigmoidoscopy History of Present Illness: This is a [MASKED] with PMHx HTN who presents with bright red blood per rectum x 1d, in the setting of recent colonoscopy with polypectomy on [MASKED]. Patient states he has had occasional small-volume bright red blood per rectum for several months. This blood was very slightly noted on the surface of stools, and particularly when wiping. He had a colonoscopy on [MASKED] to better evaluate this, and was found to have two polyps (snared per his report) as well as internal hemorrhoids and diverticulitis. The patient felt well and had no complications during/after his procedure. On [MASKED], the patient felt like he was going to have a diarrheal bowel movement. He got up and had what he describes as "pure blood" in the toilet bowl and running down his legs. Over the next few hours he had 8 more episodes of this bright red blood per rectum. He felt dizzy, had palpitations, and felt nauseous - but did not vomit or pass out. He presented to [MASKED] [MASKED] for evaluation of same, and was transferred subsequently here for further evaluation. At [MASKED], the patient reports he got 2uPRBC. His hemoglobin prior to transfer was 13.9. In the ED, initial VS were: T 98 BP 141/69 HR 107 RR 16 O2 99% on RA Exam notable for: None documented [MASKED] showed: -Hb 12.9 (no priors for comparison), WBC 8.9, Plt 168 -Lactate 1.1 -Coags pending Imaging showed: None performed Consults: GASTROENTEROLOGY: Keep NPO, will evaluate in the morning Patient received: 1uPRBC ordered, not given owing to pending crossmatch Transfer VS were: T 98 BP 138/68 HR 104 RR 17 O2 95% on RA On arrival to the floor, patient reports the above history. He does not have palpitations at the moment. He notes suprapubic [MASKED] abdominal "discomfort" that is "annoying." Otherwise he denies recent fevers/chills. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: Hypertension Social History: [MASKED] Family History: Mother with breast cancer diagnosed after [MASKED] y/o. Otherwise no family history. No early malignancies or early heart disease in particular. Physical Exam: ADMISSION PHYSCIAL EXAM: ======================== VS: T 98.6 BP 138/81 HR 99 RR 16 O2 96% on RA GENERAL: Overweight gentleman sitting up in bed, appears mildly anxious. Pleasant and cooperative, in NAD. HEENT: Sclerae anicteric, MMM. HEART: Tachycardic with regular rhythm, normal S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi. ABDOMEN: Hyperactive bowel sounds. Abdomen is soft, nondistended. There is minimal LLQ tenderness to palpation without rebound/guarding. No hepatosplenomegaly. EXTREMITIES: Warm and well perfused. No cyanosis, clubbing or edema. PULSES: 2+ posterior tibialis pulses bilaterally NEURO: CN II-XII intact. Moving all four extremities with purpose. DISCHARGE PHYSCIAL EXAM: ======================== VS: 24 HR Data (last updated [MASKED] @ 1130) Temp: 98.5 (Tm 98.6), BP: 121/78 (120-149/78-92), HR: 72 (72-87), RR: 18 ([MASKED]), O2 sat: 98% (96-98), O2 delivery: Ra GENERAL: Sitting up in bed, no apparent distress HEENT: Sclerae anicteric, EOMI, PERRLA, MMM, OP Clear. HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi. ABDOMEN: Bowel sounds present. Abdomen is soft, nondistended, nontender EXTREMITIES: Warm and well perfused. No cyanosis, clubbing or edema. PULSES: 2+ posterior tibialis pulses bilaterally NEURO: AAOx3, CN II-XII grossly intact. Moving all four extremities with purpose. Pertinent Results: ADMISSION [MASKED]: =============== [MASKED] 01:15AM BLOOD WBC-8.9 RBC-4.22* Hgb-12.9* Hct-38.8* MCV-92 MCH-30.6 MCHC-33.2 RDW-12.4 RDWSD-42.0 Plt [MASKED] [MASKED] 01:15AM BLOOD Neuts-82.5* Lymphs-12.2* Monos-4.4* Eos-0.1* Baso-0.5 Im [MASKED] AbsNeut-7.30* AbsLymp-1.08* AbsMono-0.39 AbsEos-0.01* AbsBaso-0.04 [MASKED] 02:04AM BLOOD [MASKED] PTT-24.8* [MASKED] [MASKED] 01:15AM BLOOD Glucose-121* UreaN-14 Creat-1.0 Na-138 K-4.5 Cl-105 HCO3-22 AnGap-11 [MASKED] 01:14PM BLOOD Calcium-8.6 Phos-3.2 Mg-2.0 [MASKED] 01:19AM BLOOD Lactate-1.1 DISCHARGE [MASKED]: =============== [MASKED] 05:40AM BLOOD WBC-4.1 RBC-3.75* Hgb-11.5* Hct-34.3* MCV-92 MCH-30.7 MCHC-33.5 RDW-12.6 RDWSD-41.8 Plt [MASKED] [MASKED] 05:40AM BLOOD Glucose-99 UreaN-9 Creat-0.9 Na-138 K-3.8 Cl-106 HCO3-24 AnGap-8* IMAGING/STUDIES: ================ Sigmoidoscopy [MASKED]: IMPRESSIONS: At 20cm the polypectomy site was encountered with the clip still in place. The stalk of the polyp had an ulcer at the top with adherent clot and active bleeding. One clip was palced across the top of the ulcer and two additional clips were palced at the base to control the presumed blood supply to the ulcer. Then 5cc of epinephrine was injected into the polyp stalk. Brief Hospital Course: SUMMARY: ======== Patient is a [MASKED] year old man with PMHx of hypertension who presented with bright red blood per rectum after a colonoscopy with polypectomy performed on [MASKED]. Site of polypectomy determined to be sigmoid colon after discussion with outpatient GI doctor. Patient underwent flex sigmoidoscopy with 3 clips applied and epinephrine injected into bleeding site of polyp removal. He was monitored over the next [MASKED] hours for further bleeding and was maintained on a clear liquid diet during this time. H/H remained stable with further clinical evidence of ongoing bleeding so patient was felt to be safe for discharge home [MASKED]. TRANSITIONAL ISSUES: ==================== -Follow Up Appintments: PCP -[MASKED]: CBC within [MASKED] weeks to ensure stable to uptrending Hgb -Discharge Hgb 11.5 Hct 34.3 -Follow up of polpy pathology per Atrius GI ACUTE ISSUES: ============== # GI Bleed On admission, felt to be most concerning for postprocedural bleed given recent polypectomy and subsequent development of frank blood per rectum. Patient reported hypotension at outside hospital, to a nadir of 70/40 however remained normotensive while admitted to [MASKED]. Received 2u pRBCs at outside hospital and 1u pRBCs on admission here. GI team discussed case with attending who performed prior colonoscopy and found polyps were removed from sigmoid colon. Decision made to perform flex sig instead of full colonoscopy based on likely site of bleeding. Flex sig performed [MASKED] with visualized bleeding from polypectomy site. Clips and epinephrine were applied with achievement of hemostasis. Patient monitored over subsequent 24 hours without further evidence of bleeding. CHRONIC/STABLE ISSUES: #HTN: Home losartan was held on admission. Restarted at discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY Discharge Medications: 1. Losartan Potassium 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== GI bleed SECONDARY DIAGNOSIS: ==================== HTN 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 privilege taking care of you at [MASKED] [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== - You were admitted to the hospital because you were having bloody bowel movements WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - You underwent a procedure called a flexible sigmoidoscopy to evaluate and treat the likely source of your bleeding which was felt to be the site of recent polyp removal during your outpatient colonoscopy. - Bleeding was found in this area and was stopped with clips and injection of a medication to help close off the blood vessels - You were monitored over the course of the next [MASKED] hours to ensure that you were not experiencing any further bleeding WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your [MASKED] appointments. We wish you all the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "D62", "I10", "Z87891" ]	[ "K922: Gastrointestinal hemorrhage, unspecified", "D62: Acute posthemorrhagic anemia", "I10: Essential (primary) hypertension", "Z87891: Personal history of nicotine dependence", "K635: Polyp of colon" ]
10,096,391	20,261,657	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ropinirole Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ___ laparoscopic cholecystectomy History of Present Illness: She is status post a complicated course where she had cholecystitis that was complicated by AFib with RVR with periods of bradycardia and cardiac pause. Given that she had significant cardiac issues, these were dealt with first, and her percutaneous cholecystostomy tube was placed in a delayed manner as the patient both had cardiac issues and had a delay in her HIDA scan which showed noninflamed gallbladder and then left AMA to attend family issues as her husband had an important medical exam regarding a possible cancer diagnosis that she had to attend. We brought her back in immediately requesting that she get a percutaneous cholecystostomy tube with which she has done clinically well. However, there was a small complication just prior to the ___ where the patient was visiting her primary care physician and had increased pain at the site. This was evaluated by a percutaneous cholecystostomy cholangiogram which showed that the tube was well placed. It was thought there might be a small collection of bile and that potentially bulb suction would remedy the issue; however, it resolved without changing to bulb suction and simply using gravity drainage. The patient is very eager to have her percutaneous cholecystostomy tube removed; however, she is still draining about ___ mL of what looks like hydrops and still with evidence of complete obstruction on her cholangiogram despite a well-placed tube. She is complaining of some mild tenderness at the insertion site of the tube itself. This is consistent with foreign body reaction and no evidence of infection. Otherwise, she is afebrile, nontender, able to perform her ADLs and eat. Past Medical History: Hypothyroidism Hypertension Hyperlipidemia Irritable bowel syndrome Subclavian stenosis Social History: ___ Family History: -CAD: mother, father, and brother died of heart disease -Diabetes: father, brother, sister No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ___ Physical Exam ___: VITAL SIGNS: Stable. ABDOMEN: She has the percutaneous cholecystostomy tube in place with trace redness around it that is consistent with just foreign body reaction rather than erythema, and there is no drainage. There is clear liquid in the bag, roughly 5 mL. She has a nontender abdomen and otherwise is clinically well. Discharge Physical Exam: VS: 99.2, 71, 101/53, 20, 92% RA Gen: Sitting up in chair alert and interactive with husband at bedside. HEENT: no deformities. mucus membranes moist. neck soft, supple. Trachea midline. Resp: Breath sounds clear to auscultation. NAD. CV: RRR Abd: soft, mild tenderness at surgical sites as anticipated, mild distention. Skin: Laparoscopic sites to abdomen CDI with DSD. Ext: Warm and dry. ___ pulses 2+ palpable. Pertinent Results: ___ 11:07AM BLOOD Plt ___ ___ 11:07AM BLOOD WBC-14.1* RBC-3.40* Hgb-10.2* Hct-31.1* MCV-92 MCH-30.0 MCHC-32.8 RDW-13.0 RDWSD-42.8 Plt ___ Brief Hospital Course: ___ is a ___ who was admitted to the General Surgical Service on ___ for evaluation and treatment of abdominal pain and gallstones. The patient was admitted to the Acute Care Surgery service for further medical care. The patient underwent laparoscopic cholecystectomy on HD1, which went well without complication (refer to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating on IV fluids, and on pain control. The patient was hemodynamically stable. Pain was well controlled. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient was started on her home regime of coumadin post op day 1, as well as her home medications. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Pravastatin 40 mg PO QPM 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Coumadin per INR Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Docusate Sodium 100 mg PO BID 3. Levothyroxine Sodium 100 mcg PO DAILY 4. Lisinopril 10 mg PO DAILY 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:*0 6. Pravastatin 40 mg PO QPM 7. Senna 8.6 mg PO BID:PRN constipation 8. Warfarin 2.5 mg PO DAILY dosing per ___ clinic. 9. Metoprolol Succinate XL 50 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ were admitted to the hospital with acute cholecystitis. ___ were taken to the operating room and had your gallbladder removed laparoscopically. ___ tolerated the procedure well and are now being discharged home to continue your recovery with the following instructions. Please follow up in the Acute Care Surgery clinic at the appointment listed below. ___ may resume your Coumadin medication today. Please follow up with the ___ clinic and Dr. ___ dosing and blood work. ACTIVITY: o Do not drive until ___ have stopped taking pain medicine and feel ___ could respond in an emergency. o ___ may climb stairs. o ___ may go outside, but avoid traveling long distances until ___ see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o ___ may start some light exercise when ___ feel comfortable. o ___ will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when ___ can resume tub baths or swimming. HOW ___ MAY FEEL: o ___ may feel weak or "washed out" for a couple of weeks. ___ might want to nap often. Simple tasks may exhaust ___. o ___ may have a sore throat because of a tube that was in your throat during surgery. o ___ might have trouble concentrating or difficulty sleeping. ___ might feel somewhat depressed. o ___ could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow ___ may shower and remove the gauzes over your incisions. Under these dressing ___ have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o ___ may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless ___ were told otherwise. o ___ may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o ___ may shower. As noted above, ask your doctor when ___ may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, ___ may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. ___ can get both of these medicines without a prescription. o If ___ go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If ___ find the pain is getting worse instead of better, please contact your surgeon. o ___ will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if ___ take it before your pain gets too severe. o Talk with your surgeon about how long ___ will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If ___ are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when ___ cough or when ___ are doing your deep breathing exercises. If ___ experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines ___ were on before the operation just as ___ did before, unless ___ have been told differently. If ___ have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___	[ "K8013", "E785", "I10", "I4891", "E039", "Z85828", "Z87891", "Z7901" ]	Allergies: ropinirole Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [MASKED] laparoscopic cholecystectomy History of Present Illness: She is status post a complicated course where she had cholecystitis that was complicated by AFib with RVR with periods of bradycardia and cardiac pause. Given that she had significant cardiac issues, these were dealt with first, and her percutaneous cholecystostomy tube was placed in a delayed manner as the patient both had cardiac issues and had a delay in her HIDA scan which showed noninflamed gallbladder and then left AMA to attend family issues as her husband had an important medical exam regarding a possible cancer diagnosis that she had to attend. We brought her back in immediately requesting that she get a percutaneous cholecystostomy tube with which she has done clinically well. However, there was a small complication just prior to the [MASKED] where the patient was visiting her primary care physician and had increased pain at the site. This was evaluated by a percutaneous cholecystostomy cholangiogram which showed that the tube was well placed. It was thought there might be a small collection of bile and that potentially bulb suction would remedy the issue; however, it resolved without changing to bulb suction and simply using gravity drainage. The patient is very eager to have her percutaneous cholecystostomy tube removed; however, she is still draining about [MASKED] mL of what looks like hydrops and still with evidence of complete obstruction on her cholangiogram despite a well-placed tube. She is complaining of some mild tenderness at the insertion site of the tube itself. This is consistent with foreign body reaction and no evidence of infection. Otherwise, she is afebrile, nontender, able to perform her ADLs and eat. Past Medical History: Hypothyroidism Hypertension Hyperlipidemia Irritable bowel syndrome Subclavian stenosis Social History: [MASKED] Family History: -CAD: mother, father, and brother died of heart disease -Diabetes: father, brother, sister No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: [MASKED] Physical Exam [MASKED]: VITAL SIGNS: Stable. ABDOMEN: She has the percutaneous cholecystostomy tube in place with trace redness around it that is consistent with just foreign body reaction rather than erythema, and there is no drainage. There is clear liquid in the bag, roughly 5 mL. She has a nontender abdomen and otherwise is clinically well. Discharge Physical Exam: VS: 99.2, 71, 101/53, 20, 92% RA Gen: Sitting up in chair alert and interactive with husband at bedside. HEENT: no deformities. mucus membranes moist. neck soft, supple. Trachea midline. Resp: Breath sounds clear to auscultation. NAD. CV: RRR Abd: soft, mild tenderness at surgical sites as anticipated, mild distention. Skin: Laparoscopic sites to abdomen CDI with DSD. Ext: Warm and dry. [MASKED] pulses 2+ palpable. Pertinent Results: [MASKED] 11:07AM BLOOD Plt [MASKED] [MASKED] 11:07AM BLOOD WBC-14.1* RBC-3.40* Hgb-10.2* Hct-31.1* MCV-92 MCH-30.0 MCHC-32.8 RDW-13.0 RDWSD-42.8 Plt [MASKED] Brief Hospital Course: [MASKED] is a [MASKED] who was admitted to the General Surgical Service on [MASKED] for evaluation and treatment of abdominal pain and gallstones. The patient was admitted to the Acute Care Surgery service for further medical care. The patient underwent laparoscopic cholecystectomy on HD1, which went well without complication (refer to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating on IV fluids, and on pain control. The patient was hemodynamically stable. Pain was well controlled. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient was started on her home regime of coumadin post op day 1, as well as her home medications. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Pravastatin 40 mg PO QPM 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Coumadin per INR Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Docusate Sodium 100 mg PO BID 3. Levothyroxine Sodium 100 mcg PO DAILY 4. Lisinopril 10 mg PO DAILY 5. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:*0 6. Pravastatin 40 mg PO QPM 7. Senna 8.6 mg PO BID:PRN constipation 8. Warfarin 2.5 mg PO DAILY dosing per [MASKED] clinic. 9. Metoprolol Succinate XL 50 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], [MASKED] were admitted to the hospital with acute cholecystitis. [MASKED] were taken to the operating room and had your gallbladder removed laparoscopically. [MASKED] tolerated the procedure well and are now being discharged home to continue your recovery with the following instructions. Please follow up in the Acute Care Surgery clinic at the appointment listed below. [MASKED] may resume your Coumadin medication today. Please follow up with the [MASKED] clinic and Dr. [MASKED] dosing and blood work. ACTIVITY: o Do not drive until [MASKED] have stopped taking pain medicine and feel [MASKED] could respond in an emergency. o [MASKED] may climb stairs. o [MASKED] may go outside, but avoid traveling long distances until [MASKED] see your surgeon at your next visit. o Don't lift more than [MASKED] lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o [MASKED] may start some light exercise when [MASKED] feel comfortable. o [MASKED] will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when [MASKED] can resume tub baths or swimming. HOW [MASKED] MAY FEEL: o [MASKED] may feel weak or "washed out" for a couple of weeks. [MASKED] might want to nap often. Simple tasks may exhaust [MASKED]. o [MASKED] may have a sore throat because of a tube that was in your throat during surgery. o [MASKED] might have trouble concentrating or difficulty sleeping. [MASKED] might feel somewhat depressed. o [MASKED] could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow [MASKED] may shower and remove the gauzes over your incisions. Under these dressing [MASKED] have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o [MASKED] may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless [MASKED] were told otherwise. o [MASKED] may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o [MASKED] may shower. As noted above, ask your doctor when [MASKED] may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, [MASKED] may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. [MASKED] can get both of these medicines without a prescription. o If [MASKED] go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If [MASKED] find the pain is getting worse instead of better, please contact your surgeon. o [MASKED] will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if [MASKED] take it before your pain gets too severe. o Talk with your surgeon about how long [MASKED] will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If [MASKED] are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when [MASKED] cough or when [MASKED] are doing your deep breathing exercises. If [MASKED] experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines [MASKED] were on before the operation just as [MASKED] did before, unless [MASKED] have been told differently. If [MASKED] have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: [MASKED]	[]	[ "E785", "I10", "I4891", "E039", "Z87891", "Z7901" ]	[ "K8013: Calculus of gallbladder with acute and chronic cholecystitis with obstruction", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "I4891: Unspecified atrial fibrillation", "E039: Hypothyroidism, unspecified", "Z85828: Personal history of other malignant neoplasm of skin", "Z87891: Personal history of nicotine dependence", "Z7901: Long term (current) use of anticoagulants" ]
10,096,391	25,591,360	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ropinirole Attending: ___. Chief Complaint: Epigastric pain and fatigue Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. ___ is a ___ year old woman with a history of HTN & IBS who presented with 3 days of "feeling generally horrible" and is transferred to the CCU after having 2 episodes of syncope upon arrival to the floor. She was at her baseline on ___, but developed general malaise, abdominal cramping, and chest pain on ___. Chest pain was in a band across anterior chest, did not radiate. She had one episode of diarrhea, and her abdominal cramping resolved. Since ___, she has had episodic abdominal pain, but no further chest pain. She has had decreased PO intake during this time. Also with increasing dyspnea on exertion. No fevers, chills, nausea, vomiting, changes in bowel movements, lightheadedness or dizziness. No syncope at home. She came to the ED because her malaise was progressing and she had more abdominal pain on the morning of admission. Of note, she has been feeling stressed this week due to her husband's illness, which she believes may contribute to her symptoms. In the ED, initial vitals were: T 99.3 P ___ BP 168/83 RR 20 SpO2 99% RA Exam: abdomen nontender Labs: WBC 15.2 and normal LFTs, negative U/A EKG showed afib with RVR (rate 143), with normal axis and ST depressions like rate-related. Imaging: No acute cardiopulmonary process. CT abdomen and pelvis showed a distended and inflamed gallbladder consistent with acute cholecystitis. Consults: ACS, recommended HIDA scan in the morning Patient was given: Diltiazem 30mg PO, then 10mg IV, IV fluids 1L NS, cipro 400mg IV, and flagyl 500mg IV . Vitals on transfer to floor were: P ___ BP 144/63 SpO2 99% RA On arrival the floor, patient denied abdominal pain. She endorsed urinary frequency but denied dysuria. She denied palpitations, lightheadedness, or dizziness. She was put on telemetry, and became bradycardic, with a 3.5 second pause on telemetry with brief Afib with RVR lasting seconds, followed by conversion to sinus rhythm after the pause. Code blue was called, but quickly cancelled when patient woke up and resumed normal heart rate. ECG showed normal sinus rhythm. She was not given any additional medications. 5 minutes later, she passed out again and had another pause on telemetry. A second Code Blue was called. She reported that she has frequent episodes of passing out at home. Just before passing out, she felt diaphoretic and clammy. Decision was made to admit to CCU for further management of heart rate and syncopal episodes. Upon arrival to the CCU, patient feels better. No current chest pain, palpitation, shortness of breath, or abdominal pain. No further diarrhea. She confirms that she has about 2 episodes of syncope per year since childhood. No increased frequency of syncope; last episode prior to this admission was in the ___. REVIEW OF SYSTEMS: (+) per HPI Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. Denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Denies recent fevers, chills or rigors. Denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: Hypothyroidism Hypertension Hyperlipidemia Irritable bowel syndrome Subclavian stenosis Social History: ___ Family History: -CAD: mother, father, and brother died of heart disease -Diabetes: father, brother, sister No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM VS: T 98.3 HR 88 BP 151/85 RR 25 SaO2 99% ra Tele: No events in the CCU. 3.5 second pause while on the floor. Afib with RVR converted to NSR after that pause Gen: Lying in bed, no acute distress, alert, oriented HEENT: No scleral icterus, MMM, nl OP NECK: no JVD CV: rrr, no m/r/g LUNGS: LCAB, no wheezes or crackles ABD: +bs, soft, NT/ND, no ___ sign EXT: warm, 2+ DP pulses, no edema SKIN: no cyanosis NEURO: A&Ox3, no gross deficits DISCHARGE PHYSICAL EXAM VS: T 98.1, HR 108, BP 101/56, RR 16, O2Sat 96% Gen: Lying in bed, no acute distress, alert, oriented HEENT: No scleral icterus, MMM, nl OP NECK: no JVD CV: irregular, no m/r/g LUNGS: LCAB, no wheezes or crackles ABD: +bs, soft, NT/ND, no ___ sign EXT: warm, 2+ DP pulses, no edema SKIN: no cyanosis NEURO: A&Ox3, no gross deficits Pertinent Results: ADMISSION LABS: ___ 12:05PM BLOOD WBC-15.2# RBC-4.45 Hgb-13.2 Hct-40.8 MCV-92 MCH-29.7 MCHC-32.4 RDW-12.8 RDWSD-42.5 Plt ___ ___ 12:05PM BLOOD Neuts-70.1 Lymphs-18.9 Monos-10.1 Eos-0.1* Baso-0.3 Im ___ AbsNeut-10.68* AbsLymp-2.88 AbsMono-1.54* AbsEos-0.02* AbsBaso-0.04 ___ 12:05PM BLOOD ___ PTT-29.6 ___ ___ 12:05PM BLOOD Glucose-156* UreaN-17 Creat-1.1 Na-132* K-3.6 Cl-94* HCO3-23 AnGap-19 ___ 12:05PM BLOOD ALT-15 AST-22 AlkPhos-63 TotBili-0.5 ___ 12:05PM BLOOD cTropnT-<0.01 ___ 12:05PM BLOOD Albumin-5.1 Calcium-10.4* Phos-3.6 Mg-1.8 ___ 10:35PM BLOOD ___ pO2-55* pCO2-33* pH-7.42 calTCO2-22 Base XS--1 ___ 04:58PM BLOOD Lactate-1.9 MICRO: ___ MRSA: ___ Blood cultures: IMAGING: ___ CT CHEST/ABDOMEN: 1. Nonspecific gallbladder wall edema. Recommend clinical correlation, and consider ultrasound for direct evaluation and/or HIDA scan. I note from review of the ED dashboard that HIDA scan is planned. 2. Low-attenuation liver with appearances compatible with fatty infiltration with focal fatty sparing at the gallbladder fossa. 2. No evidence for pulmonary embolism or other acute aortic process. There is atherosclerotic disease, including moderate stenosis of the left subclavian artery. 3. Moderate centrilobular emphysema. ___ CXR: No acute cardiopulmonary process. DISCHARGE LABS: ___ 04:07AM BLOOD WBC-17.1* RBC-3.78* Hgb-11.3 Hct-34.9 MCV-92 MCH-29.9 MCHC-32.4 RDW-13.0 RDWSD-44.1 Plt ___ ___ 04:07AM BLOOD Glucose-118* UreaN-19 Creat-1.0 Na-134 K-4.0 Cl-98 HCO3-22 AnGap-18 ___ 04:07AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.___ with HTN who presents with three days of epigastric discomfort, decreased appetite, and fatigue, found to have gallbladder inflammation on CT concerning for cholecystitis, as well as afib with RVR in ED. She was transferred to the CCU on ___ after having 2 episodes of syncope with a 3.5 second pause on telemetry. # CORONARIES: No cath on file # PUMP: EF>75% in ___ # RHYTHM: Afib on admission, converted to NSR after pause # SYNCOPE: Patient had 2 episodes of syncope shortly after arrival to the floor. She was on telemetry during this time, and was in Afib prior to the syncope, had a 3.5 second pause on telemetry, then converted to NSR after the syncopal episode. She immediately regained consciousness. DDx includes vasovagal, which fits with her prior episodes of syncope since childhood vs. conversion of Afib to sinus rhythm with pauses on telemetry. Also of note, she received high doses of Diltiazam in the ED, which could be contributing to her symptoms and pause on tele. Patient did not have any further episodes of syncope while inpatient. # AFIB WITH RVR: She has no known history of Afib, but on admission, was in Afib with RVR in the ED. CHADS score 2. Patient continued to flip in and out of Afib from sinus rhythm during admission. Patient started on warfarin for goal INR ___ and metoprolol for rate control. Patient was transitioned to rivaroxaban prior to discharge. # EPIGASTRIC/CHEST PAIN: Trop-T: <0.01 on admission. CT showed enlarged gall bladder concerning for cholecystitis but patient was asymptomatic after first day of admission. RUQ US showed gallstones but no active signs of cholecystitis. HIDA scan showed cystic duct obstruction. Surgery felt that patient could have cholecystectomy once cardiac issues were resolved. Patient left hospital prior to discussion with surgery as she wanted to be able to go to her husband's doctor's appointment on ___. CHRONIC ISSUES: #Hypertension: -Continued home lisinopril 10mg daily #Hyperlipidemia: -Continued home pravastatin 40mg daily #Hypothyroidism: -Continued home levothyroxine 100mcg daily * TRANSITIONAL ISSUES * ## ANTIARRHYTHMICS: to start Norpace 150 TID, combined with magnesium supplementation with EP follow up ## ANTICOAGULATION: transitioned from warfarin (received 2 doses) to rivaroxaban ## LEUKOCYTOSIS: elevated to 17 during admission, no fevers, but imaging with cystic duct obstruction - should have repeat CBC with PCP follow up ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Pravastatin 40 mg PO QPM Discharge Medications: 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Pravastatin 40 mg PO QPM 4. Metoprolol Succinate XL 100 mg PO DAILY RX metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 5. Rivaroxaban 20 mg PO DINNER RX rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth with dinner, daily Disp #30 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: =========================== Atrial fibrillation Syncope Cystic duct obstruction without clinical evidence of cholecystitis SECONDARY DIAGNOSES: =========================== Hyperthyroidism Subclavian stenosis (L) Irritable bowel syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were recently in the hospital because you were feeling unwell and you were transferred to the cardiac intensive care unit after you lost consciousness twice. You were found to have an abnormal heart rhythm, called atrial fibrillation, which can cause your heart to beat very quickly. This may have been happening at home and making you feel unwell. It may have contributed to your fainting spells as well. You were also found to have a blockage in your gallbladder which may have caused some abdominal pain or uneasiness. If you develop fevers or worsening abdominal pain, please go to the nearest emergency room. It was a pleasure participating in your care. We wish you all the best in the future. Sincerely, Your ___ Team Followup Instructions: ___	[ "K820", "J849", "I4891", "R55", "I10", "E039", "E0590", "E780", "Z87891", "R7309", "M5127", "Z66", "Z8249" ]	Allergies: ropinirole Chief Complaint: Epigastric pain and fatigue Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. [MASKED] is a [MASKED] year old woman with a history of HTN & IBS who presented with 3 days of "feeling generally horrible" and is transferred to the CCU after having 2 episodes of syncope upon arrival to the floor. She was at her baseline on [MASKED], but developed general malaise, abdominal cramping, and chest pain on [MASKED]. Chest pain was in a band across anterior chest, did not radiate. She had one episode of diarrhea, and her abdominal cramping resolved. Since [MASKED], she has had episodic abdominal pain, but no further chest pain. She has had decreased PO intake during this time. Also with increasing dyspnea on exertion. No fevers, chills, nausea, vomiting, changes in bowel movements, lightheadedness or dizziness. No syncope at home. She came to the ED because her malaise was progressing and she had more abdominal pain on the morning of admission. Of note, she has been feeling stressed this week due to her husband's illness, which she believes may contribute to her symptoms. In the ED, initial vitals were: T 99.3 P [MASKED] BP 168/83 RR 20 SpO2 99% RA Exam: abdomen nontender Labs: WBC 15.2 and normal LFTs, negative U/A EKG showed afib with RVR (rate 143), with normal axis and ST depressions like rate-related. Imaging: No acute cardiopulmonary process. CT abdomen and pelvis showed a distended and inflamed gallbladder consistent with acute cholecystitis. Consults: ACS, recommended HIDA scan in the morning Patient was given: Diltiazem 30mg PO, then 10mg IV, IV fluids 1L NS, cipro 400mg IV, and flagyl 500mg IV . Vitals on transfer to floor were: P [MASKED] BP 144/63 SpO2 99% RA On arrival the floor, patient denied abdominal pain. She endorsed urinary frequency but denied dysuria. She denied palpitations, lightheadedness, or dizziness. She was put on telemetry, and became bradycardic, with a 3.5 second pause on telemetry with brief Afib with RVR lasting seconds, followed by conversion to sinus rhythm after the pause. Code blue was called, but quickly cancelled when patient woke up and resumed normal heart rate. ECG showed normal sinus rhythm. She was not given any additional medications. 5 minutes later, she passed out again and had another pause on telemetry. A second Code Blue was called. She reported that she has frequent episodes of passing out at home. Just before passing out, she felt diaphoretic and clammy. Decision was made to admit to CCU for further management of heart rate and syncopal episodes. Upon arrival to the CCU, patient feels better. No current chest pain, palpitation, shortness of breath, or abdominal pain. No further diarrhea. She confirms that she has about 2 episodes of syncope per year since childhood. No increased frequency of syncope; last episode prior to this admission was in the [MASKED]. REVIEW OF SYSTEMS: (+) per HPI Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. Denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Denies recent fevers, chills or rigors. Denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: Hypothyroidism Hypertension Hyperlipidemia Irritable bowel syndrome Subclavian stenosis Social History: [MASKED] Family History: -CAD: mother, father, and brother died of heart disease -Diabetes: father, brother, sister No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM VS: T 98.3 HR 88 BP 151/85 RR 25 SaO2 99% ra Tele: No events in the CCU. 3.5 second pause while on the floor. Afib with RVR converted to NSR after that pause Gen: Lying in bed, no acute distress, alert, oriented HEENT: No scleral icterus, MMM, nl OP NECK: no JVD CV: rrr, no m/r/g LUNGS: LCAB, no wheezes or crackles ABD: +bs, soft, NT/ND, no [MASKED] sign EXT: warm, 2+ DP pulses, no edema SKIN: no cyanosis NEURO: A&Ox3, no gross deficits DISCHARGE PHYSICAL EXAM VS: T 98.1, HR 108, BP 101/56, RR 16, O2Sat 96% Gen: Lying in bed, no acute distress, alert, oriented HEENT: No scleral icterus, MMM, nl OP NECK: no JVD CV: irregular, no m/r/g LUNGS: LCAB, no wheezes or crackles ABD: +bs, soft, NT/ND, no [MASKED] sign EXT: warm, 2+ DP pulses, no edema SKIN: no cyanosis NEURO: A&Ox3, no gross deficits Pertinent Results: ADMISSION LABS: [MASKED] 12:05PM BLOOD WBC-15.2# RBC-4.45 Hgb-13.2 Hct-40.8 MCV-92 MCH-29.7 MCHC-32.4 RDW-12.8 RDWSD-42.5 Plt [MASKED] [MASKED] 12:05PM BLOOD Neuts-70.1 Lymphs-18.9 Monos-10.1 Eos-0.1* Baso-0.3 Im [MASKED] AbsNeut-10.68* AbsLymp-2.88 AbsMono-1.54* AbsEos-0.02* AbsBaso-0.04 [MASKED] 12:05PM BLOOD [MASKED] PTT-29.6 [MASKED] [MASKED] 12:05PM BLOOD Glucose-156* UreaN-17 Creat-1.1 Na-132* K-3.6 Cl-94* HCO3-23 AnGap-19 [MASKED] 12:05PM BLOOD ALT-15 AST-22 AlkPhos-63 TotBili-0.5 [MASKED] 12:05PM BLOOD cTropnT-<0.01 [MASKED] 12:05PM BLOOD Albumin-5.1 Calcium-10.4* Phos-3.6 Mg-1.8 [MASKED] 10:35PM BLOOD [MASKED] pO2-55* pCO2-33* pH-7.42 calTCO2-22 Base XS--1 [MASKED] 04:58PM BLOOD Lactate-1.9 MICRO: [MASKED] MRSA: [MASKED] Blood cultures: IMAGING: [MASKED] CT CHEST/ABDOMEN: 1. Nonspecific gallbladder wall edema. Recommend clinical correlation, and consider ultrasound for direct evaluation and/or HIDA scan. I note from review of the ED dashboard that HIDA scan is planned. 2. Low-attenuation liver with appearances compatible with fatty infiltration with focal fatty sparing at the gallbladder fossa. 2. No evidence for pulmonary embolism or other acute aortic process. There is atherosclerotic disease, including moderate stenosis of the left subclavian artery. 3. Moderate centrilobular emphysema. [MASKED] CXR: No acute cardiopulmonary process. DISCHARGE LABS: [MASKED] 04:07AM BLOOD WBC-17.1* RBC-3.78* Hgb-11.3 Hct-34.9 MCV-92 MCH-29.9 MCHC-32.4 RDW-13.0 RDWSD-44.1 Plt [MASKED] [MASKED] 04:07AM BLOOD Glucose-118* UreaN-19 Creat-1.0 Na-134 K-4.0 Cl-98 HCO3-22 AnGap-18 [MASKED] 04:07AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.[MASKED] with HTN who presents with three days of epigastric discomfort, decreased appetite, and fatigue, found to have gallbladder inflammation on CT concerning for cholecystitis, as well as afib with RVR in ED. She was transferred to the CCU on [MASKED] after having 2 episodes of syncope with a 3.5 second pause on telemetry. # CORONARIES: No cath on file # PUMP: EF>75% in [MASKED] # RHYTHM: Afib on admission, converted to NSR after pause # SYNCOPE: Patient had 2 episodes of syncope shortly after arrival to the floor. She was on telemetry during this time, and was in Afib prior to the syncope, had a 3.5 second pause on telemetry, then converted to NSR after the syncopal episode. She immediately regained consciousness. DDx includes vasovagal, which fits with her prior episodes of syncope since childhood vs. conversion of Afib to sinus rhythm with pauses on telemetry. Also of note, she received high doses of Diltiazam in the ED, which could be contributing to her symptoms and pause on tele. Patient did not have any further episodes of syncope while inpatient. # AFIB WITH RVR: She has no known history of Afib, but on admission, was in Afib with RVR in the ED. CHADS score 2. Patient continued to flip in and out of Afib from sinus rhythm during admission. Patient started on warfarin for goal INR [MASKED] and metoprolol for rate control. Patient was transitioned to rivaroxaban prior to discharge. # EPIGASTRIC/CHEST PAIN: Trop-T: <0.01 on admission. CT showed enlarged gall bladder concerning for cholecystitis but patient was asymptomatic after first day of admission. RUQ US showed gallstones but no active signs of cholecystitis. HIDA scan showed cystic duct obstruction. Surgery felt that patient could have cholecystectomy once cardiac issues were resolved. Patient left hospital prior to discussion with surgery as she wanted to be able to go to her husband's doctor's appointment on [MASKED]. CHRONIC ISSUES: #Hypertension: -Continued home lisinopril 10mg daily #Hyperlipidemia: -Continued home pravastatin 40mg daily #Hypothyroidism: -Continued home levothyroxine 100mcg daily * TRANSITIONAL ISSUES * ## ANTIARRHYTHMICS: to start Norpace 150 TID, combined with magnesium supplementation with EP follow up ## ANTICOAGULATION: transitioned from warfarin (received 2 doses) to rivaroxaban ## LEUKOCYTOSIS: elevated to 17 during admission, no fevers, but imaging with cystic duct obstruction - should have repeat CBC with PCP follow up [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Pravastatin 40 mg PO QPM Discharge Medications: 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Pravastatin 40 mg PO QPM 4. Metoprolol Succinate XL 100 mg PO DAILY RX metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 5. Rivaroxaban 20 mg PO DINNER RX rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth with dinner, daily Disp #30 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: =========================== Atrial fibrillation Syncope Cystic duct obstruction without clinical evidence of cholecystitis SECONDARY DIAGNOSES: =========================== Hyperthyroidism Subclavian stenosis (L) Irritable bowel syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were recently in the hospital because you were feeling unwell and you were transferred to the cardiac intensive care unit after you lost consciousness twice. You were found to have an abnormal heart rhythm, called atrial fibrillation, which can cause your heart to beat very quickly. This may have been happening at home and making you feel unwell. It may have contributed to your fainting spells as well. You were also found to have a blockage in your gallbladder which may have caused some abdominal pain or uneasiness. If you develop fevers or worsening abdominal pain, please go to the nearest emergency room. It was a pleasure participating in your care. We wish you all the best in the future. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "I4891", "I10", "E039", "Z87891", "Z66" ]	[ "K820: Obstruction of gallbladder", "J849: Interstitial pulmonary disease, unspecified", "I4891: Unspecified atrial fibrillation", "R55: Syncope and collapse", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "E0590: Thyrotoxicosis, unspecified without thyrotoxic crisis or storm", "E780: Pure hypercholesterolemia", "Z87891: Personal history of nicotine dependence", "R7309: Other abnormal glucose", "M5127: Other intervertebral disc displacement, lumbosacral region", "Z66: Do not resuscitate", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]
10,096,391	26,251,990	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ropinirole Attending: ___. Chief Complaint: Epigastric pain Major Surgical or Invasive Procedure: Percutaneous cholecystostomy History of Present Illness: ___ is a ___ year old woman with a history of hypertension and a recent admission for fatigue and epigastric pain, who was found to have cystic duct obstruction on HIDA and presents for treatment. Of note, her prior hospitalization was complicated by afib with RVR and syncopal events. She was started on Coumadin for anticoagulation but discharged on xarelto which she picked up at the pharmacy today. She underwent HIDA during her stay but left AMA before receiving the results so that she could go to her husband's doctor appointment. This morning, she was told over the phone that she has cystic duct obstruction, and she presents for direct admission for percutaneous drainage. In the ED, initial vitals: T 97.4 P 70 BP 122/46 RR 16 SpO2 100% RA - Exam notable for: mild RUQ tenderness - Labs notable for: INR 3.8, BUN 48, Cr 1.5, WBC 12.0, H/H 10.6/32.9, LFTs normal - Imaging notable for: HIDA scan on ___ suggestive of cystic duct obstruction - Pt given: 1L NS - Vitals prior to transfer: P 63 BP 114/50 She endorses fatigue over the past few days but improved from one week ago. She is unable to walk up a full flight of stairs without taking a break. She denies pain but endorses low appetite. No fevers, chills, shortness of breath, chest pain or palpitations, or additional syncopal events since discharge. ROS: No fevers, chills, night sweats, or weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No nausea or vomiting. No numbness or weakness, no focal deficits. Past Medical History: Hypothyroidism Hypertension Hyperlipidemia Irritable bowel syndrome Subclavian stenosis Social History: ___ Family History: -CAD: mother, father, and brother died of heart disease -Diabetes: father, brother, sister No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: Vitals- T 98.0 P 68 BP 107/60 RR 18 SpO2 99% RA General- Alert, oriented, no acute distress HEENT- Sclerae anicteric, MMM, oropharynx clear Neck- Supple, JVP not elevated, no LAD Lungs- Lungs clear to auscultation bilaterally, no wheezes, rales, rhonchi CV- Regular rate and rhythm, normal S1+S2, no murmurs, rubs, or gallops Abdomen- +BS, soft, mild RUQ tenderness with deep inspiration, no rebound tenderness or guarding, no organomegaly GU- No foley Ext- Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- Motor function grossly normal DISCHARGE EXAM: Vitals: Tc 98.6, Tm 98.8, BP 130-146/72-83, HR 97-100s, 97% 2L, weaned to 92-95% on RA, satted 92-93% on RA with ambulation General- Alert, oriented, no acute distress HEENT- Sclerae anicteric, MMM, oropharynx clear Neck- Supple, JVP not elevated Lungs- faint bibasilar crackles, no wheezing CV- Regular rate and rhythm, normal S1+S2, no murmurs, rubs, or gallops Abdomen- Perc chole tube in place draining blood tinged fluid. Bandage C/D/I. Tender over RUQ. Otherwise soft, nontender elsewhere, +BS. Ext- Warm, well perfused, 2+ pulses, no edema Pertinent Results: LABS ON ADMISSION: ___ 04:35PM GLUCOSE-116* UREA N-48* CREAT-1.5* SODIUM-137 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-23 ANION GAP-18 ___ 04:35PM ALT(SGPT)-38 AST(SGOT)-39 ALK PHOS-53 TOT BILI-0.2 ___ 04:35PM LIPASE-58 ___ 04:35PM ALBUMIN-4.1 CALCIUM-9.5 PHOSPHATE-3.8 MAGNESIUM-2.2 ___ 04:35PM WBC-12.0* RBC-3.52* HGB-10.6* HCT-32.9* MCV-94 MCH-30.1 MCHC-32.2 RDW-13.0 RDWSD-43.9 ___ 04:35PM NEUTS-64.6 ___ MONOS-12.6 EOS-0.6* BASOS-0.4 IM ___ AbsNeut-7.77* AbsLymp-2.59 AbsMono-1.51* AbsEos-0.07 AbsBaso-0.05 ___ 04:35PM PLT COUNT-310 ___ 04:35PM ___ PTT-43.5* ___ ___ 04:35PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 04:35PM URINE RBC-4* WBC-32* BACTERIA-FEW YEAST-NONE EPI-5 ___ 04:35PM URINE HYALINE-1* ___ 04:35PM URINE MUCOUS-RARE LABS ON DISCHARGE: ___ 05:00AM BLOOD WBC-14.5* RBC-3.43* Hgb-10.3* Hct-31.5* MCV-92 MCH-30.0 MCHC-32.7 RDW-12.9 RDWSD-43.6 Plt ___ ___ 05:00AM BLOOD ___ ___ 05:00AM BLOOD Glucose-99 UreaN-21* Creat-1.2* Na-136 K-3.7 Cl-96 HCO3-23 AnGap-21* ___ 05:00AM BLOOD Calcium-9.5 Phos-3.1 Mg-1.9 IMAGING: U/S guided percutaneous cholecystostomy tube ___: FINDINGS: Gallbladder was identified with multiple stones, and amenable to drain placement. Post-procedure imaging showed no evidence of complication. IMPRESSION: Successful ultrasound-guided placement of ___ pigtail catheter into the gallbladder. Samples was sent for microbiology evaluation. CXR ___ FINDINGS: Moderate cardiomegaly is stable. Mild to moderate pulmonary edema is new. Right lower lobe opacities are likely atelectasis. There is pleural small right effusion. There is no evident pneumothorax. Catheter projects in the right upper quadrant of the abdomen IMPRESSION: Mild to moderate pulmonary edema Brief Hospital Course: ___ with one week of epigastric pain and fatigue, with recent admission complicated by afib with RVR and syncope, found to have cystic duct obstruction on HIDA, readmitted for percutaneous cholecystostomy. #Cystic duct obstruction: She had mild RUQ pain and only mild pain with ___ test. However, imaging was consistent with cystic duct obstruction. Her INR was reversed with 3U FFP and she underwent percutaneous cholecystostomy on ___ which was uncomplicated. She received Unasyn while in house and was discharged on Augmentin for a 7 day course to end on ___. She will see Cardiology for a preoperative evaluation, then pursue follow-up with General Surgery for future elective cholecystectomy. #Atrial fibrillation: Her anti-arrhythmic medications were continued, but the dose of metoprolol was decreased due to sinus bradycardia. Her Rivaroxaban was held for supratherapeutic INR and she was instructed to restart on ___. She was monitored on telemetry and remained in sinus rhythm throughout, with no syncopal episodes. #Pulmonary edema: After her procedure and receiving IV fluids, she had an oxygen requirement and CXR evidence of pulmonary edema. She improved with diuresis and was discharged on room air. ___: Her Cr on admission was 1.5 from her baseline of 1.0, which resolved with IV fluids. Her home lisinopril was held in this setting. Her discharged Cr was 1.2. TRANSITIONAL ISSUES: -Outpatient f/u with general surgery for elective cholecystectomy -Cardiology appointment on ___. Recommend pre-operative evaluation if further work-up is needed for her arrhythmia and heart failure before cholecystectomy -Fluid from perc chole was sent for culture, results pending -Set up for home ___ to monitor chole drain. Instructions to call Radiology when output falls <10cc for 2 days in a row for consideration of removal. -Augmentin until ___ -Metoprolol decreased to 50 mg XL -should hold xarelto and restart on ___ -will need Chem 7, BUN/Cr, INR on ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Pravastatin 40 mg PO QPM 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Rivaroxaban 15 mg PO DINNER 6. Disopyramide Phosphate 150 mg PO Q8H Discharge Medications: 1. Disopyramide Phosphate 150 mg PO Q8H 2. Levothyroxine Sodium 100 mcg PO DAILY 3. Pravastatin 40 mg PO QPM 4. Rivaroxaban 15 mg PO DINNER 5. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain RX tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6 hours Disp #28 Tablet Refills:0 6. Amoxicillin-Clavulanic Acid ___ mg PO Q8H RX amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet by mouth every eight (8) hours Disp #15 Tablet Refills:0 7. Lisinopril 10 mg PO DAILY 8. Metoprolol Succinate XL 50 mg PO DAILY RX metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Obstructed cystic duct Cholecystitis Atrial fibrillation Pulmonary edema SECONDARY DIAGNOSIS: History of vasovagal syncope 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 at ___ ___. You came to the hospital because the duct from your gallbladder was blocked. You had a procedure where a tube was placed through your skin to drain your gallbladder. You will eventually need a surgery to remove your gall bladder. After the procedure, you had trouble with breathing which was likely due to extra fluid on your lungs. This improved with use of medications. You were also on antibiotics to help with your infection and you should continue those antibiotics until ___. Please below for instructions on caring for this tube. Please follow up with surgery as scheduled below. Prior to this surgery, you will need to see your cardiologist to have pre-operative evaluation. You will need to have labs drawn on ___. Dr. ___ ___ you with a lab slip. Please have them drawn in the ___. You will have your INR drawn at that time. Please hold your xarelto and restart on ___. We wish you the best! -Your ___ Team ___ Drain Care: -Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). -Note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. -Be sure to empty the drain bag or bulb frequently. Record the output daily. You should have a nurse doing this for you. -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. - If you develop worsening abdominal pain, fevers or chills please call Interventional Radiology at ___ at ___ and page ___. -When the drainage total is LESS THAN 10cc/ml for 2 days in a row, please have the ___ call Interventional Radiology at ___ at ___ and page ___. This is the Radiology fellow on call who can assist you. Followup Instructions: ___	[ "K8001", "N179", "I482", "I501", "I10", "E039", "E785", "K589", "I708", "Z87891", "R791", "T45515A", "R0902", "R339" ]	Allergies: ropinirole Chief Complaint: Epigastric pain Major Surgical or Invasive Procedure: Percutaneous cholecystostomy History of Present Illness: [MASKED] is a [MASKED] year old woman with a history of hypertension and a recent admission for fatigue and epigastric pain, who was found to have cystic duct obstruction on HIDA and presents for treatment. Of note, her prior hospitalization was complicated by afib with RVR and syncopal events. She was started on Coumadin for anticoagulation but discharged on xarelto which she picked up at the pharmacy today. She underwent HIDA during her stay but left AMA before receiving the results so that she could go to her husband's doctor appointment. This morning, she was told over the phone that she has cystic duct obstruction, and she presents for direct admission for percutaneous drainage. In the ED, initial vitals: T 97.4 P 70 BP 122/46 RR 16 SpO2 100% RA - Exam notable for: mild RUQ tenderness - Labs notable for: INR 3.8, BUN 48, Cr 1.5, WBC 12.0, H/H 10.6/32.9, LFTs normal - Imaging notable for: HIDA scan on [MASKED] suggestive of cystic duct obstruction - Pt given: 1L NS - Vitals prior to transfer: P 63 BP 114/50 She endorses fatigue over the past few days but improved from one week ago. She is unable to walk up a full flight of stairs without taking a break. She denies pain but endorses low appetite. No fevers, chills, shortness of breath, chest pain or palpitations, or additional syncopal events since discharge. ROS: No fevers, chills, night sweats, or weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No nausea or vomiting. No numbness or weakness, no focal deficits. Past Medical History: Hypothyroidism Hypertension Hyperlipidemia Irritable bowel syndrome Subclavian stenosis Social History: [MASKED] Family History: -CAD: mother, father, and brother died of heart disease -Diabetes: father, brother, sister No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: Vitals- T 98.0 P 68 BP 107/60 RR 18 SpO2 99% RA General- Alert, oriented, no acute distress HEENT- Sclerae anicteric, MMM, oropharynx clear Neck- Supple, JVP not elevated, no LAD Lungs- Lungs clear to auscultation bilaterally, no wheezes, rales, rhonchi CV- Regular rate and rhythm, normal S1+S2, no murmurs, rubs, or gallops Abdomen- +BS, soft, mild RUQ tenderness with deep inspiration, no rebound tenderness or guarding, no organomegaly GU- No foley Ext- Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- Motor function grossly normal DISCHARGE EXAM: Vitals: Tc 98.6, Tm 98.8, BP 130-146/72-83, HR 97-100s, 97% 2L, weaned to 92-95% on RA, satted 92-93% on RA with ambulation General- Alert, oriented, no acute distress HEENT- Sclerae anicteric, MMM, oropharynx clear Neck- Supple, JVP not elevated Lungs- faint bibasilar crackles, no wheezing CV- Regular rate and rhythm, normal S1+S2, no murmurs, rubs, or gallops Abdomen- Perc chole tube in place draining blood tinged fluid. Bandage C/D/I. Tender over RUQ. Otherwise soft, nontender elsewhere, +BS. Ext- Warm, well perfused, 2+ pulses, no edema Pertinent Results: LABS ON ADMISSION: [MASKED] 04:35PM GLUCOSE-116* UREA N-48* CREAT-1.5* SODIUM-137 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-23 ANION GAP-18 [MASKED] 04:35PM ALT(SGPT)-38 AST(SGOT)-39 ALK PHOS-53 TOT BILI-0.2 [MASKED] 04:35PM LIPASE-58 [MASKED] 04:35PM ALBUMIN-4.1 CALCIUM-9.5 PHOSPHATE-3.8 MAGNESIUM-2.2 [MASKED] 04:35PM WBC-12.0* RBC-3.52* HGB-10.6* HCT-32.9* MCV-94 MCH-30.1 MCHC-32.2 RDW-13.0 RDWSD-43.9 [MASKED] 04:35PM NEUTS-64.6 [MASKED] MONOS-12.6 EOS-0.6* BASOS-0.4 IM [MASKED] AbsNeut-7.77* AbsLymp-2.59 AbsMono-1.51* AbsEos-0.07 AbsBaso-0.05 [MASKED] 04:35PM PLT COUNT-310 [MASKED] 04:35PM [MASKED] PTT-43.5* [MASKED] [MASKED] 04:35PM URINE COLOR-Yellow APPEAR-Hazy SP [MASKED] [MASKED] 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG [MASKED] 04:35PM URINE RBC-4* WBC-32* BACTERIA-FEW YEAST-NONE EPI-5 [MASKED] 04:35PM URINE HYALINE-1* [MASKED] 04:35PM URINE MUCOUS-RARE LABS ON DISCHARGE: [MASKED] 05:00AM BLOOD WBC-14.5* RBC-3.43* Hgb-10.3* Hct-31.5* MCV-92 MCH-30.0 MCHC-32.7 RDW-12.9 RDWSD-43.6 Plt [MASKED] [MASKED] 05:00AM BLOOD [MASKED] [MASKED] 05:00AM BLOOD Glucose-99 UreaN-21* Creat-1.2* Na-136 K-3.7 Cl-96 HCO3-23 AnGap-21* [MASKED] 05:00AM BLOOD Calcium-9.5 Phos-3.1 Mg-1.9 IMAGING: U/S guided percutaneous cholecystostomy tube [MASKED]: FINDINGS: Gallbladder was identified with multiple stones, and amenable to drain placement. Post-procedure imaging showed no evidence of complication. IMPRESSION: Successful ultrasound-guided placement of [MASKED] pigtail catheter into the gallbladder. Samples was sent for microbiology evaluation. CXR [MASKED] FINDINGS: Moderate cardiomegaly is stable. Mild to moderate pulmonary edema is new. Right lower lobe opacities are likely atelectasis. There is pleural small right effusion. There is no evident pneumothorax. Catheter projects in the right upper quadrant of the abdomen IMPRESSION: Mild to moderate pulmonary edema Brief Hospital Course: [MASKED] with one week of epigastric pain and fatigue, with recent admission complicated by afib with RVR and syncope, found to have cystic duct obstruction on HIDA, readmitted for percutaneous cholecystostomy. #Cystic duct obstruction: She had mild RUQ pain and only mild pain with [MASKED] test. However, imaging was consistent with cystic duct obstruction. Her INR was reversed with 3U FFP and she underwent percutaneous cholecystostomy on [MASKED] which was uncomplicated. She received Unasyn while in house and was discharged on Augmentin for a 7 day course to end on [MASKED]. She will see Cardiology for a preoperative evaluation, then pursue follow-up with General Surgery for future elective cholecystectomy. #Atrial fibrillation: Her anti-arrhythmic medications were continued, but the dose of metoprolol was decreased due to sinus bradycardia. Her Rivaroxaban was held for supratherapeutic INR and she was instructed to restart on [MASKED]. She was monitored on telemetry and remained in sinus rhythm throughout, with no syncopal episodes. #Pulmonary edema: After her procedure and receiving IV fluids, she had an oxygen requirement and CXR evidence of pulmonary edema. She improved with diuresis and was discharged on room air. [MASKED]: Her Cr on admission was 1.5 from her baseline of 1.0, which resolved with IV fluids. Her home lisinopril was held in this setting. Her discharged Cr was 1.2. TRANSITIONAL ISSUES: -Outpatient f/u with general surgery for elective cholecystectomy -Cardiology appointment on [MASKED]. Recommend pre-operative evaluation if further work-up is needed for her arrhythmia and heart failure before cholecystectomy -Fluid from perc chole was sent for culture, results pending -Set up for home [MASKED] to monitor chole drain. Instructions to call Radiology when output falls <10cc for 2 days in a row for consideration of removal. -Augmentin until [MASKED] -Metoprolol decreased to 50 mg XL -should hold xarelto and restart on [MASKED] -will need Chem 7, BUN/Cr, INR on [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Pravastatin 40 mg PO QPM 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Rivaroxaban 15 mg PO DINNER 6. Disopyramide Phosphate 150 mg PO Q8H Discharge Medications: 1. Disopyramide Phosphate 150 mg PO Q8H 2. Levothyroxine Sodium 100 mcg PO DAILY 3. Pravastatin 40 mg PO QPM 4. Rivaroxaban 15 mg PO DINNER 5. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain RX tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6 hours Disp #28 Tablet Refills:0 6. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q8H RX amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet by mouth every eight (8) hours Disp #15 Tablet Refills:0 7. Lisinopril 10 mg PO DAILY 8. Metoprolol Succinate XL 50 mg PO DAILY RX metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: Obstructed cystic duct Cholecystitis Atrial fibrillation Pulmonary edema SECONDARY DIAGNOSIS: History of vasovagal syncope 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 at [MASKED] [MASKED]. You came to the hospital because the duct from your gallbladder was blocked. You had a procedure where a tube was placed through your skin to drain your gallbladder. You will eventually need a surgery to remove your gall bladder. After the procedure, you had trouble with breathing which was likely due to extra fluid on your lungs. This improved with use of medications. You were also on antibiotics to help with your infection and you should continue those antibiotics until [MASKED]. Please below for instructions on caring for this tube. Please follow up with surgery as scheduled below. Prior to this surgery, you will need to see your cardiologist to have pre-operative evaluation. You will need to have labs drawn on [MASKED]. Dr. [MASKED] [MASKED] you with a lab slip. Please have them drawn in the [MASKED]. You will have your INR drawn at that time. Please hold your xarelto and restart on [MASKED]. We wish you the best! -Your [MASKED] Team [MASKED] Drain Care: -Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). -Note color, consistency, and amount of fluid in the drain. Call the doctor, [MASKED], or [MASKED] nurse if the amount increases significantly or changes in character. -Be sure to empty the drain bag or bulb frequently. Record the output daily. You should have a nurse doing this for you. -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. - If you develop worsening abdominal pain, fevers or chills please call Interventional Radiology at [MASKED] at [MASKED] and page [MASKED]. -When the drainage total is LESS THAN 10cc/ml for 2 days in a row, please have the [MASKED] call Interventional Radiology at [MASKED] at [MASKED] and page [MASKED]. This is the Radiology fellow on call who can assist you. Followup Instructions: [MASKED]	[]	[ "N179", "I10", "E039", "E785", "Z87891" ]	[ "K8001: Calculus of gallbladder with acute cholecystitis with obstruction", "N179: Acute kidney failure, unspecified", "I482: Chronic atrial fibrillation", "I501: Left ventricular failure, unspecified", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "K589: Irritable bowel syndrome without diarrhea", "I708: Atherosclerosis of other arteries", "Z87891: Personal history of nicotine dependence", "R791: Abnormal coagulation profile", "T45515A: Adverse effect of anticoagulants, initial encounter", "R0902: Hypoxemia", "R339: Retention of urine, unspecified" ]
10,096,391	27,466,615	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ropinirole Attending: ___. Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: ___ reports a cough and URI symptoms for the past week. Over the past two days she has felt excessively weak and tired. She hasn't been drinking or eating much. Two days ago, while walking into her bedroom she felt weak and lightheaded and fell down 'before she could make it to her bed' and last night she felt dizzy and weak while brushing her teeth and had a "bad fall on her right side.' She may have grazed her head but did not lose consciousness. Her right posterior chest is sore and painful. She initially felt ok and thought she could 'tough it out' at home but was convinced by her family that she should come to the hospital. Past Medical History: hypothyroid, HTN, HLD, IBS, subclavian stenosis, atrial fibrillation, ?interstitial lung disease (notes that she has never been on steroids and that her breathing and exercise have improved, she was last told by a specialist that she does not have diminished lung function) Social History: ___ Family History: -CAD: mother, father, and brother died of heart disease -Diabetes: father, brother, sister No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Physical Exam: VS: T: 97.9 HR: 72 BP: 115/47 RR: 18 O2: 97% RA HEENT: Head normocephalic, no external signs of trauma Pupils 4->2 mm bilaterally, no blood in orifices midface stable trachea midline, equal chest rise, no bruising or tenderness on CHEST: chest wall anteriorly, 8 cm oblique abrasion to right back abdomen: soft, non-distended, non-tender pelvis: stable and non-tender extremities: warm, non-tender, no lacerations or abrasions gross motor and sensory function intact x 4 extremities Discharge Physical Exam: VS: R: 98.5 PO BP: 117/83 L Sitting HR: 79 RR: 18 O2: 97% Ra GEN: normocephalic, atraumatic HEENT: atraumatic, MMM CV: RRR PULM: coarse rhonchi b/l, no respiratory distress CHEST: right chest wall tenderness with palpation, no overlying skin changes ABD: soft, non-distended, non-tender to palpation EXT: warm, well-perfused, no edema b/l Pertinent Results: IMAGING: ___: ECHO: Normal global and regional biventricular systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. ___: CXR (PA&LAT): Emphysema. Mild fluid overload. No pneumonia. Although no acute fracture or other chest wall lesion is seen, conventional chest radiographs are not sufficient for detection or characterization of most such abnormalities. If the demonstration of trauma to the chest wall is clinically warranted, the location of any referrable focal findings should be clearly marked and imaged with either bone detail radiographs or Chest CT scanning. ___: CT Head: 1. No acute intracranial process. 2. There is acute paranasal sinusitis with fluid, and chronic sphenoid sinusitis. ___: CT C-spine: 1. No evidence for a fracture. 2. Mild retrolisthesis of C4 on C5 is almost certainly degenerative, though there are no prior exams to confirm chronicity. 3. Multilevel degenerative disease. 4. Paraseptal emphysema and partially visualized pleural/parenchymal scarring at the included lung apices. Concurrent CT torso is reported separately. ___: CT Torso: 1. Displaced posterior right tenth and eleventh rib fractures with diminutive right pneumothorax. 2. Diffuse centrilobular emphysema, fibrosis, and multiple areas of scarring. New borderline and enlarged mediastinal and hilar lymph nodes, compared to prior examination. In the setting of centrilobular emphysema and lung fibrosis, tissue sampling could be considered. 3. Severe aortic and coronary artery calcifications. ___: CXR (PA & LAT): Improved vascular congestion. Small pleural effusions. Mild basilar opacities, likely atelectasis. LABS: ___ 06:35AM GLUCOSE-157* UREA N-22* CREAT-1.1 SODIUM-130* POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-22 ANION GAP-14 ___ 06:35AM cTropnT-<0.01 ___ 06:35AM CALCIUM-7.7* PHOSPHATE-2.8 MAGNESIUM-1.6 ___ 05:25AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 05:25AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-SM ___ 05:25AM URINE RBC-25* WBC-54* BACTERIA-FEW YEAST-NONE EPI-1 TRANS EPI-1 ___ 05:25AM URINE MUCOUS-RARE ___ 12:00AM GLUCOSE-204* UREA N-28* CREAT-1.3* SODIUM-129* POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-20* ANION GAP-19 ___ 12:00AM cTropnT-<0.01 ___ 12:00AM WBC-8.2 RBC-4.02 HGB-12.0 HCT-36.3 MCV-90 MCH-29.9 MCHC-33.1 RDW-13.3 RDWSD-44.0 ___ 12:00AM NEUTS-53.0 ___ MONOS-12.3 EOS-0.1* BASOS-0.1 IM ___ AbsNeut-4.33 AbsLymp-2.77 AbsMono-1.01* AbsEos-0.01* AbsBaso-0.01 ___ 12:00AM PLT COUNT-225 ___ 12:00AM ___ PTT-44.7* ___ ___ 11:55PM LACTATE-1.5 Brief Hospital Course: Ms. ___ is a ___ y/o F w/ hx of atrial fibrillation on Coumadin s/p fall. She reported feeling weak and had a cough and URI symptoms for the past week. Imaging revealed displaced posterior right tenth and eleventh rib fractures with diminutive right pneumothorax. She was also diagnosed with a UTI and was started on Augmentin to cover both possible PNA and UTI. The patient was admitted to the Trauma Surgery service for pain control and respiratory monitoring. On the evening of HD1, the patient had a CXR which demonstrated improved vascular congestion, small pleural effusions, and mild basilar opacities, likely atelectasis. On HD2, the patient had a repeat CXR which showed no relevant change when compared to prior CXR. The lateral radiogram showed minimal b/l dorsal pleural effusions, no evidence of PTX. The patient was alert and oriented throughout hospitalization; pain was managed with acetaminophen, ibuprofen and tramadol. She remained stable from a cardiovascular and pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. The patient tolerated a regular diet and intake and output were closely monitored. The patient's blood counts were closely watched for signs of bleeding, of which there were none. The patient's home Coumadin was initially held for a super therapeutic INR of 3.6. When rechecked on HD1, INR was 2.2 so Coumadin was restarted. ___ 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: synthroid ___, lisinopril 10', metoprolol 25ER', pravastatin 40', warfarin 2.5' Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H please take with food RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #8 Tablet Refills:0 3. Ibuprofen 400 mg PO Q6H:PRN Pain - Moderate please take with food 4. TraMADol 25 mg PO Q6H:PRN Pain - Severe do NOT drink alcohol or drive while taking this medication RX tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #20 Tablet Refills:0 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Pravastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary: -Posterior right tenth and eleventh rib fractures -Right pneumothorax Secondary: -Urinary tract infection -Pneumonia 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 suffering a fall. You were found to have two right rib fractures and a small right pneumothorax (puncture of the lung). You were also subsequently found to have a urinary tract infection and an upper respiratory infection concerning for pneumonia. Your rib fractures will heal on their own and you should continue to practice with your incentive spirometer to help with your breathing. You had repeat chest x-rays which showed resolution of the pneumothorax. You were started on an antibiotic called Augmentin (amoxicillin/clavulanate) to treat both your urinary tract infection and pneumonia. You are now ready to be discharged home to continue your recovery. Please note the following discharge instructions: Rib Fractures: * Your injury caused right-sided rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non-steroidal ___ drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). General 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: ___	[ "S270XXA", "J189", "N179", "I4891", "E860", "S2241XA", "N390", "Y92012", "Z87891", "Z7901", "I10", "E039", "E785", "I708", "W1830XA", "R791" ]	Allergies: ropinirole Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] reports a cough and URI symptoms for the past week. Over the past two days she has felt excessively weak and tired. She hasn't been drinking or eating much. Two days ago, while walking into her bedroom she felt weak and lightheaded and fell down 'before she could make it to her bed' and last night she felt dizzy and weak while brushing her teeth and had a "bad fall on her right side.' She may have grazed her head but did not lose consciousness. Her right posterior chest is sore and painful. She initially felt ok and thought she could 'tough it out' at home but was convinced by her family that she should come to the hospital. Past Medical History: hypothyroid, HTN, HLD, IBS, subclavian stenosis, atrial fibrillation, ?interstitial lung disease (notes that she has never been on steroids and that her breathing and exercise have improved, she was last told by a specialist that she does not have diminished lung function) Social History: [MASKED] Family History: -CAD: mother, father, and brother died of heart disease -Diabetes: father, brother, sister No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Physical Exam: VS: T: 97.9 HR: 72 BP: 115/47 RR: 18 O2: 97% RA HEENT: Head normocephalic, no external signs of trauma Pupils 4->2 mm bilaterally, no blood in orifices midface stable trachea midline, equal chest rise, no bruising or tenderness on CHEST: chest wall anteriorly, 8 cm oblique abrasion to right back abdomen: soft, non-distended, non-tender pelvis: stable and non-tender extremities: warm, non-tender, no lacerations or abrasions gross motor and sensory function intact x 4 extremities Discharge Physical Exam: VS: R: 98.5 PO BP: 117/83 L Sitting HR: 79 RR: 18 O2: 97% Ra GEN: normocephalic, atraumatic HEENT: atraumatic, MMM CV: RRR PULM: coarse rhonchi b/l, no respiratory distress CHEST: right chest wall tenderness with palpation, no overlying skin changes ABD: soft, non-distended, non-tender to palpation EXT: warm, well-perfused, no edema b/l Pertinent Results: IMAGING: [MASKED]: ECHO: Normal global and regional biventricular systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. [MASKED]: CXR (PA&LAT): Emphysema. Mild fluid overload. No pneumonia. Although no acute fracture or other chest wall lesion is seen, conventional chest radiographs are not sufficient for detection or characterization of most such abnormalities. If the demonstration of trauma to the chest wall is clinically warranted, the location of any referrable focal findings should be clearly marked and imaged with either bone detail radiographs or Chest CT scanning. [MASKED]: CT Head: 1. No acute intracranial process. 2. There is acute paranasal sinusitis with fluid, and chronic sphenoid sinusitis. [MASKED]: CT C-spine: 1. No evidence for a fracture. 2. Mild retrolisthesis of C4 on C5 is almost certainly degenerative, though there are no prior exams to confirm chronicity. 3. Multilevel degenerative disease. 4. Paraseptal emphysema and partially visualized pleural/parenchymal scarring at the included lung apices. Concurrent CT torso is reported separately. [MASKED]: CT Torso: 1. Displaced posterior right tenth and eleventh rib fractures with diminutive right pneumothorax. 2. Diffuse centrilobular emphysema, fibrosis, and multiple areas of scarring. New borderline and enlarged mediastinal and hilar lymph nodes, compared to prior examination. In the setting of centrilobular emphysema and lung fibrosis, tissue sampling could be considered. 3. Severe aortic and coronary artery calcifications. [MASKED]: CXR (PA & LAT): Improved vascular congestion. Small pleural effusions. Mild basilar opacities, likely atelectasis. LABS: [MASKED] 06:35AM GLUCOSE-157* UREA N-22* CREAT-1.1 SODIUM-130* POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-22 ANION GAP-14 [MASKED] 06:35AM cTropnT-<0.01 [MASKED] 06:35AM CALCIUM-7.7* PHOSPHATE-2.8 MAGNESIUM-1.6 [MASKED] 05:25AM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 05:25AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-SM [MASKED] 05:25AM URINE RBC-25* WBC-54* BACTERIA-FEW YEAST-NONE EPI-1 TRANS EPI-1 [MASKED] 05:25AM URINE MUCOUS-RARE [MASKED] 12:00AM GLUCOSE-204* UREA N-28* CREAT-1.3* SODIUM-129* POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-20* ANION GAP-19 [MASKED] 12:00AM cTropnT-<0.01 [MASKED] 12:00AM WBC-8.2 RBC-4.02 HGB-12.0 HCT-36.3 MCV-90 MCH-29.9 MCHC-33.1 RDW-13.3 RDWSD-44.0 [MASKED] 12:00AM NEUTS-53.0 [MASKED] MONOS-12.3 EOS-0.1* BASOS-0.1 IM [MASKED] AbsNeut-4.33 AbsLymp-2.77 AbsMono-1.01* AbsEos-0.01* AbsBaso-0.01 [MASKED] 12:00AM PLT COUNT-225 [MASKED] 12:00AM [MASKED] PTT-44.7* [MASKED] [MASKED] 11:55PM LACTATE-1.5 Brief Hospital Course: Ms. [MASKED] is a [MASKED] y/o F w/ hx of atrial fibrillation on Coumadin s/p fall. She reported feeling weak and had a cough and URI symptoms for the past week. Imaging revealed displaced posterior right tenth and eleventh rib fractures with diminutive right pneumothorax. She was also diagnosed with a UTI and was started on Augmentin to cover both possible PNA and UTI. The patient was admitted to the Trauma Surgery service for pain control and respiratory monitoring. On the evening of HD1, the patient had a CXR which demonstrated improved vascular congestion, small pleural effusions, and mild basilar opacities, likely atelectasis. On HD2, the patient had a repeat CXR which showed no relevant change when compared to prior CXR. The lateral radiogram showed minimal b/l dorsal pleural effusions, no evidence of PTX. The patient was alert and oriented throughout hospitalization; pain was managed with acetaminophen, ibuprofen and tramadol. She remained stable from a cardiovascular and pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. The patient tolerated a regular diet and intake and output were closely monitored. The patient's blood counts were closely watched for signs of bleeding, of which there were none. The patient's home Coumadin was initially held for a super therapeutic INR of 3.6. When rechecked on HD1, INR was 2.2 so Coumadin was restarted. [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: synthroid [MASKED], lisinopril 10', metoprolol 25ER', pravastatin 40', warfarin 2.5' Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H please take with food RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #8 Tablet Refills:0 3. Ibuprofen 400 mg PO Q6H:PRN Pain - Moderate please take with food 4. TraMADol 25 mg PO Q6H:PRN Pain - Severe do NOT drink alcohol or drive while taking this medication RX tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #20 Tablet Refills:0 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Pravastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary: -Posterior right tenth and eleventh rib fractures -Right pneumothorax Secondary: -Urinary tract infection -Pneumonia 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 suffering a fall. You were found to have two right rib fractures and a small right pneumothorax (puncture of the lung). You were also subsequently found to have a urinary tract infection and an upper respiratory infection concerning for pneumonia. Your rib fractures will heal on their own and you should continue to practice with your incentive spirometer to help with your breathing. You had repeat chest x-rays which showed resolution of the pneumothorax. You were started on an antibiotic called Augmentin (amoxicillin/clavulanate) to treat both your urinary tract infection and pneumonia. You are now ready to be discharged home to continue your recovery. Please note the following discharge instructions: Rib Fractures: * Your injury caused right-sided rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non-steroidal [MASKED] drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). General 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]	[]	[ "N179", "I4891", "N390", "Z87891", "Z7901", "I10", "E039", "E785" ]	[ "S270XXA: Traumatic pneumothorax, initial encounter", "J189: Pneumonia, unspecified organism", "N179: Acute kidney failure, unspecified", "I4891: Unspecified atrial fibrillation", "E860: Dehydration", "S2241XA: Multiple fractures of ribs, right side, initial encounter for closed fracture", "N390: Urinary tract infection, site not specified", "Y92012: Bathroom of single-family (private) house as the place of occurrence of the external cause", "Z87891: Personal history of nicotine dependence", "Z7901: Long term (current) use of anticoagulants", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "I708: Atherosclerosis of other arteries", "W1830XA: Fall on same level, unspecified, initial encounter", "R791: Abnormal coagulation profile" ]
10,097,383	22,623,208	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old M w/ hx of idiopathic recurrent pancreatitis ___ episodes since ___ y.o.), celiac disease, and remote h/o hep C who is presenting with acute on chronic abdominal pain for ___ days. Patient states that he has chronic abdominal pain that is fairly mild, ___ in intensity, and described as "nagging" in the epigastrium. This has been present since the Pt was ___ years old to some degree, when his pancreatitis first started; however, it has been constant for the past year. Pt generally manages this chronic pain with OTC ibuprofen or the occasional 5mg oxycodone BID-TID:PRN that his primary care prescribes him. Over the past ___ days, the patient's pain has risen acutely to a ___ in intensity. It is a similar pain character, with additional "sharp/acidic" components. It radiates to the back and RLQ/R flank. This pain is intermittent, made worse with deep breathing and any food/drink (generally 10 minutes or so after eating). It has not been relieved by home Tylenol or ibuprofen. The patient has decreased his PO intake over the past few days to just sips of water, because food has so reliably made his pain worse; in spite of this, his pain persists. Patient was trying to hold out until his follow-up with General Surgery on ___ (with Dr. ___ for discussion of surgical management of his ongoing pancreatitis. However, his pain became more severe - and he also began to notice other symptoms (including nausea, two episodes of nonbloody clear vomiting, and ___ stools) that prompted him to present earlier. He called his primary gastroenterologist's office (Dr. ___, who encouraged him to come to ___ for further evaluation by his primary teams. Of note, the patient has had an extensive workup for the cause of his pancreatitis in the past including genetic testing, IgG subclasses, sweat testing (see outpatient GI notes) which have thus far been unrevealing. During prior admissions for acute on chronic pancreatitis, he responded well to IV Zofran and Dilaudid (he occasionally takes home oxycodone for pain as discussed above). Past Medical History: Celiac disease Recurrent idiopathic pancreatitis s/p multiple ERCPs, stent exchanges; being considered for proactive Whipple with General Surgery Remote hepatitis C (with spontaneous clearance per Pt, never treated) Remote OUD, no longer using IVDU and taking only prescribed opiates for pain Status post appendectomy Social History: ___ Family History: Mother with pancreas divisum and acute pancreatitis, for which she underwent underwent modified whipple and had great symptomatic improvement. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: T 97.2 BP 136/77 HR 62 RR 18 O2 95% on RA GENERAL: Alert and interactive Caucasian male, ambulatory from stretcher to bed. Pleasant, cooperative, in no acute distress. HEENT: Sclerae anicteric, MMM. CARDIAC: Regular rate and rhythm, normal S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No dullness to percussion bilaterally. BACK: Mild pain with CVA percussion bilaterally, which Pt endorses as pain that radiates to his abdomen. ABDOMEN: NABS. Abdomen is soft, non distended, tender mildly in the lower quadrants but worst in the epigastrium > RUQ with rebound tenderness in the epigastrium. EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: Warm. No jaundice. NEUROLOGIC: A&O x3, moves all four extremities with purpose. No asterixis. DISCHARGE PHYSICAL EXAM: *VS: BP 124/68 T 97.4 HR 52 RR 18 O2Sat 97 RA GENERAL: NAD HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD 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, tender most in epigastric and RUQ regions. Pain on palpation improved from yesterday. No rebound/guarding. EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric DERM: Warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ___ 09:00PM BLOOD WBC-6.1 RBC-4.90 Hgb-13.9 Hct-40.1 MCV-82 MCH-28.4 MCHC-34.7 RDW-13.3 RDWSD-39.4 Plt ___ ___ 09:00PM BLOOD Neuts-62.8 ___ Monos-7.1 Eos-3.3 Baso-0.5 Im ___ AbsNeut-3.83 AbsLymp-1.59 AbsMono-0.43 AbsEos-0.20 AbsBaso-0.03 ___ 05:33PM BLOOD Glucose-117 UreaN-10 Creat-0.8 Na-140 K-3.9 Cl-106 HCO3-22 AnGap-12 ___ 05:33PM BLOOD ALT-41* AST-31 AlkPhos-113 Amylase-27 TotBili-0.3 ___ 05:33PM BLOOD Lipase-9 ___ 09:00PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-POS* IgM HAV-NEG ___ 07:27AM BLOOD HIV Ab-NEG ___ 07:27AM BLOOD HCV VL-NOT DETECT DISCHARGE LABS: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ___ 07:57AM BLOOD WBC-6.1 RBC-5.36 Hgb-14.9 Hct-43.5 MCV-81* MCH-27.8 MCHC-34.3 RDW-13.1 RDWSD-38.2 Plt ___ ___ 07:57AM BLOOD Glucose-91 UreaN-5* Creat-0.9 Na-145 K-4.1 Cl-104 HCO3-28 AnGap-13 ___ 07:57AM BLOOD ALT-34 AST-22 LD(LDH)-167 AlkPhos-120 TotBili-0.4 ___ 07:57AM BLOOD Calcium-9.6 Phos-3.9 Mg-1.9 MICROBIOLOGY: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ___ BLOOD CULTURE NGTD ___ URINE CULTURE No growth IMAGING: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ___ FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 2 mm GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: There is equivocal peripancreatic edema. Pancreas is not fully assessed due to overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 13 cm, borderline in size. KIDNEYS: Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones, or hydronephrosis in the kidneys. Right kidney: 11.0 cm Left kidney: 11.2 cm RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: Equivocal peripancreatic edema. Normal gallbladder. No biliary dilatation. ___ ABDOMEN W&W/O C & RECON 1. No evidence of acute pancreatitis. 2. Mild unchanged main pancreatic ductal dilation measuring up to 4 mm in diameter without an obstructing process identified. 3. Nonspecific prominence of multiple retroperitoneal and mesenteric lymph nodes measuring up to 1 cm. Brief Hospital Course: SUMMARY: ========================================= Mr. ___ is a ___ with hx chronic pancreatitis and recurrent flares since age ___, who presented with acute on chronic epigastric pain radiating to the RUQ, felt to be related to his chronic pancreatitis. ACUTE ISSUES: ========================================= # Epigastric pain # Chronic Pancreatitis The patient presented with ___ days of worsening epigastric, RUQ pain, and acholic stools. Lipase was not elevated. RUQUS showed no evidence of cholelithiasis or biliary dilatation. CTA of the abdomen additionally showed no evidence of acute pancreatitis, no biliary obstruction, and chronic pancreatic ductal dilatation up to 4mm. He was evaluated by GI as well as ___ Surgery. His pain was treated with APAP, ketorolac, oxycodone up to 15mg Q4H, and IV hydromorphone up to 1mg Q3H PRN for breakthrough pain. This regimen was weaned over the hospital course and he was discharged on oxycodone taper (15 5mg tabs) and APAP PRN. At time of discharge he was tolerating a regular diet with no issues. He was also started on gabapentin 300mg TID for his chronic pancreatic pain. Notably, records from ___ state that the patient is heterozygous for N291 mutation in cationic trypsinogen (T PRSS1). # Constipation The patient was noted to have last BM several days prior to admission, likely secondary to narcotics and decreased PO intake. He was started on a bowel regimen including senna, bisacodyl, polyethylene glycol. He was discharged with plan to continue senna, polyethylene glycol as needed. CHRONIC ISSUES: ========================================= # Celiac disease Repeat Ttg-IgA was sent during this admission. He was maintained on gluten-free diet. # History of HCV Unclear history. Per patient, he acquired HCV in the past in the setting of IVDU but spontaneously cleared. HCV VL during this admission was negative. TRANSITIONAL ISSUES: ========================================= [] Plan to follow up with ___ Surgery on ___ for further discussion of surgical intervention for his chronic pancreatitis [] Continue to monitor chronic abdominal pain. He was discharged on new medication of gabapentin 300mg TID which could be uptitrated as needed in addition to other neuromodulators e.g. duloxetine for his presumed hereditary pancreatitis [] Patient is hepatitis A immune but hepatitis B non-immune. Should get vaccinated in setting of history of HCV. [] The patient's genetic testing reports from ___ ___ were requested through medical records, but had not arrived by the time of patient discharge. MEDICATION CHANGES: ========================================= - Started gabapentin 300mg TID - Started senna and polyethylene glycol PRN - Prescribed 3-day oxycodone taper, total of 15 5mg tabs CODE STATUS: Full code 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. [x]>30 minutes spent on discharge planning and care coordination on day of discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild 3. Creon 12 3 CAP PO TID W/MEALS Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Gabapentin 300 mg PO TID RX gabapentin 300 mg 1 capsule(s) by mouth three times a day Disp #90 Capsule Refills:0 3. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every six (6) hours Disp #15 Tablet Refills:0 4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line RX polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by mouth once daily Refills:0 5. Creon 12 3 CAP PO TID W/MEALS 6. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild 7. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: # Chronic pancreatitis flare SECONDARY: # Hereditary chronic pancreatitis # Celiac disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You had worse abdominal pain than usual WHAT HAPPENED TO ME IN THE HOSPITAL? - You were given pain medications for the abdominal pain - You were given intravenous fluids - You had a CT scan of the belly done which did not show acute pancreatitis or any other complications - You were seen by Gastroenterologists and Surgery WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments including with Surgery We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___	[ "K861", "K900", "K219", "R740", "K5903", "T40605A", "Y929", "Z720" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] year old M w/ hx of idiopathic recurrent pancreatitis [MASKED] episodes since [MASKED] y.o.), celiac disease, and remote h/o hep C who is presenting with acute on chronic abdominal pain for [MASKED] days. Patient states that he has chronic abdominal pain that is fairly mild, [MASKED] in intensity, and described as "nagging" in the epigastrium. This has been present since the Pt was [MASKED] years old to some degree, when his pancreatitis first started; however, it has been constant for the past year. Pt generally manages this chronic pain with OTC ibuprofen or the occasional 5mg oxycodone BID-TID:PRN that his primary care prescribes him. Over the past [MASKED] days, the patient's pain has risen acutely to a [MASKED] in intensity. It is a similar pain character, with additional "sharp/acidic" components. It radiates to the back and RLQ/R flank. This pain is intermittent, made worse with deep breathing and any food/drink (generally 10 minutes or so after eating). It has not been relieved by home Tylenol or ibuprofen. The patient has decreased his PO intake over the past few days to just sips of water, because food has so reliably made his pain worse; in spite of this, his pain persists. Patient was trying to hold out until his follow-up with General Surgery on [MASKED] (with Dr. [MASKED] for discussion of surgical management of his ongoing pancreatitis. However, his pain became more severe - and he also began to notice other symptoms (including nausea, two episodes of nonbloody clear vomiting, and [MASKED] stools) that prompted him to present earlier. He called his primary gastroenterologist's office (Dr. [MASKED], who encouraged him to come to [MASKED] for further evaluation by his primary teams. Of note, the patient has had an extensive workup for the cause of his pancreatitis in the past including genetic testing, IgG subclasses, sweat testing (see outpatient GI notes) which have thus far been unrevealing. During prior admissions for acute on chronic pancreatitis, he responded well to IV Zofran and Dilaudid (he occasionally takes home oxycodone for pain as discussed above). Past Medical History: Celiac disease Recurrent idiopathic pancreatitis s/p multiple ERCPs, stent exchanges; being considered for proactive Whipple with General Surgery Remote hepatitis C (with spontaneous clearance per Pt, never treated) Remote OUD, no longer using IVDU and taking only prescribed opiates for pain Status post appendectomy Social History: [MASKED] Family History: Mother with pancreas divisum and acute pancreatitis, for which she underwent underwent modified whipple and had great symptomatic improvement. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: T 97.2 BP 136/77 HR 62 RR 18 O2 95% on RA GENERAL: Alert and interactive Caucasian male, ambulatory from stretcher to bed. Pleasant, cooperative, in no acute distress. HEENT: Sclerae anicteric, MMM. CARDIAC: Regular rate and rhythm, normal S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No dullness to percussion bilaterally. BACK: Mild pain with CVA percussion bilaterally, which Pt endorses as pain that radiates to his abdomen. ABDOMEN: NABS. Abdomen is soft, non distended, tender mildly in the lower quadrants but worst in the epigastrium > RUQ with rebound tenderness in the epigastrium. EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: Warm. No jaundice. NEUROLOGIC: A&O x3, moves all four extremities with purpose. No asterixis. DISCHARGE PHYSICAL EXAM: *VS: BP 124/68 T 97.4 HR 52 RR 18 O2Sat 97 RA GENERAL: NAD HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD 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, tender most in epigastric and RUQ regions. Pain on palpation improved from yesterday. No rebound/guarding. EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric DERM: Warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ [MASKED] 09:00PM BLOOD WBC-6.1 RBC-4.90 Hgb-13.9 Hct-40.1 MCV-82 MCH-28.4 MCHC-34.7 RDW-13.3 RDWSD-39.4 Plt [MASKED] [MASKED] 09:00PM BLOOD Neuts-62.8 [MASKED] Monos-7.1 Eos-3.3 Baso-0.5 Im [MASKED] AbsNeut-3.83 AbsLymp-1.59 AbsMono-0.43 AbsEos-0.20 AbsBaso-0.03 [MASKED] 05:33PM BLOOD Glucose-117 UreaN-10 Creat-0.8 Na-140 K-3.9 Cl-106 HCO3-22 AnGap-12 [MASKED] 05:33PM BLOOD ALT-41* AST-31 AlkPhos-113 Amylase-27 TotBili-0.3 [MASKED] 05:33PM BLOOD Lipase-9 [MASKED] 09:00PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-POS* IgM HAV-NEG [MASKED] 07:27AM BLOOD HIV Ab-NEG [MASKED] 07:27AM BLOOD HCV VL-NOT DETECT DISCHARGE LABS: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ [MASKED] 07:57AM BLOOD WBC-6.1 RBC-5.36 Hgb-14.9 Hct-43.5 MCV-81* MCH-27.8 MCHC-34.3 RDW-13.1 RDWSD-38.2 Plt [MASKED] [MASKED] 07:57AM BLOOD Glucose-91 UreaN-5* Creat-0.9 Na-145 K-4.1 Cl-104 HCO3-28 AnGap-13 [MASKED] 07:57AM BLOOD ALT-34 AST-22 LD(LDH)-167 AlkPhos-120 TotBili-0.4 [MASKED] 07:57AM BLOOD Calcium-9.6 Phos-3.9 Mg-1.9 MICROBIOLOGY: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ [MASKED] BLOOD CULTURE NGTD [MASKED] URINE CULTURE No growth IMAGING: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ [MASKED] FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 2 mm GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: There is equivocal peripancreatic edema. Pancreas is not fully assessed due to overlying bowel gas. SPLEEN: Normal echogenicity. Spleen length: 13 cm, borderline in size. KIDNEYS: Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones, or hydronephrosis in the kidneys. Right kidney: 11.0 cm Left kidney: 11.2 cm RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: Equivocal peripancreatic edema. Normal gallbladder. No biliary dilatation. [MASKED] ABDOMEN W&W/O C & RECON 1. No evidence of acute pancreatitis. 2. Mild unchanged main pancreatic ductal dilation measuring up to 4 mm in diameter without an obstructing process identified. 3. Nonspecific prominence of multiple retroperitoneal and mesenteric lymph nodes measuring up to 1 cm. Brief Hospital Course: SUMMARY: ========================================= Mr. [MASKED] is a [MASKED] with hx chronic pancreatitis and recurrent flares since age [MASKED], who presented with acute on chronic epigastric pain radiating to the RUQ, felt to be related to his chronic pancreatitis. ACUTE ISSUES: ========================================= # Epigastric pain # Chronic Pancreatitis The patient presented with [MASKED] days of worsening epigastric, RUQ pain, and acholic stools. Lipase was not elevated. RUQUS showed no evidence of cholelithiasis or biliary dilatation. CTA of the abdomen additionally showed no evidence of acute pancreatitis, no biliary obstruction, and chronic pancreatic ductal dilatation up to 4mm. He was evaluated by GI as well as [MASKED] Surgery. His pain was treated with APAP, ketorolac, oxycodone up to 15mg Q4H, and IV hydromorphone up to 1mg Q3H PRN for breakthrough pain. This regimen was weaned over the hospital course and he was discharged on oxycodone taper (15 5mg tabs) and APAP PRN. At time of discharge he was tolerating a regular diet with no issues. He was also started on gabapentin 300mg TID for his chronic pancreatic pain. Notably, records from [MASKED] state that the patient is heterozygous for N291 mutation in cationic trypsinogen (T PRSS1). # Constipation The patient was noted to have last BM several days prior to admission, likely secondary to narcotics and decreased PO intake. He was started on a bowel regimen including senna, bisacodyl, polyethylene glycol. He was discharged with plan to continue senna, polyethylene glycol as needed. CHRONIC ISSUES: ========================================= # Celiac disease Repeat Ttg-IgA was sent during this admission. He was maintained on gluten-free diet. # History of HCV Unclear history. Per patient, he acquired HCV in the past in the setting of IVDU but spontaneously cleared. HCV VL during this admission was negative. TRANSITIONAL ISSUES: ========================================= [] Plan to follow up with [MASKED] Surgery on [MASKED] for further discussion of surgical intervention for his chronic pancreatitis [] Continue to monitor chronic abdominal pain. He was discharged on new medication of gabapentin 300mg TID which could be uptitrated as needed in addition to other neuromodulators e.g. duloxetine for his presumed hereditary pancreatitis [] Patient is hepatitis A immune but hepatitis B non-immune. Should get vaccinated in setting of history of HCV. [] The patient's genetic testing reports from [MASKED] [MASKED] were requested through medical records, but had not arrived by the time of patient discharge. MEDICATION CHANGES: ========================================= - Started gabapentin 300mg TID - Started senna and polyethylene glycol PRN - Prescribed 3-day oxycodone taper, total of 15 5mg tabs CODE STATUS: Full code 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. [x]>30 minutes spent on discharge planning and care coordination on day of discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild 3. Creon 12 3 CAP PO TID W/MEALS Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Gabapentin 300 mg PO TID RX gabapentin 300 mg 1 capsule(s) by mouth three times a day Disp #90 Capsule Refills:0 3. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every six (6) hours Disp #15 Tablet Refills:0 4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line RX polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by mouth once daily Refills:0 5. Creon 12 3 CAP PO TID W/MEALS 6. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild 7. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: # Chronic pancreatitis flare SECONDARY: # Hereditary chronic pancreatitis # Celiac disease 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 privilege caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? - You had worse abdominal pain than usual WHAT HAPPENED TO ME IN THE HOSPITAL? - You were given pain medications for the abdominal pain - You were given intravenous fluids - You had a CT scan of the belly done which did not show acute pancreatitis or any other complications - You were seen by Gastroenterologists and Surgery WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments including with Surgery We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "K219", "Y929" ]	[ "K861: Other chronic pancreatitis", "K900: Celiac disease", "K219: Gastro-esophageal reflux disease without esophagitis", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "K5903: Drug induced constipation", "T40605A: Adverse effect of unspecified narcotics, initial encounter", "Y929: Unspecified place or not applicable", "Z720: Tobacco use" ]
10,097,383	22,668,607	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: acute pancreatitis Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ male with the past medical history noted below who presents from ___ with recurrent acute pancreatitis. ___ was recently hospitalized here at ___ from ___ after presented to ___ on ___ with recurrent epigastric/RUQ pain. During this recent ___ admission, he was treated supportively with bowel rest, fluids, and pain management. He had expected and hoped for an ERCP evaluation while he was here last time, and when discussed with him that this was not advised in the setting of acute pancreatitis, he decided to go home. At the time of discharge on ___, he had tolerated one regular meal and felt his pain was tolerable without requiring pain medications at home. After he went home, he took in clears that evening and went to bed. He woke up on the ___ with severe epigastric pain to the RUQ/RLQ, nausea and vomiting. He re-presented to ___. His evaluations there was notable for a normal RUQ u/s, normal CBC and LFTs, and an elevated lipase of 1800. He was treated with bowel rest, IVF, and pain meds. He was transferred here for further management, although he was made aware that no procedures would take place while he is recovering from acute inflammation. Currently, he reports ___ pain with nausea. No f/c/s. Stools were a bit soft at the OSH but no frank diarrhea. No other symptoms or concerns. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Idopathic recurrent acute pancreatitis Hepatitis C Question of prior opiate use Tobacco abuse Social History: ___ Family History: Mother with recurrent pancreatitis ___ pancreatic divisum Physical Exam: ADMISSION PHYSICAL 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, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, slightly distended, +TTP over epigastric, RUQ, and RLQ areas without peritoneal signs. 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: 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, slightly distended, mildly +TTP over epigastric, RUQ, and RLQ areas but overall improved since admission. 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: ADMISSION LABS: ___ 06:54AM BLOOD WBC-3.9* RBC-4.81 Hgb-13.6* Hct-39.6* MCV-82 MCH-28.3 MCHC-34.3 RDW-12.7 RDWSD-37.7 Plt ___ ___ 05:30AM BLOOD ___ ___ 06:54AM BLOOD Glucose-83 UreaN-4* Creat-0.8 Na-143 K-3.9 Cl-101 HCO3-27 AnGap-15 ___ 06:54AM BLOOD ALT-22 AST-22 AlkPhos-97 TotBili-0.5 ___ 06:54AM BLOOD Lipase-144* ___ 06:54AM BLOOD Calcium-9.2 Phos-4.5 Mg-1.7 ___ 05:30AM BLOOD IgA-155 ___ 05:30AM BLOOD tTG-IgA-95* DISCHARGE LABS: ___ 05:51AM BLOOD WBC-3.8* RBC-4.88 Hgb-13.5* Hct-39.3* MCV-81* MCH-27.7 MCHC-34.4 RDW-12.3 RDWSD-35.6 Plt ___ ___ 05:51AM BLOOD ___ ___ 05:51AM BLOOD Glucose-83 UreaN-5* Creat-0.8 Na-146 K-4.1 Cl-102 HCO3-28 AnGap-16 ___ 05:51AM BLOOD ALT-30 AST-31 AlkPhos-106 TotBili-0.6 ___ 05:51AM BLOOD Albumin-4.0 Calcium-9.4 Mg-1.6 RUQ US ___: 1. No evidence of cholelithiasis or acute cholecystitis. 2. Mild dilatation of the main pancreatic duct. 3. Mild splenomegaly. Trace ascites. EUS ___: Findings consistent with acute-on-chronic pancreatitis. No pancreatic duct stones or panchymal calcifications ERCP ___: Dilated pancreatic duct noted. Successful ERCP performed with pancreatic sphincterotomy and stent placement as described above. Brief Hospital Course: Mr. ___ is a ___ male with hepC, celiac disease, OUD, and recurrent episodes of pancreatitis who presents with recurrent acute pancreatitis. # Recurrent acute pancreatitis - Pt presented with persistent symptoms of acute-on-chronic pancreatitis that he could not manage at home. Pancreas team notified and they performed an EUS which showed e/o acute on chronic pancreatitis. ERCP with pancreatic sphincterotomy was performed and a pancreatic stent placed. Pt tolerated this procedure well and was tolerating a regular diet with pain relatively well controlled on discharge. He was given a script for a few days of PO dilaudid for pain control. He will also start Viokace per pancreas team recs. Unclear cause of pt's recurrent bouts of pancreatitis but per Dr. ___ autoimmune component. IgG subclasses were sent and were wnl. He will follow-up for repeat ERCP with stent pull in a few weeks. # Chronic hep C - LFTs wnl, outpatient f/u # Pancreatic insufficiency - home Creon changed to viokace per above. # GERD - restart PPI when eating # Celiac - restarted gluten free diet Billing: Greater than 30 minutes spent on discharge counseling and coordination of care. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon 12 1 CAP PO TID W/MEALS 2. Omeprazole 20 mg PO DAILY Discharge Medications: 1. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain RX hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth every 4 hours Disp #30 Tablet Refills:0 2. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild RX ibuprofen 400 mg ___ tablet(s) by mouth every 8 hours Disp #30 Tablet Refills:0 3. Viokace (lipase-protease-amylase) 10,440-39,150- 39,150 unit oral two tabs with meals and one tab with snacks RX lipase-protease-amylase [Viokace] 10,440 unit-39,150 unit-39,150 unit ___ tablet(s) by mouth see below Disp #120 Tablet Refills:*0 4. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Acute on chronic pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came in with ongoing abdominal pain after a recent diagnosis of pancreatitis. We did an endoscopy which showed that you have a recurrent flare of your pancreatitis. A pancreatic stent was placed to help your pancreas drain and you were started on a new medication called Viokase. It is unclear what is causing these episodes but there is likely a genetic component. We treated you with bowel rest and pain medications and you improved. Please return if you have worsening pain, nausea, vomiting, or you are unable to tolerate any oral intake. It was a pleasure taking care of you at ___ ___. Followup Instructions: ___	[ "K8590", "B1920", "K219", "K900", "K861", "F1121", "F17200" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: acute pancreatitis Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [MASKED] is a [MASKED] male with the past medical history noted below who presents from [MASKED] with recurrent acute pancreatitis. [MASKED] was recently hospitalized here at [MASKED] from [MASKED] after presented to [MASKED] on [MASKED] with recurrent epigastric/RUQ pain. During this recent [MASKED] admission, he was treated supportively with bowel rest, fluids, and pain management. He had expected and hoped for an ERCP evaluation while he was here last time, and when discussed with him that this was not advised in the setting of acute pancreatitis, he decided to go home. At the time of discharge on [MASKED], he had tolerated one regular meal and felt his pain was tolerable without requiring pain medications at home. After he went home, he took in clears that evening and went to bed. He woke up on the [MASKED] with severe epigastric pain to the RUQ/RLQ, nausea and vomiting. He re-presented to [MASKED]. His evaluations there was notable for a normal RUQ u/s, normal CBC and LFTs, and an elevated lipase of 1800. He was treated with bowel rest, IVF, and pain meds. He was transferred here for further management, although he was made aware that no procedures would take place while he is recovering from acute inflammation. Currently, he reports [MASKED] pain with nausea. No f/c/s. Stools were a bit soft at the OSH but no frank diarrhea. No other symptoms or concerns. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Idopathic recurrent acute pancreatitis Hepatitis C Question of prior opiate use Tobacco abuse Social History: [MASKED] Family History: Mother with recurrent pancreatitis [MASKED] pancreatic divisum Physical Exam: ADMISSION PHYSICAL 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, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, slightly distended, +TTP over epigastric, RUQ, and RLQ areas without peritoneal signs. 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: 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, slightly distended, mildly +TTP over epigastric, RUQ, and RLQ areas but overall improved since admission. 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: ADMISSION LABS: [MASKED] 06:54AM BLOOD WBC-3.9* RBC-4.81 Hgb-13.6* Hct-39.6* MCV-82 MCH-28.3 MCHC-34.3 RDW-12.7 RDWSD-37.7 Plt [MASKED] [MASKED] 05:30AM BLOOD [MASKED] [MASKED] 06:54AM BLOOD Glucose-83 UreaN-4* Creat-0.8 Na-143 K-3.9 Cl-101 HCO3-27 AnGap-15 [MASKED] 06:54AM BLOOD ALT-22 AST-22 AlkPhos-97 TotBili-0.5 [MASKED] 06:54AM BLOOD Lipase-144* [MASKED] 06:54AM BLOOD Calcium-9.2 Phos-4.5 Mg-1.7 [MASKED] 05:30AM BLOOD IgA-155 [MASKED] 05:30AM BLOOD tTG-IgA-95* DISCHARGE LABS: [MASKED] 05:51AM BLOOD WBC-3.8* RBC-4.88 Hgb-13.5* Hct-39.3* MCV-81* MCH-27.7 MCHC-34.4 RDW-12.3 RDWSD-35.6 Plt [MASKED] [MASKED] 05:51AM BLOOD [MASKED] [MASKED] 05:51AM BLOOD Glucose-83 UreaN-5* Creat-0.8 Na-146 K-4.1 Cl-102 HCO3-28 AnGap-16 [MASKED] 05:51AM BLOOD ALT-30 AST-31 AlkPhos-106 TotBili-0.6 [MASKED] 05:51AM BLOOD Albumin-4.0 Calcium-9.4 Mg-1.6 RUQ US [MASKED]: 1. No evidence of cholelithiasis or acute cholecystitis. 2. Mild dilatation of the main pancreatic duct. 3. Mild splenomegaly. Trace ascites. EUS [MASKED]: Findings consistent with acute-on-chronic pancreatitis. No pancreatic duct stones or panchymal calcifications ERCP [MASKED]: Dilated pancreatic duct noted. Successful ERCP performed with pancreatic sphincterotomy and stent placement as described above. Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with hepC, celiac disease, OUD, and recurrent episodes of pancreatitis who presents with recurrent acute pancreatitis. # Recurrent acute pancreatitis - Pt presented with persistent symptoms of acute-on-chronic pancreatitis that he could not manage at home. Pancreas team notified and they performed an EUS which showed e/o acute on chronic pancreatitis. ERCP with pancreatic sphincterotomy was performed and a pancreatic stent placed. Pt tolerated this procedure well and was tolerating a regular diet with pain relatively well controlled on discharge. He was given a script for a few days of PO dilaudid for pain control. He will also start Viokace per pancreas team recs. Unclear cause of pt's recurrent bouts of pancreatitis but per Dr. [MASKED] autoimmune component. IgG subclasses were sent and were wnl. He will follow-up for repeat ERCP with stent pull in a few weeks. # Chronic hep C - LFTs wnl, outpatient f/u # Pancreatic insufficiency - home Creon changed to viokace per above. # GERD - restart PPI when eating # Celiac - restarted gluten free diet Billing: Greater than 30 minutes spent on discharge counseling and coordination of care. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon 12 1 CAP PO TID W/MEALS 2. Omeprazole 20 mg PO DAILY Discharge Medications: 1. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain RX hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth every 4 hours Disp #30 Tablet Refills:0 2. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild RX ibuprofen 400 mg [MASKED] tablet(s) by mouth every 8 hours Disp #30 Tablet Refills:0 3. Viokace (lipase-protease-amylase) 10,440-39,150- 39,150 unit oral two tabs with meals and one tab with snacks RX lipase-protease-amylase [Viokace] 10,440 unit-39,150 unit-39,150 unit [MASKED] tablet(s) by mouth see below Disp #120 Tablet Refills:*0 4. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Acute on chronic pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came in with ongoing abdominal pain after a recent diagnosis of pancreatitis. We did an endoscopy which showed that you have a recurrent flare of your pancreatitis. A pancreatic stent was placed to help your pancreas drain and you were started on a new medication called Viokase. It is unclear what is causing these episodes but there is likely a genetic component. We treated you with bowel rest and pain medications and you improved. Please return if you have worsening pain, nausea, vomiting, or you are unable to tolerate any oral intake. It was a pleasure taking care of you at [MASKED] [MASKED]. Followup Instructions: [MASKED]	[]	[ "K219" ]	[ "K8590: Acute pancreatitis without necrosis or infection, unspecified", "B1920: Unspecified viral hepatitis C without hepatic coma", "K219: Gastro-esophageal reflux disease without esophagitis", "K900: Celiac disease", "K861: Other chronic pancreatitis", "F1121: Opioid dependence, in remission", "F17200: Nicotine dependence, unspecified, uncomplicated" ]
10,097,383	25,378,217	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Mr. ___ is a ___ male w/ PMH of idiopathic pancreatitis who presented to the ___ ED with epigastric/RUQ pain following an admission 2 days prior to ___ for acute pancreatitis, admitted for evaluation by ___ team. Per the patient, he developed epigastric pain over the last two days. He reports that it is squeezing in quality, worse with drinking liquids, and radiating to the RUQ. He reports that he was admitted to ___ for acute pancreatitis and was discharged two days ago. He has been essentially NPO for the last few days. He reports normal bowel movement today. Given ongoing pain, he presented to ___ where his LFT's were noted to be elevated so he was transferred to ___ for further evaluation by the advanced endoscopy team. Of note, the patient has had multiple admissions yearly for acute pancreatitis. No cause has been identified. Per the patient, he has followed with Dr. ___ this in the past, although there are no OMR notes from Dr. ___ I could see. Has had an ERCP many years ago which was normal, a cystic fibrosis workup was unrevealing. He reports that he drinks ___ beers/month and denies any other drugs. In the ___ ED, he had stable vitals and was afebrile. Labs were notable for lipase 127 (was 500 at ___ 57, AST 71, INR 1.2, lactate 0.8. RUQUS showed mild dilatation of the main pancreatic duct and Mild splenomegaly with Trace ascites. He was given morphine 4 mg x1, Zofran 5 mg, IVF, dilaudid 1 mg x2 On arrival to the floor, the patient reports that his abdominal pain continues to be severe and has not improved at all. He lives with an element of chronic pain but this is definitely more severe than usual, up to close to a ___ when moving at all, ___ at rest. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Idopathic recurrent acute pancreatitis Hepatitis C Question of prior opiate use Tobacco abuse Social History: ___ Family History: Mother w/ recurrent pancreatitis due to pancreatic dvisium Physical Exam: ADMISSION VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in moderate distress with any movement 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 but with voluntary guarding, nondistended, tender to palpation in epigastrium and RUQ. Normal BS 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 VS: ___ 0126 Temp: 98.3 PO BP: 125/78 HR: 53 RR: 18 O2 sat: 99% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ Gen - supine in bed, comfortable appearing Eyes - EOMI, anicteric ENT - OP clear, MMM Heart - RRR no mrg Lungs - CTA bilaterally Abd - soft, mild tenderness to deep palpation throughout; no flank pain; normal bowel sounds Ext - no edema Skin - no rashes Vasc - 2+ DP/radial pulses Neuro - AOx3, moving all extremities Psych - appropriate Pertinent Results: ADMISSION ___ 06:45PM BLOOD WBC-4.5 RBC-4.76 Hgb-14.0 Hct-39.6* MCV-83 MCH-29.4 MCHC-35.4 RDW-12.8 RDWSD-38.8 Plt ___ ___ 06:45PM BLOOD Glucose-86 UreaN-8 Creat-0.7 Na-139 K-4.2 Cl-102 HCO3-23 AnGap-14 ___ 06:45PM BLOOD ALT-57* AST-71* AlkPhos-107 TotBili-0.5 ___ 06:45PM BLOOD Lipase-127* DISCHARGE ___ 06:09AM BLOOD WBC-4.3 RBC-4.63 Hgb-13.2* Hct-38.6* MCV-83 MCH-28.5 MCHC-34.2 RDW-12.8 RDWSD-38.5 Plt ___ ___ 06:09AM BLOOD Glucose-78 UreaN-8 Creat-0.8 Na-142 K-4.0 Cl-103 HCO3-25 AnGap-14 ___ 06:09AM BLOOD ALT-52* AST-55* LD(LDH)-191 AlkPhos-99 TotBili-0.5 ___ 06:09AM BLOOD Lipase-150* RUQ US 1. No evidence of cholelithiasis or acute cholecystitis. 2. Mild dilatation of the main pancreatic duct. 3. Mild splenomegaly. Trace ascites. Via ___ Records, scanned ___ Record CT Abd/Pelvis w contrast ___ "Unremarkable liver gallbladder and spleen. Mildly dilated pancreatic duct with a slightly heterogeneous pancreatic head. Unremarkable adrenals and kidneys. Unremarkable stomach. Markedly thick-walled second and third duodenal segments with adjacent stranding and failr low density fluid that extends to the adjacent pancreatic head and into the adjacent retroperitoneum, mesentery, R paracolic gutter and pelvis. Unremarkable mesenteric small bowel. Status post appendectomy. Unremarkable large bowel. ... Findings most likely represent a duodenitis quite possibly secondary to pancreatitis." Via ___ Records, scanned ___ MRCP ___ "Signal abnormality in the pancreas and edema in the peripancreatic fascial planes suspicious for acute pancreatitis. Dilation of the pancreatic duct may be related. A tiny focus of low signal in the distal pancreatic duct may be artifactual but raises the possibility of a tiny stone. No evidence of biliary obstruction." Brief Hospital Course: ___ year old male with past medical history of celiac disease, chronic abdominal pain attributed to idiopathic pancreatitis, recent hospitalization at ___ for acute pancreatitis, admitted ___ with continued acute pancreatitis, evaluated by advanced endoscopy service who recommended endoscopic ultrasound in ___ weeks for evaluation for underlying explanatory pathology, treated conservatively and subsequently able to advance diet, discharged home # Acute pancreatitis # Chronic idiopathic pancreatitis Patient with chronic abdominal pain symptoms attributed to pancreatic pathology, with recent hospitalizations at ___ and ___ for acute pancreatitis, with cross-sectional imaging consistent with peripancreatic edema concerning for pancreatitis, who presented with ongoing abdominal pain, OSH lipase of 550 (upper limit of normal for their assay is 393), ___ lipase 150 (upper limit of normal for our assay is 60). RUQ ultrasound showed mild dilatation of the main pancreatic duct. Patient was seen by advanced endoscopy service who recommended patient undergo an endoscopic ultrasound, but recommended waiting to perform this until ___ weeks after the episode of acute pancreatitis so as to best visualize area and identify any potential underlying anatomic abnormalities. Patient grew very upset upon hearing he would not be having an ERCP/EUS this admission, and reported he was told by the referring ED that this was the reason why he was being transferred to ___. Following this conversation he requested to advance his diet and be discharged home. IV pain medications were stopped, and he tolerated clears, and then a regular diet. He asked about opiate medications at home---he was advised that if he was still having acute pain intense enough to require opiate pain medications that this would be a sign he should stay in the hospital. He reported feeling comfortable and that he was ready for discharge home. Discharged with previously scheduled follow-up with Dr. ___. # Chronic Hepatitis C # Abnormal LFTs Patient with reported history of chronic hep C, noted to have mild transaminitis; this admission without elevation in bilirubin or alk phos. Remained stable during this brief admission--would consider check at follow-up to ensure stability. Consider referral to hepatologist for additional testing and treatment. Discharge ALT 52 AST 55 AP 99 Tbili 0.5. # Pancreatic insufficiency Continued Creon # GERD Continued PPI Transitional issues - Discharged home - Consider repeat LFTs as above - Has previously scheduled appointment with Dr. ___ on ___ @ 09:20a; Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon 12 1 CAP PO TID W/MEALS 2. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Creon 12 1 CAP PO TID W/MEALS 2. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: # Acute epigastric abdominal pain secondary to acute pancreatitis # Abnormal LFTs # Pancreatic insufficiency # GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___: It was a pleasure caring for you at ___. You were admitted with abdominal pain. You were seen by GI specialists who reviewed your recent blood tests and imaging studies. They think you had inflammation of the pancreas ("pancreatitis"). They recommended treatment with bowel rest, IV fluids and pain medications. They recommended an endoscopic ultrasound as an outpatient after you recover from the pancreatitis. You improved and were able to tolerate a regular diet. You are now able be discharged home. Followup Instructions: ___	[ "K8500", "K861", "K8681", "R740", "K219", "K900", "Z720", "F1121", "B182" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Mr. [MASKED] is a [MASKED] male w/ PMH of idiopathic pancreatitis who presented to the [MASKED] ED with epigastric/RUQ pain following an admission 2 days prior to [MASKED] for acute pancreatitis, admitted for evaluation by [MASKED] team. Per the patient, he developed epigastric pain over the last two days. He reports that it is squeezing in quality, worse with drinking liquids, and radiating to the RUQ. He reports that he was admitted to [MASKED] for acute pancreatitis and was discharged two days ago. He has been essentially NPO for the last few days. He reports normal bowel movement today. Given ongoing pain, he presented to [MASKED] where his LFT's were noted to be elevated so he was transferred to [MASKED] for further evaluation by the advanced endoscopy team. Of note, the patient has had multiple admissions yearly for acute pancreatitis. No cause has been identified. Per the patient, he has followed with Dr. [MASKED] this in the past, although there are no OMR notes from Dr. [MASKED] I could see. Has had an ERCP many years ago which was normal, a cystic fibrosis workup was unrevealing. He reports that he drinks [MASKED] beers/month and denies any other drugs. In the [MASKED] ED, he had stable vitals and was afebrile. Labs were notable for lipase 127 (was 500 at [MASKED] 57, AST 71, INR 1.2, lactate 0.8. RUQUS showed mild dilatation of the main pancreatic duct and Mild splenomegaly with Trace ascites. He was given morphine 4 mg x1, Zofran 5 mg, IVF, dilaudid 1 mg x2 On arrival to the floor, the patient reports that his abdominal pain continues to be severe and has not improved at all. He lives with an element of chronic pain but this is definitely more severe than usual, up to close to a [MASKED] when moving at all, [MASKED] at rest. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Idopathic recurrent acute pancreatitis Hepatitis C Question of prior opiate use Tobacco abuse Social History: [MASKED] Family History: Mother w/ recurrent pancreatitis due to pancreatic dvisium Physical Exam: ADMISSION VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in moderate distress with any movement 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 but with voluntary guarding, nondistended, tender to palpation in epigastrium and RUQ. Normal BS 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 VS: [MASKED] 0126 Temp: 98.3 PO BP: 125/78 HR: 53 RR: 18 O2 sat: 99% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: [MASKED] Gen - supine in bed, comfortable appearing Eyes - EOMI, anicteric ENT - OP clear, MMM Heart - RRR no mrg Lungs - CTA bilaterally Abd - soft, mild tenderness to deep palpation throughout; no flank pain; normal bowel sounds Ext - no edema Skin - no rashes Vasc - 2+ DP/radial pulses Neuro - AOx3, moving all extremities Psych - appropriate Pertinent Results: ADMISSION [MASKED] 06:45PM BLOOD WBC-4.5 RBC-4.76 Hgb-14.0 Hct-39.6* MCV-83 MCH-29.4 MCHC-35.4 RDW-12.8 RDWSD-38.8 Plt [MASKED] [MASKED] 06:45PM BLOOD Glucose-86 UreaN-8 Creat-0.7 Na-139 K-4.2 Cl-102 HCO3-23 AnGap-14 [MASKED] 06:45PM BLOOD ALT-57* AST-71* AlkPhos-107 TotBili-0.5 [MASKED] 06:45PM BLOOD Lipase-127* DISCHARGE [MASKED] 06:09AM BLOOD WBC-4.3 RBC-4.63 Hgb-13.2* Hct-38.6* MCV-83 MCH-28.5 MCHC-34.2 RDW-12.8 RDWSD-38.5 Plt [MASKED] [MASKED] 06:09AM BLOOD Glucose-78 UreaN-8 Creat-0.8 Na-142 K-4.0 Cl-103 HCO3-25 AnGap-14 [MASKED] 06:09AM BLOOD ALT-52* AST-55* LD(LDH)-191 AlkPhos-99 TotBili-0.5 [MASKED] 06:09AM BLOOD Lipase-150* RUQ US 1. No evidence of cholelithiasis or acute cholecystitis. 2. Mild dilatation of the main pancreatic duct. 3. Mild splenomegaly. Trace ascites. Via [MASKED] Records, scanned [MASKED] Record CT Abd/Pelvis w contrast [MASKED] "Unremarkable liver gallbladder and spleen. Mildly dilated pancreatic duct with a slightly heterogeneous pancreatic head. Unremarkable adrenals and kidneys. Unremarkable stomach. Markedly thick-walled second and third duodenal segments with adjacent stranding and failr low density fluid that extends to the adjacent pancreatic head and into the adjacent retroperitoneum, mesentery, R paracolic gutter and pelvis. Unremarkable mesenteric small bowel. Status post appendectomy. Unremarkable large bowel. ... Findings most likely represent a duodenitis quite possibly secondary to pancreatitis." Via [MASKED] Records, scanned [MASKED] MRCP [MASKED] "Signal abnormality in the pancreas and edema in the peripancreatic fascial planes suspicious for acute pancreatitis. Dilation of the pancreatic duct may be related. A tiny focus of low signal in the distal pancreatic duct may be artifactual but raises the possibility of a tiny stone. No evidence of biliary obstruction." Brief Hospital Course: [MASKED] year old male with past medical history of celiac disease, chronic abdominal pain attributed to idiopathic pancreatitis, recent hospitalization at [MASKED] for acute pancreatitis, admitted [MASKED] with continued acute pancreatitis, evaluated by advanced endoscopy service who recommended endoscopic ultrasound in [MASKED] weeks for evaluation for underlying explanatory pathology, treated conservatively and subsequently able to advance diet, discharged home # Acute pancreatitis # Chronic idiopathic pancreatitis Patient with chronic abdominal pain symptoms attributed to pancreatic pathology, with recent hospitalizations at [MASKED] and [MASKED] for acute pancreatitis, with cross-sectional imaging consistent with peripancreatic edema concerning for pancreatitis, who presented with ongoing abdominal pain, OSH lipase of 550 (upper limit of normal for their assay is 393), [MASKED] lipase 150 (upper limit of normal for our assay is 60). RUQ ultrasound showed mild dilatation of the main pancreatic duct. Patient was seen by advanced endoscopy service who recommended patient undergo an endoscopic ultrasound, but recommended waiting to perform this until [MASKED] weeks after the episode of acute pancreatitis so as to best visualize area and identify any potential underlying anatomic abnormalities. Patient grew very upset upon hearing he would not be having an ERCP/EUS this admission, and reported he was told by the referring ED that this was the reason why he was being transferred to [MASKED]. Following this conversation he requested to advance his diet and be discharged home. IV pain medications were stopped, and he tolerated clears, and then a regular diet. He asked about opiate medications at home---he was advised that if he was still having acute pain intense enough to require opiate pain medications that this would be a sign he should stay in the hospital. He reported feeling comfortable and that he was ready for discharge home. Discharged with previously scheduled follow-up with Dr. [MASKED]. # Chronic Hepatitis C # Abnormal LFTs Patient with reported history of chronic hep C, noted to have mild transaminitis; this admission without elevation in bilirubin or alk phos. Remained stable during this brief admission--would consider check at follow-up to ensure stability. Consider referral to hepatologist for additional testing and treatment. Discharge ALT 52 AST 55 AP 99 Tbili 0.5. # Pancreatic insufficiency Continued Creon # GERD Continued PPI Transitional issues - Discharged home - Consider repeat LFTs as above - Has previously scheduled appointment with Dr. [MASKED] on [MASKED] @ 09:20a; Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon 12 1 CAP PO TID W/MEALS 2. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Creon 12 1 CAP PO TID W/MEALS 2. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: # Acute epigastric abdominal pain secondary to acute pancreatitis # Abnormal LFTs # Pancreatic insufficiency # GERD 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 caring for you at [MASKED]. You were admitted with abdominal pain. You were seen by GI specialists who reviewed your recent blood tests and imaging studies. They think you had inflammation of the pancreas ("pancreatitis"). They recommended treatment with bowel rest, IV fluids and pain medications. They recommended an endoscopic ultrasound as an outpatient after you recover from the pancreatitis. You improved and were able to tolerate a regular diet. You are now able be discharged home. Followup Instructions: [MASKED]	[]	[ "K219" ]	[ "K8500: Idiopathic acute pancreatitis without necrosis or infection", "K861: Other chronic pancreatitis", "K8681: Exocrine pancreatic insufficiency", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "K219: Gastro-esophageal reflux disease without esophagitis", "K900: Celiac disease", "Z720: Tobacco use", "F1121: Opioid dependence, in remission", "B182: Chronic viral hepatitis C" ]

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